الفهرس 
Clinical comparison of coronally advanced lingual flap to periosteal releasing incision for flap advancement in partially edentulous patients undergoing guided bone regeneration using titanium mesh : a randomized controlled tria
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Abstract
Having an adequate bone volume is certainly an important prerequisite for a long-term implant
success. Insufficient bone volume for dental implant placement in the mandibular segment is a
constant challenge in oral surgery. Several techniques have been suggested to reconstruct deficient
alveolar ridges and to facilitate dental implant placement. These techniques include bone splitting
osteotomy, distraction osteogenesis, inlay and onlay bone grafting.
Among the various techniques developed to increase bone volume, GBR and the use of bone
grafting materials or combination of these two methods are reported as providing the best and the
most predictable results. The principal idea of GBR is the use of membranes to exclude epithelial
cells with a high turnover and to allow the migration of the desired cells (particularly osteoblasts) in
the established wound space. Barriers membranes must fulfill a certain design criteria as described
by Scantlebury such as biocompatibility, space making, cell conclusiveness, tissue integration and
clinical manageability. Barriers membranes are grouped as resorbable and non-resorbable
membranes. Titanium mesh is non-resorbable membrane that has been extensively used in surgical
dental application because of its contouring and adaptation to define space that mimics the shape of
the desired alveolar ridge.
Many factors contribute to successful GBR outcomes. For successful GBR, four major factors
should be considered including primary wound closure, angiogenesis, space creation/maintenance
and stability of the initial blood clot. It is believed that tension-free adaptation of the flap margins
results in primary wound closure. This should be maintained throughout the entire healing phase of
the flap.
There is no doubt that passive soft tissue primary closure may be predictably attained and
maintained throughout the course of regeneration despite the numerous anatomical and clinical
challenges that face clinicians when performing regenerative therapy. Primary closure results in
decreased discomfort and faster healing and is critically important in attaining desired objectives (e.g.
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bone regeneration). Failure to attain tensionless closure may result in a soft tissue dehiscence along
the incision line that can cause a poor outcome and/or postoperative complications.
To achieve such a stable situation of the wound, both the tension applied to the wound margins
during suturing and the thickness and mobilization of the flaps may be determining factors. PRI with
vertical releasing incisions is a commonly used technique in flap advancement. However, if the
incision does not provide the desired primary closure, additional deep incisions into the submucosa
are required for major flap advancement. It is important to note that each additional deep incision
repeated for PRI brings a higher risk of morbidity to the overall outcome.
Many studies suggested different clinical protocols for management of the soft tissues to reach
satisfactory results in regenerative surgery. It was reported that in order to properly achieve primary
closure, minimize the occurrence of complications, and maximize long-term regenerative outcomes,
adequate flap release of the buccal and lingual flaps is required.
In our study, a comparison between buccal flap advancement alone and with lingual flap
release revealed the role of lingual flap advancement in preventing post-operative complication
during GBR procedure using TM for horizontal ridge augmentation.
No TM exposures were observed in the test group where lingual flap was released with buccal
flap advancement. On contrary, 83.3 % of cases in the control group where buccal flap was executed
alone, showed TM exposures. No infection or inflammation reported at the exposed sites. Although
early TM exposures were observed, it did not affect the regenerative outcomes and implants of proper
diameters were placed in all cases. There was no statistical difference in pain and swelling between
the two groups