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 195

Horizontal Bone Augmentation in the

Anterior Esthetic Area of the Maxilla Using a
Flap Design Adapted from Mucogingival Surgery in
Association with PLA Membrane and β-TCP
Luigi Canullo, DDS1/Mauro Tronchi, DT1 Guided bone regeneration (GBR)
Shunsuke Kawakami, DDS2/Takahisa Iida, DDS2 is a surgical technique that is often
Luca Signorini, DDS, MS1/Lorenzo Mordini, DDS, MS3 required during or prior to dental
implant placement.1 GBR aims to
recreate adequate bone volume to
provide dental implants with ideal
Systematic reviews showed possible esthetic complications with the use of prosthetic location and long-term
traditional flap designs after guided bone regeneration (GBR) procedures in the stability.2–5 Modern implantology
esthetic zone and the aim of this case series was to analyze hard and soft tissue concepts pose great attention on
changes over 18 months after these procedures. Healthy subjects requiring tooth
esthetics and implant-prosthetic
extraction and single-implant placement in the anterior maxilla were enrolled
in the study. Three months after tooth extraction and ridge preservation, a design.
prosthetic-driven implant was placed. The horizontal bone deficiency was treated In order to be successful, GBR
with a resorbable bone graft substitute (beta tricalcium phosphate [β-TCP]) and procedures depend on four key
a bioresorbable polylactic acid (PLA) membrane. Primary closure was obtained factors outlined by Wang and Boy-
by a novel coronally advanced flap adapted from mucogingival techniques. Final
apati6: primary wound closure, an-
metal-free implant restorations were delivered 4 months after placement. Clinical
measurements, pictures, and radiographs were acquired after delivery of the giogenesis, stability of the blood
final restoration (T1) and at the 18-month follow-up (T2). Digital impressions were clot, and space maintenance. For
taken at the time of tooth extraction (T-1) and implant insertion (baseline; T0) primary wound closure, flap design
and at T2. Marginal bone level changes were assessed by radiographic analysis, and releasing techniques play a cru-
while soft tissue changes were evaluated with ExoCad software. Student t test
cial role in achieving a tensionless
for paired data was used to detect differences between the different time points.
Twelve subjects (7 men and 5 women; mean age: 63.7 ± 14 years) completed complete closure for graft coverage.
the study and received 15 implants. All implants healed uneventfully and were Wound dehiscence with membrane
clinically osseointegrated and stable, showing no sign of infection. No GBR exposure was reported to result in
complications were noted. Statistically significant ridge-width changes were inferior quality and quantity of bone
observed after extraction (T-1 vs T0 = –1.72 ± 0.30 mm; P = .00001) and after
regeneration, with fewer success-
horizontal GBR (T0 vs T2 = 1.41 ± 0.64 mm; P = .00001). Radiographic bone levels
after implant placement remained stable T0 to T2 (0.09 ± 0.08 mm). Periodontal ful dental implant performances.7–10
parameters never exceeded physiologic levels. It can be concluded that GBR Aiming to optimize primary closure
using a bioresorbable PLA membrane and resorbable β-TCP bone graft in and flap release, numerous flap ap-
conjunction with a coronally advanced flap is a predictable procedure for horizontal proaches have been described in
bone augmentation with simultaneous implant placement in the esthetic area.
the literature.11 Some designs allow
Int J Periodontics Restorative Dent 2019;39:195–201. doi: 10.11607/prd.3894
limited flap advancement and can
be utilized in small grafting proce-
Private Practice, Rome, Italy.
1

Osaka Dental University, Osaka, Japan; ARDEC Academy, Rimini, Italy.

2 dures.12–14 Buser et al15,16 proposed
3Creighton University School of Dentistry, Omaha, Nebraska, USA.
the lateral incision technique for
localized staged horizontal ridge
Correspondence to: Dr Luigi Canullo, Via Nizza, 46 00198 Rome, Italy.
Email: luigicanullo@yahoo.com augmentation. Some other flaps al-
Submitted April 23, 2018; accepted August 30, 2018.
low for a moderate advancement,
©2019 by Quintessence Publishing Co Inc. defined to be around 5 to 6 mm.17–20

Volume 39, Number 2, 2019

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196

Table 1 Subject and Study-Site Inclusion and Exclusion Criteria

Inclusion criteria
Subject
Need for fixed implant-supported
prosthesis in the anterior esthetic area buccal bone recession in
(canine to canine) of the maxilla
Age > 18 years
No relevant medical conditions
Nonsmoking or smoking ≤ 10 cigarettes/day
(all pipe or cigar smokers were excluded)
Full-Mouth Plaque Score and
Full-Mouth Bleeding Score ≤ 25%
Exclusion criteria
Study site Specific subject and site
Hopeless tooth with Uncontrolled periodontitis
Patients with a history of bisphosphonate
the anterior esthetic area therapy or intake of medications that
affect bone metabolism
Patients with uncontrolled diabetes
(HbA1c > 6%, glycemic level > 110 mg/dL)

cruited from April 2015 to January

a b
Fig 1 (a) Buccal and (b) occlusal preoperative views.
Surgical procedures in the es-
thetic area employ flap designs that
aim to preserve the gingival integ-
rity of adjacent restorations and
teeth; the goal is to avoid gingival
recessions, scarring, and poten-
tial loss of the interdental papilla,
as these can have adverse esthetic
impacts21 and may affect the teeth
adjacent to those involved in GBR
of the anterior zone.22,23 Some gingi-
val flaps used for GBR can be em-
ployed to improve unsatisfactory or
symptomatic gingival deformities
affecting neighboring teeth and/or
restorations.24 In other words, a spe-
cific flap could be designed to aid
in treating gingival recession and
increasing soft tissue on the teeth
proximal to the edentulous ridge
being augmented.
A GBR procedure was per-
formed to regenerate horizontal
bone deficiencies in the anterior es-
thetic area by way of (1) a flap design
adapted from mucogingival surgery
used in association with (2) a resorb-
able membrane and bone graft sub-
stitute (beta tricalcium phosphate
[β-TCP]). The purpose of this case
series was to investigate, over 1 year,
the hard and soft tissue changes fol-
lowing this GBR procedure.
Materials and Methods
Twelve consecutive patients pre-
senting hopeless maxillary anterior
teeth (from canine to canine) with
absence of buccal plate (socket Class
II, according to Elian et al25), were re-
2016 from a private dental clinic in
Rome. Inclusion/exclusion criteria are
summarized in Table 1. All subjects
belonged to American Society of
Anesthesiologists Class I and signed
a detailed informed consent form ex-
plaining the study steps and require-
ments. These subjects were followed
up during a period of 18 months after
final implant prosthetic rehabilitation.
The present study was per-
formed following the principles out-
lined in the Declaration of Helsinki
on experimentation involving hu-
man subjects.
Tooth Extraction and Ridge
Preservation
Preoperatively, each patient under-
went a full periodontal examination
and had a series of radiographs tak-
en. One week prior to dental extrac-
tion, subjects were treated with a
full-mouth professional prophylaxis.
Antibiotic therapy (amoxicillin and
clavulanic acid) began 1 day prior to
extraction (1 g) and continued for 4
days postoperation (1 g, tid) (Fig 1).

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Teeth were extracted with a
minimally invasive approach fol-
lowed by ridge preservation in type
II sockets according to a specific
protocol.26 β-TCP grafting mate-
rial (GUIDOR calc-i-oss CLASSIC,
Sunstar) was used (Fig 2). Right af-
ter ridge preservation (T-1), a digital
impression of the area was taken
by means of a scanner (F3600, Car-
estream). This digital file would be
superimposed to the one at final
crown delivery (T1) and the one at
18 months postoperation (T2) for
GBR analysis.
Horizontal Bone Augmentation
Virtual implant planning was per-
formed at 3 months after ridge pres-
ervation, using cone beam computed
tomography analysis to compare the
ideal prosthetic implant location and
the available bone volume (Fig 3).
One week prior to surgical implant
placement, a full-mouth professional
prophylaxis was performed and a
digital impression of the oral cavity
was taken (baseline; T0).
The proposed surgical tech-
nique represents a combination
of GBR and mucogingival surgical
techniques. The buccal flap was de-
signed similarly to the coronally ad-
vanced flap used for the treatment
of multiple recession defects in soft
tissue plastic surgery27: an envelope
flap was performed at the buccal
aspects, and the design included a
midcrestal incision and creation of
surgical papillae (part of the flap to
be adapted on the de-epithelialized
papilla at time of suturing) bilaterally
two or three teeth away from the
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Fig 2 (right) Occlusal view at 3 months
postextraction.
Fig 3 (below) A mucogingival flap was
elevated to expose bone for implant
insertion and bone regeneration. A crestal
incision was performed crestally at the
regeneration site. The flap dissected the
papillae and continued intrasulcularly
without any vertical releasing incisions.
Papillae were then de-epithelialized.
site to be regenerated. The flap was
elevated as split-thickness up to the
cementoenamel junction level, then
elevated as full-thickness thereafter.
The interdental papillae were de-
epithelialized in order to act as con-
nective tissue beds for the surgical
papillae.
The lateral extension of the flap
allowed for a tensionless coronal
advancement and graft coverage,
without the need of vertical releas-
ing incisions.
A prosthetically driven crestal
implant (3.8 mm in diameter, 13 mm
in length; CSR Implants, Sweden &
Martina) placement was performed
(Fig 4). The peri-implant bone defi-
ciency was treated with resorbable
β-TCP graft material mixed with pa-
tient autogenous bone (50/50) har-
vested locally and covered with a
bioresorbable polylactic acid (PLA)
membrane (GUIDOR bioresorbable
matrix barrier, Sunstar). The mem-
brane was fixated in place via metal
197
Fig 4 The exposed surface of an inserted
implant.
tacks positioned buccally 2 to 3 mm
away from the bony defect. An ad-
ditional amount of graft was then
applied, and finally the membrane
was secured on the palatal wall by
means of resorbable sutures (Vicryl
6.0, Ethicon, Johnson & Johnson)
(Figs 5 and 6).
To obtain primary closure, the
flaps were coronally advanced by
double periosteal and submuco-
sal incisions and sutured on the
anatomic papilla (left in place after
de-epithelialization of interproximal
papillae) without vertical releasing
incisions. Synthetic, nonresorbable
monofilament 6.0 sutures were used
(Polynil, Sweden & Martina) (Fig 7).
Postoperative Treatment
Patients were instructed to avoid
brushing in the surgical area for at
least 15 days postsurgery, and su-
tures were removed after 14 days.
Volume 39, Number 2, 2019
198

Fig 5 An inserted implant and beta tricalcium phosphate and poly- Fig 6 Membrane envelope was used to stabilize the bone graft.
lactic acid membrane for bone defect regeneration. The membrane was fixed buccally with pins and secured occlusally
using a suture anchored to the palatal flap.

a b
Fig 7 (a) Buccal and (b) occlusal views of the sutured flap.

Follow-up Evaluation exposure included potential crestal Clinical measurements, images,

Second-stage implant exposure
was performed by minimal crestal
incisions over the implant location
3 months after implant placement.
The abutments were connected to
the implants, and provisional resto-
rations were seated and secured by
temporary cement according to the
manufacturer’s instructions. Keratin-
ized mucosa was left attached cir-
cumferentially to the implants.
Clinical evaluation criteria at
the time of second-stage implant
bone resorption (due to an early,
unintentional implant exposure) and
patients’ reports of pain and/or dis-
comfort.
The final metal-free restorations
were connected 2 months after im-
plant exposure (T1).
Follow-ups
Patients were recalled every 6
months until 18 months after pros-
thetic loading (Fig 8).
and radiographs were taken at the
time of final restoration delivery
(T1) and after 18 months (T2); digi-
tal impressions were taken at the
time of tooth extraction (T-1), before
implant placement (T0), and at 18
months postloading (T2).
Primary Measurements
The primary study measurements
calculated the change in ridge width
(intended as a combination of soft

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and hard tissue volume) from tooth
extraction and ridge preservation to
right before implant insertion and
flap elevation (T-1 to T0) and from
just before implant placement to fi-
nal restoration after 18 months (T0
to T2). This was achieved by com-
paring digital models, following a
previously published protocol.28
Briefly, using an intraoral scanner,
patient maxillae were scanned. Ste-
reolithography (STL) files were then
imported into a dedicated software
(ExoCad, Exocad). Digital models
taken at different time points were
superimposed to identify tissues’
volumetric changes. Measurements
were taken at different heights
(–1 mm and –3 mm, using the soft
tissue margin of neighboring teeth
as a reference). Mean values were
used for each patient.
The second outcome assessed
was the change in marginal bone
level (MBL). Radiographs taken at
the time of definitive restoration (T1)
were compared to those after 18
months of follow-up. A dedicated
software was used according to an
existing published protocol.29
Periodontal parameters as well
as biologic (pain, swelling, suppura-
tion, etc) and/or mechanical compli-
cations (fracture of the framework
and/or the veneering material, screw
loosening, etc) occurring during the
follow-up period were recorded.
Statistical Analysis
Descriptive statistics, including mean
values and standard deviations, were
used to describe changes in MBL
and ridge width over time. Data were
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a b
Fig 8 (a) Buccal view and (b) radiograph 18 months after prosthetic loading.
normally distributed. Student t test
for paired data was used to compare
MBL at different time points. The
same statistical test was performed
to evaluate any significant difference
of ridge width changes at T-1 vs T0
and T0 vs T2. Statistical significance
was set at P < .05.
Results
At the end of the study, 12 consecu-
tive patients (7 men and 5 women
with a mean age of 63.7 ± 14 years)
received 15 dental implants. No
dropouts were experienced during
the study.
During the healing phase, no
membrane exposures were noticed.
All implants were clinically osseoin-
tegrated with no signs of pathology
or infection. Periodontal parameters
never exceeded physiologic levels
during the 18 months. Absences of
biologic and biomechanical com-
plications were noticed. Alveolar
ridge width showed a statistically
significant (P < .0001) reduction
after tooth extraction (T-1 vs T0 =
–1.7 ± 0.3 mm). On the other hand,
199
comparing the baseline with the last
follow-up, significant ridge width in-
crease was observed (T0 vs T2 = 1.3
± 0.6 mm; P < .00001; Table 2). Ra-
diographic analysis showed stable
MBL from baseline to the final fol-
low-up (T0 to T2 = 0.09 ± 0.08 mm).
Discussion
In the present prospective study,
the combination of a flap design
adapted from mucogingival surgery
and traditional GBR techniques, us-
ing a resorbable PLA membrane
with resorbable β-TCP, compensat-
ed for the bone resorption that usu-
ally follows tooth extraction.
In fact, superimposition of digi-
tal impressions showed a significant
horizontal buccal tissue reduction
(1.7 mm) after the ridge preservation
procedure following tooth extrac-
tion. Eighteen months after GBR,
soft tissue width showed a significant
gain of 1.4 mm compared to the pre–
implant placement time point (T0).
At the first observation point,
the difference between ridge pres-
ervation (T-1) and pre–implant
Volume 39, Number 2, 2019
200
placement (T0) volumes seems to
be comparable with previously pub-
lished studies.30,31
Although some authors suggest
including soft tissue augmentation
during GBR procedures to improve
implant-esthetic outcomes,32 the
technique used in the present study
did not entail any kind of connective
tissue augmentation.
Additionally, the reported out-
comes may be related to the surgi-
cal sequence adopted. In fact, two
interventions were performed: (1)
postextraction site preservation and
(2) horizontal ridge augmentation
with simultaneous implant place-
ment using a combination of a novel
surgical approach and established
protocols.
If the use of graft material at the
time of tooth extraction allowed for
minimization of physiologic bone
resorption, correct timing of the
implant insertion and bone regen-
eration approach allowed a com-
plete restoration of tissue volume.
It has to be noted that the site se-
lection included anterior teeth with
absence or major resorption of the
buccal plate, as described by Elian
et al25 for type II sockets.
Considering the adopted pres-
ervation technique used flapless
bone grafting without membrane
to treat Class II sockets, it can be
concluded that the results reported
in the present study align with aver-
ages reported in the literature.30,33,34
One study’s interesting obser-
vation was that the risk of wound
dehiscence and membrane expo-
sure was lower with delayed implant
placement, regardless of the type of
membrane used.35
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Cosyn et al36,37 demonstrated
that esthetic complications following
delayed implant placement and GBR
mainly related to insufficient volume
of mesial and distal papillae after
healing. In fact, mean Papilla Esthetic
Scores following GBR were signifi-
cantly lower than scores following im-
mediate implant placement. Surgery
with bone augmentation was found
to be a significant predictor of insuf-
ficient volume of mesial papillae. The
authors hypothesized that multiple
surgeries increase the risk for incom-
plete wound closure, leading to soft
tissue grooves or depressions. They
indicated that, regardless of the un-
derlying mechanisms responsible for
interproximal recession, procedures
that include elevation of interdental
papillae should be limited to favor
their preservation. Gomez-Roman21
concluded that a minimum interden-
tal papilla width of 1 mm, remaining
firmly attached to the adjacent tooth
and bone, assures adequate blood
supply to the papillary tip and pre-
vents necrosis as well as detrimental
esthetic outcomes.
In a more dated study on guid-
ed tissue regeneration with non-
resorbable membranes, Murphy38
reported that the use of crestal inci-
sions, maintenance of the full thick-
ness of papillae, and the exposure of
interproximal bone on the inner sur-
face of the healing flap decrease the
incidence of flap recession in esthet-
ically sensitive areas. The technique
described in this study proposed a
novel flap design concept that pre-
vented soft tissue recession around
teeth involved in GBR procedures,
without the need of connective tis-
sue augmentation.
The selection of materials in
the present study was based on
their specific properties. The hard-
ening and union of β-TCP particles
greatly improved the stabilization of
the graft and coagulum mixed with
autogenous bone. The synthetic
resorbable membranes used in the
present study allow additional graft
stabilization, eliminate the need
for membrane removal at second
stage, and show improved soft tis-
sue responses compared to a non-
resorbable membrane.
Conclusions
Within the limitations of this trial, it
can be concluded that the use of
a resorbable PLA membrane and
resorbable bone graft substitute
(β-TCP) in conjunction with a coro-
nally advanced flap is a predictable
procedure to restore atrophic ridge
with simultaneous implant place-
ment in the esthetic zone.
Acknowledgments
The authors highly appreciate the skills and
commitment of Dr Audrenn Gautier in the
supervision of the study and Dr Gabriel
Canullo for his scientific and clinical support.
The study was entirely self-supported. The
authors report no conflicts of interest related
to this study.
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