Volume 10, N o.

3 April 2018

The Journal of Implant & Advanced Clinical Dentistry

Rebuilding Buccal
Plate Deficiency
During Immediate
Implant Placement

The Bernotti
V-Y Flap
 The Journal of Implant & Advanced Clinical Dentistry

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 The Journal of Implant & Advanced Clinical Dentistry
Volume 10, No. 3 • A pril 2018

Table of Contents

6 A New Technique for Rebuilding

the Buccal Plate during Placement
of Immediate Dental Implants
in an Extraction Site with
Buccal Defects
Héctor N. Norero, Mauricio A. Ibanez

16 T he Bernotti V-Y Flap: An

Alternative to Manage Soft
Tissue Esthetic Issues
with Implants
Ana Luisa Bernotti, Gregori M. Kurtzman

2 • Vol. 10, No. 3 • April 2018

The Journal of Implant & Advanced Clinical Dentistry
Volume 10, No. 3 • A pril 2018

Table of Contents

28 Soft Tissue Augmentation to

Increase Width of Keratinized
Tissue Around Dental Implants
Using Tissue Fixation Screws:
A Novel Technique
for Graft Tissue Stabilization
Dr. Lank Mahesh, Dr. Nitika Poonia,
Dr. Vishal Gupta

34 The Waya Technique: A Novel

Approach Using a Palatal Flap of
Apical Repositioning for Primary
Tension-Free Closure in
Maxillary Bone Augmentation
Britto Falcón-Guerrero

The Journal of Implant & Advanced Clinical Dentistry • 3

 The Journal of Implant & Advanced Clinical Dentistry
Volume 10, No . 3 • April 2018

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4 • Vol. 10, No. 3 • April 2018

 The Journal of Implant & Advanced Clinical Dentistry
Founder, Co-Editor in Chief
Dan Holtzclaw, DDS, MS
Tara Aghaloo, DDS, MD
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Michael Apa, DDS
Alan M. Atlas, DMD
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Co-Editor in Chief
Leon Chen, DMD, MS, DICOI, DADIA
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Richard Hughes, DDS Georgios E. Romanos, DDS, PhD
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Gregori Kurtzman, DDS Frank Setzer, DDS
Burton Langer, DMD Maurizio Silvestri, DDS, MD
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Uwe Mohr, MDT Tiziano Testori, MD, DDS
Dwight Moss, DMD, MS Michael Tischler, DDS
Peter K. Moy, DMD Tolga Tozum, DDS, PhD
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Marcel Noujeim, DDS, MS Emil Verban, DDS
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George Priest, DMD Richard K. Yoon, DDS
Giulio Rasperini, DDS
The Journal of Implant & Advanced Clinical Dentistry • 5
Norero et al
A New Technique for Rebuilding the Buccal Plate
during Placement of Immediate Dental Implants
in an Extraction Site with Buccal Defects

Héctor N. Norero, DDS1 • Mauricio A. Ibanez , DDS2

Abstract

T
he final decision when placing a den-
tal implant in an extraction site must
be done looking at the integrity of the
socket walls. When the buccal plate is par-
tially or totally lost, the primary treatment
goal is to preserve the socket until it matures
for good implant stability and good esthetic
results. What this technique proposes is to
allow an immediate implant placement without
the problems, esthetic and functional issues of
the future final restoration. Platelet rich fibrin
mixed with allogeneic mineral bone is rich in
leucocytes and it is the best way to avoid com-
plications when placing immediate implants.
This L-PRF produces a dense and rich fibrin
matrix containing five of the most important
growth factors involved in bone and soft tissue
healing. This mix of autologous fibrin glue and
allogeneic mineral bone provides the stabili-
zation of the bone graft in that gap, improving
the primer stability of the implant in the extrac-
tion site. This report presents the step-by-step
technique to obtain a successful result in the
immediate implantation of the dental implant.

KEY WORDS: Dental implant, immediate dental implant, platelet rich fibrin, bone graft

1. Periodontist, Universidad de Chile. Private Practice, Santiago, Chile

2. Periodontist, Universidad Diego Portales. Private Practice, Santiago, Chile

6 • Vol. 10, No. 3 • April 2018


BACKGROUND
Several studies have shown that the results
obtained when placing implants in a fresh sock-
ets are greater than to preserve the site and delay
installation of the implant. This would cause greater
difficulty for the correct placement of the implant
with aesthetic consequences for the patient.1,2
In the last 10 years, the installation of dental
implants in fresh post-extraction sockets has
demonstrated that there are numerous factors
involved in the aesthetic success of a dental
implant and the maintenance of the parame-
ters that show us the stability of the biological
complex around the implant. The position of the
gingiva and stability of the bone level, the rela-
tionship of proximity to the neighboring teeth,
the loads of the opposing dentition to which the
prosthesis is subjected to, and position of the
implant- abutment interface.3,4 Within the most
challenging problems, it is difficult to determine
the thickness and the indemnity or not of the ves-
tibular bone plate.5 We must be careful with the
selection of the diameter of the implant in rela-
tion to the diameter of the socket where it is to
be inserted and how the gap fill will heal and
the bone plate when it is partially or totally lost.6
There have been numerous attempts to recon-
struct the vestibular plate,7 using a bone graft
from the tuberosity repairing the bone defect,
with the complications that arise from taking the
graft and then positioning it. Another way is to
keep part of the vestibular root without extract-
ing it, in order to keep the bone contour with the
implant more palatine. This is achieved only with
skill from the operator and not exempt of early
or late complications of the piece of root that
remains in the socket.8 The use of platelet rich
fibrin (L-PRF)9,10,11 to obtain a gel-like mixture
Norero et al
with the filling material used, and placed in the
gap left by the implant and the vestibular socket,
prior to placing the implant, allows one to create
a new buccal wall, and a wider surface that will
be in contact with the implant and will not put
pressure on the remaining vestibular plate. This
allows for very good stability of the implant and a
healing accelerated by the contribution of cyto-
kines and growth factors that come from the gel
installed in the gap of autologous origin.12,13,14
The way that we propose to protect the bone
plate and fill the gap is easy to perform does
not require specialized instruments, and is inex-
pensive. For the past four years, using this
technique we have seen positive results in all
aesthetic parameters where it has been used
with dental implants. In this paper, we will
show the technique step by step so that any
clinician in their daily work can reproduce it.
CLINICAL PROTOCOL
lP
 atients healthy or with controlled general
disease
lP atients with or without history of periodontal
disease with control of plaque less
than 20% of covered surfaces
lP atient is a candidate for immediate replace-
ment of tooth extraction by an implant
l Surgery without flap
lD ebridement of the epithelial insert
with blunt instrument
lE xtraction atraumatic as possible with
a periotome or luxator
l Checking the anatomy of the remaining socket15
l Preparing the bed that will receive the implant
lP rocess collected blood to obtain L-PRF
(3 tubes) for 12 minutes at 2700 rpm16
The Journal of Implant & Advanced Clinical Dentistry • 7
Norero et al
Figure 1: Post-extraction socket with final bur in position.
lR
 emove the supernatant from each tube
in a sterile 10ml syringe and preserve
lR
 emove from the tube the fibrin clot obtained
and particulate it, within a glass cup and inte-
grate with the bone filling, to be used in this
case Puros® ,mineral small cortical particles17
lP
 ositioning inside the prepared bed for the
installation of the implant, the last bur used
lB
 egin to fill with the fibrin gel that includes
bone filling, the space between the bur and
the internal wall of the gingival tissue, mold-
ing gently and compacting it apically
lS
 pace must be filled to the free edge
of the gingiva
8 • Vol. 10, No. 3 • April 2018
Figure 2: Filling the gap with L-PRF+Allograft gel form.
lA
 fter this, with the supernatant from each tube
collected, put some drops on the already stable
filling causing greater stiffness in the filling gap
lT  he implant is installed to its final sub osse-
ous position in the case of implants of
conical connection and platform shift
l If the insertion of the implant exceeds 25 Ncm2
proceed to install the final prosthetic abutment
and torque it, otherwise, it is left with a heal-
ing abutment to shape the emergence profile
lT  he temporary crown is made without
occlusal contact
lT  he osseointegration protocol is followed
according to the implant manufacturers
recommendation to go to the definitive
prosthesis phase
 Norero et al

Figure 3: Final reconstruction of socket buccal plate, ready Figure 4: Implant in position, showing the rebuilt buccal
to receive the implant plate.

PROSTETHIC PROTOCOL
lO
 nce the osseointegration time has been
completed, the provisional crown is removed
lT he final impression is made with reproduction
of the emergence profile
l The definitive prosthesis is made
lA djustment, aesthetic and occlusal tests
are performed
l The final restoration is screw in or cemented

CLINICAL CASE SAMPLE

lP
 atient chief complain to solve an old tooth frac-
ture (5 years of evolution) in tooth 1.1 (Photo 1)
lR
 adiographically (CBCT) shows a fracture of
the apical third with slight vestibular displace-
ment and ankylosis of the apical third (Photo 2)
lA
 CBCT is able to demonstrate the absence of
at least half of the vestibular plate of the socket

Figure 5: Implant with crown.

The Journal of Implant & Advanced Clinical Dentistry • 9

Norero et al

Photo 1: Pre-op view.

Photo 3: PRF clot.

Photo 4: Mixing with mineralized allogeneic bone.

Photo 2: Diagnostic CBCT.

Photo 5: L-PRF as
10 • Vol. 10, No. 3 • April 2018 membrane.
 Norero et al

Photo 6: Gel form of the mixed bone particles and L-PRF Photo 7: Introducing the gel prep in the vestibular defect.
membrane.

Photo 8: Final adaptation of the gel prep. Photo 9: Implant placement.

l It
was decided to make the extraction of lT
 wo of them was particulate and
1.1 tooth, the upper two-thirds and maintain the mixed with mineralize allogeneic
apical third, considering the difficulties of the bone small particles (Photo 4)
extraction of the apex and the possible bony lT
 he other two was processed to obtain
destruction by an apical external approach, 2 L-PRF membranes (Photo 5)
which would compromise the stability of the lF
 irst I proceed with a careful extraction
future implant of tooth 1.1
lB efore the surgery, 40 cc of patient venous lT
 he preparation of the surgical bed is located
blood is taken in 4 tubes red cap. The blood in a more palatal position of the socket
was centrifuged for 12 minutes and 2700 rpm lT
 he gap was filled with Sticky bone prior
l The result was 4 fibrin clot (Photo 3) to implant placement (Photos 6-7)

The Journal of Implant & Advanced Clinical Dentistry • 11

Norero et al

Photo 10: Implant in is final position, covering the graft Photo 11: Healing abutment in position.
with L-PRF membrane form.

Photo 12: View of the temporal crown at four month.

lT
 he implant was putting in the previous
preparation (Photos 8- 9)
lT
 he stability of the implant was less than
25 Ncm2, so it was left only with a healing
abutment (Photo 10)
lB
 esides of the healing abutment was placed
two L-PRF in membranes form, covering the
graft (Photo 11)
lT
 he crown of the extracted tooth was used as
temporary using adhesion to the neighboring
Photo 13: Control CBCT at 4 month post-opt.
teeth (Photo 12)

12 • Vol. 10, No. 3 • April 2018

 Norero et al

Photo 14: Emergency profile at four month after retrieval Photo 15: Probing the Titanium base for CAD-CAM
of the healing abutment. rehabilitation.

Photo 16: Try in of CAD-CAM Zi structure. Photo 17: Final CAD-CAM restoration.

lA
 t four month a CBCT was taken (Photo 13) CLINICAL EVALUATION
lA fter retrieval of the healing abutment lB
 oth bone and soft tissue healing performed
(Photo 14), we proceed to take an impres- without complications
sion coping the emergence profile and the lT
 he regenerated site healed well and was
dental laboratories did the stone model. evaluated after a 2 years at this time
lT his model was scanned optically and lA
 CBCT was taken at four months before
designed the crown in the software Cerec4.5 the final restoration was placed
lT he crown was printed and after that was lA
 formation of a vestibular wall with a bony fill-
cemented outside the mouth to obtain the ing of the socket with normal characteristics
final screw restoration (Photos 15, 16) lT
 he final crown was did by CAD-CAM
l The crown was screwed in position (Photo 17) Cerec® (Dentsply Sirona)

The Journal of Implant & Advanced Clinical Dentistry • 13

Norero et al
DISCUSSION
The increased use of dental implants in the last
20 years has brought to light the appearance
of bony defects produced by deficient bone at
the time of implant surgery, poor implant place-
ment or poor operator experience that have
underestimated the implant and lack of pre-
installation analysis. Bony defects increase gin-
gival irritation, poor healing with aesthetic and
functional consequences, which are very dif-
ficult to reverse once the implant has already
osseointegrated and rehabilitated.18 Immedi-
ate placement of implants after dental extrac-
tion represents many advantages for the patient
and the treating Dentist, like shorter appoint-
ments and faster healing of the soft tissues that
is enhanced by the use of the membranes of
L-PRF and the mixed with the bone fillers who
has an important roll in the hard tissue heal-
ing.19,20 Numerous publications have addressed
this issue in different ways to totally or partially
restore the defect with different success rates
and with high difficulty and reproducibility. But
the advantage of using a highly compact filler
and healing with autologous accelerators for
the support of the soft tissue is improving.21
Such techniques make the presence of the
contours of the osseous tissue more predict-
able.22 All of the above is relevant in areas of
high aesthetic demand especially in single
tooth replacements where the similarity of
nearby sites should be maintained or replicated.
The first open protocol shown by Chouk-
roun and Dohan to produce L-PRF, using cen-
trifugation speed 2700 rpm for 12 minutes,23 is
the best way to obtain a very resistant L-PRF
membrane, to use alone o mixed with same
mineral allogeneic graft. It is so important the
14 • Vol. 10, No. 3 • April 2018
selection of the biomaterial for fill the gap, it
must be, quick replace for natural bone and
maintaining the space between the vestibular
face of the implant and the soft tissue at least
for 3 month. In our experience in according
with the literature the mineralized bone, alloge-
neic small particles have the best results along
the life of the implant.24 The experience in this
type of technique of preservation or enhanc-
ing the vestibular wall partially or totally lost for
already four years indicates that the bone lev-
els are maintained or even improved allowing
the coronary advancement of the free edge of
the gingiva in up to two millimeters on average.
CONCLUSIONS
This technique leads us to think that with-
out incurring in major costs we have the
possibility of reconstructing the vestibu-
lar wall loss in areas of high esthetic
demand with predictable and reproduc-
ible results after the extraction of the tooth.
The use of the technique for 4 years in
more than 60 cases show that it clinically
behaves in a stable manner. Another advan-
tage observed is that the insertion torque
of the implant is increased at least by 20%
making it more feasible for the implant to
be loaded immediately in a greater number
of times. The following 3-year research will
give us insight into its long-term stability. l
Correspondence:
Dr. Héctor N. Norero,
Fax: 56-222338594
e-mail: norerohector@yahoo.com

Product Identification
Ankylos® Dental implant system and
Cerec® system(Dentsply Sirona, Delaware,
221 W.Philadelphia Street York,PA
17405-0872.E.E.U.U.).
Puros®mineralized bone allograft particulate
(Zimmer-Biomet dental, Palm Beach Gardens,
Florida 33410).
Disclosure
The authors report no conflicts of interest with
anything mentioned in this article.
Special thanks
Ms. Daniela Diaz, for the artwork.
Ms. Paulina Nunez. Dental technician
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Oral Med Oral Pathol Oral Radiol Endod. 2010
Mouhyi J, Dohan DM, Platelet-rich fibrin (PRF)
Sep; 110(3):275-8; author reply 278-80.
Second-generation platelet concentrate
14. Dong-Seok Sohn, Bingzhen Huang, Jin Kim,
.Part IV: clinical effects on tissue healing.
W. Eric Park, Charles C. Park, Utilization of
Oral Surg Oral Med Oran Pathol Oral Radiol
Autologous Concentrated Growth Factors
Endod.2006,101(3):e56-60
(CGF) Enriched Bone Graft Matrix (Sticky
 ollins, James Rudolph DDS*; Jiménez, Ely
24. C
Bone) and CGF-Enriched Fibrin Membrane
DDS†; Martínez, Carol DDS†; Polanco, Rubén
in Implant Dentistry. The Journal of Implant &
Tobias DDS‡; Hirata, Ronaldo DDS, MS, PhD§;
Advanced Clinical Dentistry, Volume 7, No . 10 •
Mousa, Ramy MS‖; Coelho, Paulo G. DDS,
December 2015; 11-30
MS, BS, MSMtE, PhD¶; Bonfante, Estevam
15. Elian N, Cho SC, Froum S, Smith RB, Tarnow A. DDS, MS, PhD#; Tovar, Nick PhD** .Clinical
DP. A simplified socket classification and and Histological Evaluation of Socket Grafting
repair technique. Pract Proced Aesthet Dent, Using Different Types of Bone Substitute in
2007,Mar;19(2):99-104. Adult Patients. Implant Dentistry:  August 2014
16. David M. Dohan, et al The impact of the - Volume 23 - Issue 4 - p 489–495.
centrifuge characteristics and centrifugation
protocols on the cells, growth factors and
fibrin architecture of a Leukocyte- and Platelet-
Rich Fibrin (L-PRF) clot and membrane.
Part 1: evaluation of the vibration shocks
of 4 models of table centrifuges for L-PRF.
POSEIDO.2014;2(2);129-39
The Journal of Implant & Advanced Clinical Dentistry • 15
Bernotti et al
The Bernotti V-Y Flap: An Alternative to
Manage Soft Tissue Esthetic Issues with Implants

Ana Luisa Bernotti, DDS1 • Gregori M. Kurtzman, DDS, MAGD, DICOI2

Abstract

M
ucosal issues such as inflammation,
swelling, fistulas, lack of sufficient kera-
tinized tissue, deficient buccal contour
volume, recession and thin biotype became treat-
ment challenges with implant and natural tooth
restorations, especially when less than ideal 3D
position implant placement has resulted. Man-
agement of the soft tissue with an inadequate flap
incision may complicate surgical results instead
of improving the clinical situation, leading to api-
cal mucosal recession and the resulting aesthetic
complications that may ensue. This may lead treat-
ment toward explantation of the implant, grafting
and new implant placement to correct the clinical
issues that warranted correction treatment. The
“Bernotti V-Y Flap” eliminates the complications
reported with other approaches to correct these
clinical issues. It is a predictable minimal coro-
nally advanced flap for root coverage when iso-
lated recession is present and biotype mucosal
improvement is sought. The Bernotti V-Y Flap may
be combined with or without connective tissue
grafting, PRF membranes or decellularized human
dermal tissue (freeze-dried or dehydrated allograft
tissue) at natural tooth or implants sites. This tech-
nique eliminates the need for vertical incisions that
could compromise the blood supply and the mar-
ginal surrounding bone, preserving the papillae.
Additionally, the technique allows tissue prosthetic
guidance for the maintenance and improvement
of the vestibular aesthetic area of the site being
treated. A case describing soft tissue biotype and
aesthetic improvement of a malpositioned implant
that had been previously restored with the Ber-
notti V-Y flap will be discussed as an example
what can be accomplished with this technique.

KEY WORDS: Dental implants, mucogingival graft, soft tissue defect

1. Private practice, Caracas, Venezuela

2. Private practice, Silver Spring, Maryland, USA

16 • Vol. 10, No. 3 • April 2018


Figure 1: A “V” incision is made with the scalpel apical
to the mucosal recession, extended to the mucogingival
junction while sparing the papilla by 4mm on each side.
INTRODUCTION
Mucosal issues such as inflammation, swelling,
fistulas, lack of sufficient keratinized tissue, defi-
cient buccal contour volume, recession and thin
biotype became treatment challenges with implant
and natural tooth restorations, especially when
less than ideal 3D position implant placement has
resulted. Management of the soft tissue with an
inadequate flap incision may complicate surgi-
cal results instead of improving the clinical situa-
tion, leading to apical mucosal recession and the
resulting aesthetic complications that may ensue.
This may lead treatment toward explantation of
the implant, grafting and new implant placement
to correct the clinical issues that warranted cor-
rection treatment. The “Bernotti V-Y Flap” elimi-
nates the complications reported with other
approaches to correct these clinical issues. It is
a predictable minimal coronally advanced flap for
root coverage when isolated recession is present
and biotype mucosal improvement is sought. The
Bernotti et al
Figure 2: Total Thickness flap is elevated toward the
coronal and scaling and topic antibiotic application is used
to decontaminate the exposed implant surface, which is
followed by a water rinse.
Bernotti V-Y Flap may be combined with or with-
out connective tissue grafting, PRF membranes
or decellularized human dermal tissue (freeze-
dried or dehydrated allograft tissue) at natural
tooth or implants sites. This technique eliminates
the need for vertical incisions that could compro-
mise the blood supply and the marginal surround-
ing bone, preserving the papillae. Additionally,
the technique allows tissue prosthetic guidance
for the maintenance and improvement of the ves-
tibular aesthetic area of the site being treated.
A case describing soft tissue biotype and aes-
thetic improvement of a malpositioned implant
that had been previously restored with the Ber-
notti V-Y flap will be discussed as an example
what can be accomplished with this technique.
THE BERNOTTI V-Y FLAP
Isolated mucosal recession Miller Class I reces-
sion can be challenging to treat with predictable
results, especially in the aesthetic zone. Periodon-
The Journal of Implant & Advanced Clinical Dentistry • 17
Bernotti et al

Figure 3: The connective tissue graft taken from tuberosity, which has the epithelial layer removed is placed under the flap
and suture to the interior of the flap, using an interrupted suture technique.

Figure 4: The flap is repositioned over the underlying connective tissue graft.

18 • Vol. 10, No. 3 • April 2018

 Bernotti et al

Figure 5: Tissue above the “V” flap is approximated and sutured using horizontal mattress sutures utilizing 6-0 monofilament
Polypropylene.

Figure 6: The technique derives its name from the “V” incision initially placed (left) and the resulting “Y” closure (right) to
correct the single tooth recession.

The Journal of Implant & Advanced Clinical Dentistry • 19

Bernotti et al

Figure 7: Resulting esthetics presents with a lateral incisor

that is longer then the adjacent teeth as the patient’s chief
complaint.

tal Plastic Surgery (PPS), was first suggested

by Miller (1988), defined as surgical proce-
dures performed to prevent or correct anatomi-
cal, development, traumatic or plaque disease,
induced defects of the gingiva, alveolar mucosa,
or bone. (The American Academy of Periodon-
tology 1996) Periodontal plastic surgery will
improve aesthetics, blending soft tissue color
and texture of the implant area with the adja-
cent soft tissues (De Sanctis & Zucchelli 2007),
while improving mucosa biotype to a thicker bio-
type and increasing keratinized mucosa band.
The Bernotti V-Y flap technique alone or Figure 8: Lateral view of the facial soft tissue
in combination with soft tissue grafting, PRF demonstrating thin tissue with a pin point perforation
3mm below the mucosal margin.
membranes or Decellularized Human Dermal
Tissue (freeze-dried or dehydrated allograft tis-
sue) at natural tooth or implant sites may be tion, inspired by Tarnow’s Semilunar Flap and
indicated when thin mucosa biotype and/or V-Y frenillectomy. It is a simple technique to treat
isolated gingival recessions are present, kera- isolated mucosal recession.  The technique con-
tinized tissue gain is needed and soft tissue sists of a pedicle flap, a ¨V ¨incision, without lose
aesthetic results require improvement. This of flap blood supply and suturing with a horizon-
technique allows protecting and maintaining tal mattress technique the vertical slope making
the stability of subjacent peri- implant bone.  a ¨Y¨ design while pushing or advancing the flap
The Bernotti V-Y flap periodontal plastic coronally to cover the mucosal recession with-
approach, is a coronally advanced flap modifica- out tension to the pedicle flap. The apical por-

20 • Vol. 10, No. 3 • April 2018

 Bernotti et al

Figure 10: The single piece restoration with porcelain

fused to the morse taper Bicon abutment.

Figure 9: Periapical radiograph as patient presented

demonstrating crestal defect present when implant had
been placed by prior practitioner with Bicon® implant
(3,5mm∅, 11mm long) positioned supracrestally. Vestibular
placement (Bicon® implants are always placed subcretally ).

tion of the flap rests on the bone following the Figure 11: The implant restoration was removed revealing
coronal advancement to cover the recession moderate inflammation at the mucosal cuff.
defect. The incision should end at least 4mm
from the papilla on each inter-proximal area to be
treated, but not extended to the tip of the papilla
(Figure 1). To prevent papilla loss, 2 mm must
be left attached on each side of the flap to pre-

The Journal of Implant & Advanced Clinical Dentistry • 21

Bernotti et al

Figure 12: Inflammation is present at the thin facial tissue

between the gingival margin and crestal bone creating
additional esthetic issues.

Figure 13: A diamond in a high-speed handpiece is

utilized to modify the emergence profile (umbrella
concept: space for the tissue) of the single piece restoration
and place the gingival emergence at its proper position
incisal-apically.

serve blood supply. Next, a mid-facial intrasulcu-

Figure 14: The modified single piece restoration has been
reinserted into the implant and the perforation in the facial
gingival tissue is noted.
lar incision is made, to allow coronal movement
of the marginal tissue to cover the concave zone
(sub-critical zone) and re-design the scalloped
mucosal margin according to the lip line (smile)
and the coronal zenith (Figure 2). Suturing of
the connective tissue graft internally collected
from the tuberosity to the “V” flap and the flap
to the attached tissue (Figures 3, 4). The vertical
slope is sutured with a horizontal mattress tech-
nique making a ¨Y¨ design (Figure 5). The flap is
advanced coronally without tension to the ped-
icle flap. The soft tissue margin is placed 2 mm
coronally from the CEJ of adjacent teeth. Hence

22 • Vol. 10, No. 3 • April 2018

 Bernotti et al

Figure 15: A connective tissue graft is harvested from the Figure 16: The keratinized layer of the donor graft is
edentulous tuberosity. removed with a scalpel blade 15c.

Figure 17: A “V” incision is made up to the mucogingival Figure 18: The full thickness flap is elevated in a coronal
junction with a scalpel blade 15c. A mid-facial intrasulcular direction and ultrasonics utilized to remove any calculus at
incision mesial to distal site preserving 2 mm of attached the coronal aspect of the implant.
papilla and all the way apically to the “v” incision.

The Journal of Implant & Advanced Clinical Dentistry • 23

Bernotti et al
Figure 19: Conditioning of the site with a gauze
impregnate with Tetracycline previous to place the donor
connective tissue graft over the site and under the “V” flap.
Figure 21: The site at 7 days at post-operative recall,
demonstrating mild inflammation and thicker tissue
at the site with no exposure of the underlying implant
restoration.
24 • Vol. 10, No. 3 • April 2018
Figure 20: The site is sutured closed using 6-0
monofilament horizontal mattress sutures from the
middle of both incisions mesial and distal making a vertical
slope of the “Y” pushing or moving coronally the “V” flap,
keeping the flap tension free.
Figure 22: Post-operative evaluation of the donor graft
site at the tuberosity at 7 days demonstrating ongoing
healing.
Figure 23: The surgical site at 3-month post -operatively
demonstrating mild peripheral inflammation as healing
progresses and thicker tissue over the site.

Figure 24: 1 year post-operative evaluation
demonstrating a lack of inflammation at the site, stability
of the repositioned gingival margin with improved
esthetics and thicker tissue on the facial.
the name is derived from the initial incision (“V”)
and the resulting tissue closure (“Y”) (Figure 6).
The Bernotti V-Y flap technique is recom-
mended when a keratinized mucosal band is
present, to cover mucosal recession on teeth
or implants sites. Factors such as gingival bio-
type and keratinized mucosa width must be con-
sidered, when performing the technique. When
insufficient keratinized tissue is not present, it
can be combined with soft tissue grafts, PRF
membranes, Decellularized Human Dermal Tis-
sue (freeze-dried or dehydrated allograft tissue).
 
CASE REPORT
A Caucasian 69-year-old female presented
in good general health was referred to evalu-
ate and treat an aesthetic issue in the maxillary
anterior. The patient complaint was an aes-
thetic concern, with the implant crown appear-
ing longer than the adjacent teeth (Figures 7,
8). Radiographically it was noted that a narrow
diameter Bicon® implant (3.5 mm x 11 mm)
with associated restoration was present at the
maxillary right lateral incisor (Figure 9). Dur-
Bernotti et al
Figure 25: Occlusal view at 1-year post-operative
demonstrating thicker tissue with a better facial volume.
ing oral examination it was noted a peri-implant
mucositis lesion present at the right maxillary
lateral incisor where a restored implant was
present. A 4mm buccal recession defect was
noted measured from the CEJ of adjacent teeth
to the zenith implant-crown restoration. A fis-
tula was identified with associated inflammation
at the mid-facial buccal tissue of the restored
implant. Suppuration from the fistula was noted.
The implant had been placed and restored 3
years earlier in an unfavorable 3D position.
Removal of the implant was not an option due to
financial considerations (socioeconomic status)
and the patient’s declination of that treatment
option. Additionally, explantation in the ante-
rior maxilla with the position of this particular
implant could lead to a severe bone lose further
complicating treatment. Following discussion
with the patient on what treatment options
were available it was decided to treat the site
to improve the tissue health (eliminate the fistula
and associated mucositis) and improve the aes-
thetics utilizing the Bernotti V-Y Flap technique
to allow a minimal invasive coronally reposi-
The Journal of Implant & Advanced Clinical Dentistry • 25
Bernotti et al
tioned flap combined with soft tissue grafting.
Prior to surgery full-mouth scaling and
root planning had been performed to improve
the general periodontal health of the tis-
sue. The patient was prescribed Amoxicil-
lin 500 mg 3 times a day for 7 days, starting
the day before surgery. Local anesthesia was
administered (2% Xylocaine w/ 1: 200 000
epinephrine) to the surgical areas. The crown-
abutment complex was removed from the
implant. As the abutment post is friction fit-
ted into the Morse taper connection in the
implant, the restoration was removed from
the implant with forceps (Figure 10). The
mucosa surrounding the implant connec-
tor demonstrated mucositis (Figures 11, 12).
The contour of the abutment/crown com-
plex was modified to create a concave sub-
gingival area that would lie below where the
intended new position of the gingival margin
would lie. This was performed using a round
diamond in a high-speed handpiece to cor-
rect the over-contoured convex shape of the
restoration and allow the soft tissue to posi-
tion more coronally (Figure 13). The “umbrella
concept” (Alberto Miselli, 2016) allows space
for the soft tissue of the single piece restora-
tion and place the gingival emergence at its
proper position incisal-apically. The restora-
tion was reinserted into the implant (Figure 14).
Incisions were made in the edentulous tuber-
osity with a #15c scalpel blade (SM: Swann
Morton, Devemed GmbH. Germany) to col-
lect donor connective tissue for the recession
defect. A partial thickness piece of tissue was
removed from the tuberosity (Figure 15). The
connective tissue graft from the tuberosity was
depithelized by scraping the exterior surface
26 • Vol. 10, No. 3 • April 2018
with the edge of the #15c blade (Figure 16).
A ¨V¨ incision was made with a #15c scal-
pel blade at the muco-gingival junction apical
to the recession defect, from proximally 4mm
from the mesial papilla, and 4 mm from the dis-
tal papilla, and extended to the mid-facial region
into the mucosa, converging with the first inci-
sion, making a “V” full thickness flap (Figure
17). The flap was elevated with a periosteal
elevator. (PPS 1100F Allen#2 17,3 cm/2mm
Devemed GmbH, Germany) elevating the tissue
coronally. An ultrasonic instrument (Satelec,
Aceton North America, Mt Laurel, NJ) was uti-
lized to clean the supracrestal portion of the
implant under the elevated flap (Figure 18).
The connective tissue donor graft procured
from the tuberosity was placed under the flap
and sutured to it, using an interrupted suture
technique utilizing 6-0 monofilament Polypro-
pylene Suture with a 3/8 Circle Reverse Cut-
ting needle (Dolphin Sutures, Bangalore, India),
covering the exposed implant connector and
restorative complex (Figure 19). The “V” flap
was closed. Tissue above the “V” flap was
then approximated and sutured using horizon-
tal mattress sutures utilizing 6-0 monofilament
Polypropylene sutures 6-0 (Figure 20). The
patient was dismissed and instructed to con-
tinue with the antibiotics and return in 1 week
to check site healing and 2 weeks post surgi-
cally for suture removal. Ibuprophen (400mg)
was recommended for pain management taken
twice daily for the first 3 days post surgically.
One week post surgery the site appeared
to have a small area of exposure of the under-
lying connective tissue was noted with slight
soft tissue inflammation as the recipient site
(Figure 21). The donor site demonstrated cov-

erage of the tuberosity by granulation tissue
and normal healing was evident (Figure 22).
The patient returned at 2 weeks and sutures
were removed and the patient instructed to con-
tinue using warm salt water rinses a few times
daily for the next week to aid in tissue healing.
Re-evaluation at 3 months’ post-surgery
demonstrated mild peripheral inflammation as
healing progresses and thicker tissue over the
site (Figure 23). At 1 year post-operative evalu-
ation the site demonstrated a lack of inflamma-
tion and stability of the repositioned gingival
margin with improved esthetics and thicker tis-
sue on the facial (Figure 24). The overall con-
tour of the facial had a more natural appearance
compared to the initial presentation (Figure 25).
CONCLUSION
The Periodontal plastic surgery coronally
advanced flap using the Bernotti V-Y flap tech-
nique is a minimally invasive surgery used as an
alternative for isolated tissue issues at implant
and tooth sites, without compromising the mar-
ginal soft tissue that could lead to create aes-
thetics concerns for the patient. The flap design
protects the interdental tissue without expos-
ing underlying bone in association with an
improved blood supply to the soft tissue in the
surgical site, with less potential crestal bone
loss. The technique allows coronal placement
of the mucosal tissue with no tensions favored
for the horizontal mattress suture made at the
vertical slope of the ¨Y¨ incision, to secure the
stability of the coronally flap position. Alone
or in combination with tissue graft, will reduce
mucosal recession, gain keratinized tissue
and obtain satisfactory aesthetic results main-
taining margin tissue in a predictable way. l
The Journal of Implant & Advanced Clinical Dentistry
Bernotti et al
Correspondence:
Dr. Gregori Kurtzman
dr_kurtzman@maryland-implants.com
Disclosure
The authors report no conflicts of interest with anything mentioned in this article.
References
1. Zuchelli. G; Mele. M; Mazzotti. C; Marzadori. M; Montebugnoli. L; De Sanctis. M.
(2009). Coronally Advanced Flap With and Without Vertical Releasing Incisions
for the Treatment of Multiple Gingival Recessions: A Comparative Controlled
Randomized Clinical Trial. Journal of Periodontology. Vol.80, No. 7, Pages 1083-
1094.
2. 
Cordaro. L; Mirisola. V; Torsello. F. (2012). Split-Mouth Comparison of a
Coronally Advanced Flap With or Without Enamel Matrix Derivative for Coverage
of Multiple Gingival Recession Defects: 6- and 24-month Follow-up. The
International Journal of Periodontics & Restorative Dentistry, Volume 32, No 1,
Pages 10-19.
3. Sunitha. V; Ramakrishnan. T; Sunil. S; Emmadi. Pamela. (2008) Soft Tissue
Preservation And Crestal Bone Loss Around Single-Tooth Implants. MD Journal
of Oral Implantology .Vol. XXXIV. No. Four. Pages 223-229.
4. Kumar. A;  Surendra. S. (2013) A new classification system for gingival and
palatal recession. J Indian Soc Periodontol. Vol. 17. Pages 175-181.
5. Tarnow DP, Magner AW, Fletcher P. (1992) The effect of the distance from
the contact point to the crest of the bone on the presence or absence of the
interproximal dental papilla. J Periodontol. Vol. 63. Pages 995–996.
6. Salama H, Salama MA, Garber D, Adar P. (1998) The interproximal height of
bone—a guide post to predictable esthetic strategies and soft tissue contours
in anterior tooth replacement. Pract Periodont Aesthet Dent. Vol. 10. Pages
1131–1141.
7. Langer B, Langer L. (1990) The overlapped flap: a surgical modification for implant
fixture installation. Int J Periodontics Restorative Dent. Vol.10. Pages:209–215.
8. M
 iselli A. (2015). The “Umbrella Concept”. Unpublished article.
9. Miller PD Jr. (1987). Root Coverage with free gingival graft. Factors associated
with incomplete Coverage. J.Periodontol. Pages 674-681.
10. Raetzke PB.(1985) Covering localized areas of root exposure employing the
“Envelope” Technique. J. Periodontol. Pages 39 – 402.
• 27
Mahesh et al
Soft Tissue Augmentation to Increase Width
of Keratinized Tissue Around Dental Implants
Using Tissue Fixation Screws: A Novel Technique
for Graft Tissue Stabilization

Dr. Lank Mahesh1 • Dr. Nitika Poonia1 • Dr. Vishal Gupta1

Abstract

P
resence of adequate width of attached
gingiva for longevity of implants has long
been debated upon. The implant-mucosa
interface differs from the interface between
the mucosa and natural teeth, and these differ-
ences are important to the understanding of the
susceptibility of implants to infection. Few stud-
ies have examined the relationship between the
width of keratinized mucosa and the health of
peri-implant tissues. The results of these stud-
ies are contradictory. Further studies are there-
fore required to clarify the role of the width of the
keratinized mucosa around dental implants and
their overall soft and hard tissue health. Most reli-
able method for increasing WKG is autogenous
free gingival graft. However the stability of FGG
on the recipient site is of paramount importance
for the uptake of graft. Traditional methods have
described the use of sutures for achieving sta-
bility of graft. Through this case report a suture-
less technique is described where we achieve
stability of FGG with help of soft tissue screws.

KEY WORDS: Mucogingival grafting, free gingival graft, width of keratinized gingiva, soft tissue screws

1. Dental Practice, India

28 • Vol. 10, No. 3 • April 2018


Figure 1: Pre-surgical photo demonstrating inadequate
keratinized gingival tissue at recipient site.
INTRODUCTION
Although Lang and Löe1 concluded that 2 mm
of keratinized tissue were necessary to main-
tain periodontal health, this reported figure
was refuted by Kennedy et al.2 The impor-
tance of the amount of keratinized tissue
around dental implants is still controversial.
Experienced clinicians taking long term fol-
low ups of their cases have never undermined
the importance and role of attached gingiva
in maintaining longevity of results in implan-
tology. A study on monkeys and humans
demonstrated dental implants without kera-
Mahesh et al
Figure 2: Tacking kit.
tinized mucosa demonstrated significantly
more recession and slightly more attachment
loss than the other implants.3 The results sug-
gested that the absence of keratinized mucosa
around dental endosseous implants might
increase the susceptibility of the peri-implant
region to plaque-induced tissue destruction.
Various modalities exist to increase the
width of keratinized gingiva around implants
and to improve quality of soft tissue. Some
of these techniques are apically positioned
flap, v estibuloplasty, a llogeneic s oft t issue
graft and autogenous soft tissue grafting.4
The soft tissue dimensions surrounding den-
tal implants can further be improved by using
mini-flaps, u sing s pecific in cision te chniques
at the time of abutment connection (ie. U
shaped incision, T shaped incision, modified
Palacci technique and split finger t echnique).
No soft tissue is removed in these modalities
instead soft tissue is pulled in required direc-
tions which is usually buccal or interdental.
The Journal of Implant & Advanced Clinical Dentistry • 29
Mahesh et al
Figure 3: Partial thickness preparation of recipient site and
fixation of mucogingival tissue with screw.
Based on past scientific evidences, autog-
enous FGG were proven to be effective and
predictable in both animal models and humans
in increasing the width of attached gingiva
with high success rate. Traditionally FGG is har-
vested from palatal site of the patient. Ideally
anterior and premolar sites are chosen keep-
ing incision 2mm away from free gingival mar-
gin. Adipose and gland tissue on the graft are
removed using scraping motion. After the donor
tissue is shaped suiting the recipient site, tissue
is fixed with periosteal sutures and sling sutures.5
In the view of the authors, one of the most diffi-
cult aspects of a FGG and reason for its failure
comes from inadequate fixation of tissue to the
underlying bed. To overcome this authors have
used soft tissue screws which resulted in immedi-
ate stabilization of soft tissue graft to underlying
connective tissue and resulted in faster healing.
30 • Vol. 10, No. 3 • April 2018
Figure 4: Additional fixation of mucogingival tissues with
screws.
CASE REPORT
A 54 year female patient reported to the den-
tal office for replacement of her posterior miss-
ing teeth desiring dental implants, the patient
had no relevant medical history. On examina-
tion she had teeth 45,46, 47 (FDI tooth num-
bering system) missing with adequate ridge
width and height (Fig 1) as was observed on
the panoramic radiograph. The mesiodis-
tal width of the edentulous span was approxi-
mately 20 mm. Therefore, it was decided to
place three implant fixtures to support a por-
celain fused to meatal bridge. The implants
(Bioner, Barcelona) placed were 4 x 11.5mm
in regions on 45 and 46 and an implant of
5 x 11.5mm at site 47. The implants were
placed in a two staged (submerged proto-
col) following manufacturer’s instructions.
Following an uneventful healing period the
 Mahesh et al

Figure 6: Screw being used to fixate the free gingival graft

to the recipient site.

Figure 5: Harvesting of free gingival graft.

Figure 7: Additional screws being used to fixate the free

gingival graft to the recipient site.

The Journal of Implant & Advanced Clinical Dentistry • 31

Mahesh et al
Figure 8: Well healed free gingival graft at recipient site
creates a wider zone of keratinized gingival tissue around
the dental implants.
patient was recalled and on examination the
tissue thickness around the implant area was
observed as deficient. A soft tissue augmen-
tation procedure with a free gingival graft har-
vested from the palate fixed with soft tissue
screws (Fig 2) was planned along with heal-
ing collar placement on the implants. On the
day of surgery an incision was placed at the
mucogingival junction adjacent to the implants
and a partial thickness flap was elevated
and fixed with the soft tissue anchor screws
32 • Vol. 10, No. 3 • April 2018
Figure 9: Stable graft tissue seen at 12 months healing.
(Figs 3, 4). A free gingival graft (FGG) was
harvested from palate (Fig 5) and fixated with
the screws at the recipient site (Figs 6, 7). No
sutures were used to secure the FGG. After
healing (Fig 8), open tray impressions were
recorded. A screw retained prosthesis was
later delivered. Twelve month recall demon-
strated stable peri- implant tissues (Fig 9).
DISCUSSION
The role of stable peri-implant tissue for predict-
able long term functional and esthetic outcomes
of dental implants is an evidence based reality.
This case report supports the view that narrow
zones of keratinized gingiva are less resistant
to insult along the implant-mucosa interface.
When inflammation is present, its apical pro-
liferation may occur more rapidly compared to
those sites with wider zones of keratinized gin-

giva that have an epithelial seal. Wider zones of
keratinized gingiva may offer more resistance
to the forces of mastication and frictional con-
tact that occur during oral hygiene procedures.6
Thus, a lack of keratinized gingiva may create
an environment that is less amenable to oral
cleansing and more susceptible to irritation and
discomfort during such routine procedures.7
Sites with less keratinized tissue exhibit higher
amount of peri implant recession.8 Different
remodeling processes in keratinized and non-
keratinized tissues or in the underlying bone
over time, but especially during the initial heal-
ing phase and the first 12 months after pros-
thesis delivery, could explain these findings.9
CONCLUSION
In this Case Report, a free gingival graft was
used for augmentation. One disadvantages of
using FGG is difficulty of fixation to underly-
ing tissues. Hence, in this Case Report, fixa-
tion screws were used to secure the graft
in lieu of sutures. Using this technique, the
FGG healed uneventfully and remained sta-
ble after 12 months of follow up. The tech-
nique of soft tissue graft fixation with screws
offers an alternate to graft fixation with
sutures, however more randomized clinical tri-
als are needed to confirm this technique. l
Correspondence:
Dr. Lanka Mahesh
drlanka.mahesh@gmail.com
The Journal of Implant & Advanced Clinical Dentistry
Mahesh et al
Disclosure
The authors report no conflicts of interest with anything in this article.
References
1. L
 ang NP, Löe H. The relationship between the width of keratinized gingiva
And gingival Health. J Periodontol 1972; 43: 623–627.
2. K
 ennedy JE, Bird WC, Palcanis KG, Dorfman HS. A longitudinal evaluation of
Varying widths of attached gingiva. J Clin Periodontol 1985; 12:667–675.
3. W
 arrer K, Buser D, Lang NP, Karring T. Plaque-induced peri-implantitis in the
Presence or absence of keratinized mucosa. An experimental study in
monkeys. Clin Oral Implants Res 1995; 6:131–138.
4. Y
 an JJ,Alex Yi-min.Comparison of acellular dermal graft and palatal autograft
in the reconstruction of keratinized gingiva around dental implants: A case
report. Int J Periodontics Restorative Dent 2006;26:287-292
5.Hall WB, Lundergan WP. Free gingival grafts. Current indications and
techniques.Dent Clin North Am 1993; 37:227–242.
6.Alpert, A. (1994). A rationale for attached gingiva at the soft-tissue/implant
interface: esthetic and Functional dictates. Compendium of Continuing
Education in Dentistry 15:356, 358, 360-2 passim; Quiz 368.
7. |Horning GM, Mullen MP. Peri-implant free gingival grafts: Rationale and
technique. Compend Contin Educ Dent 1990; 11: 604–610.
8. Q
 uarrymen, M., De Soete, M. & van Steenberghe, D. (2002) Infectious risks for
oral implants: a review Of the literature. Clinical Oral Implants Research
13: 1–19.
9. B
 engazi, F., Wennstrom, J.L, & Lekholm, U. (1996) Recession of the soft
tissue margin at oral implants. A 2-year longitudinal prospective study. Clin Oral
• 33
Falcón-Guerrero
The Waya Technique: A Novel Approach Using a
Palatal Flap of Apical Repositioning for Primary
Tension-Free Closure in Maxillary Bone Augmentation

Britto Falcón-Guerrero, DDS, MDS, PhD1

Abstract

T
he success of the processes of horizon-
tal bone augmentation requires that the
procedure has a tension-free closure.
The greatest challenge in these regenerative
techniques is to establish a flap design that
covers an increased dimension after the bone
graft had been applied to the defect; for this
objective there are frequently using alterna-
tives, but they cause loss of vestibular depth
and keratinized mucosa, that cause functional
and aesthetic discomfort. This preliminary report
describes a new surgical technique that uses
a palatal flap of apical reposition (Waya Tech-
nique) for primary tension-free closure in max-
illae bone augmentation that eliminates the
secondary effects of traditional techniques,
being a new alternative to take into account
in the procedures regenerative of the maxilla.

KEY WORDS: Mucogingival graft, maxilla, bone graft, dental implants

1. Private Practice. Tacna, Perú

34 • Vol. 10, No. 3 • April 2018

 Falcón-Guerrero

Figure 1a: Preoperative panoramic radiograph and cone

beam computed tomography scan showing inadequate
alveolar ridge width for implant placement.

INTRODUCTION
Defects of the alveolar ridge represent seri-
ous problems when planning implants, fixed or
removable prostheses.1 The presence of alveo- Figure 1b: Preoperative panoramic radiograph and cone
lar ridge defects due to bone resorption has led beam computed tomography scan showing inadequate
to the development of many bone augmenta- alveolar ridge width for implant placement.

tion procedures with the intention of improving

the quantity and quality of the bone to achieve a
predictable dental implant treatment.2 There are
several surgical techniques to increase alveo-
lar crests with reduced thickness that can be
classified as: 1) guided bone regeneration; 2)
bone block grafts; 3) ridge split and; 4) distrac-
tion osteogenesis. Each of these techniques
should always be accompanied by vascularized
flaps.3 These reconstructive efforts are limited
in the efficacy due to inadequate flap coverage
and vascular perfusion. Procedures to prevent
the collapse of the alveolar ridge are highly tech-
nique sensitive and require different surgical
designs depending upon the size of the defect.4
Primary closure results in decreased discom-
fort and faster healing, Failure to attain tension- Figure 1c: Preoperative panoramic radiograph and cone
less closure may result in a soft tissue dehiscence beam computed tomography scan showing inadequate
along the incision line that can cause a poor alveolar ridge width for implant placement.
outcome and/or postoperative complications.5

The Journal of Implant & Advanced Clinical Dentistry • 35

Falcón-Guerrero

Figure 2: Preoperative situation with a low insertion of the

lateral frenum.

Figure 4: Partial-thickness flap from the palatal area to the

alveolar crest.

The flap design must serve primary tension-

free closure would need to be achieved over an
increased dimension after the bone graft had
been applied to the defect. The key to achieving
wound closure is not only the clinician’s ability
to obtain tension-free release flap but also good
soft tissue quality and quantity. In an attempt to
Figure 3: Incisions in the palate, covering 6 mm of this achieve wound closure and hence graft stabil-
area. ity, the buccal mucosa is often broadly released,
and this often results in a severe apical translo-
cation of the mucogingival line, loss of vestibule,

36 • Vol. 10, No. 3 • April 2018

 Falcón-Guerrero

Figure 5a: Passive elevation of full-thickness flap to

expose the atrophic alveolar ridge.

and keratinized mucosa, even limiting the mobil-

ity of the lip. When the vestibule becomes shal-
low, it often leads to an esthetic challenge as well
as a phonetics problem. Moreover, research has
shown that areas with minimal keratinized mucosa
often have a higher peri-implant plaque accumu-
lation, inflammation, and attachment loss.6,7,8,9,10
One of the basic principles of surgery is
flap design and simplicity should be a key
goal with unnecessary complexity avoided.5,11
Taking into account these antecedents where
some unwanted effects of the coronally advanced
flap are seen, the aim is to present a preliminary Figure 5b: Passive elevation of full-thickness flap to
report of a new approach with a palatal flap of expose the atrophic alveolar ridge.
apical reposition (Waya Technique), to attain pas-
sive coverage of the wound and maintain a pre- radiographs and study models. Then a computed
dictable flap closure during the entire healing tomographic scan evaluation was accomplished
period, seeking to demonstrate the simplicity, to plan implant surgery. After the radiographic
predictability and simplicity of this new proposal. study it was determined to install two implants in
the canine and an upper premolar area and the
CASE PRESENTATION tomographic study a substantial horizontal bone
A 61-year-old woman with a history of con- defect was apparent (figs 1a,1b and 1c). Clini-
trolled diabetes mellitus presented to the office cally, this area presented a low insertion of the
to rehabilitate the maxilla with an overdenture on lateral frenum, which suggested a plan of coro-
implants. At the initial visit, the patient underwent nal repositioning flap to avoid a tear of the suture
clinical examination with periapical and panoramic (fig 2). Anatomic issues in this area also included

The Journal of Implant & Advanced Clinical Dentistry • 37

Falcón-Guerrero
Figure 6a: Ridge split procedure.
a shallow vestibule, so it was proposed to use a
new technique with a palatal flap of apical reposi-
tioning to avoid problems and achieve a suture by
tension-free primary closure. The treatment plan
consisted of two immediate implant placements
in conjunction with ridge split and guide bone
regeneration. The patient did not accept any
treatment with bone grafts, nor maxillary sinus lift.
The patient received through explanations of the
process and signed a written informed consent
form prior to being start the surgery. The patient
received antibiotic prophylaxis beginning prior to
38 • Vol. 10, No. 3 • April 2018
Figure 6b: Ridge split procedure.
surgery (2 g amoxicillin 1 hour prior to surgery).
After rinsing with a 0.12% chlorhexidine-digluco-
nate solution and application of local anesthesia in
the zone of surgery, a vertical incision mesial and
distal on the buccal zone was performed with a
surgery blade 15-C. These incisions were pro-
jected to the palatal area, covering 6 millimeters
of this area (this will compensate the projection
of the flap to cover the regenerated area) and
achieve tension free suture (fig 3). First, we raised
a partial-thickness flap from the palatal area to the
alveolar crest (leaving only connective tissue on

Figure 7: Passive suture of flap without modifying the
muco-gingival junction.
the palatal side), being careful prevent flap perfo-
ration (fig 4). Secondly, from the crest to the buc-
cal side, a full-thickness mucoperiosteal flap was
elevated to expose the entire all the bone surfaces
to make the ridge split and, make the regenera-
tion (figs 5a and 5b). The osteotomies were per-
formed directly on the bone to divide the crest,
the division is made with chisels and two implants
are installed to replace the canine and the sec-
ond right upper premolar, the bone regeneration is
made with particulate bone and barrier membrane,
Falcón-Guerrero
and then replenish the flap (figs 6a and 6b). The
mattress and interrupted suture are made with 4-0
chromic catgut and acid polyglycolic 5-0, achiev-
ing a totally passive and tension-free suture of
the entire operated area. Without presenting any
change or alteration of the vestibule or the muco-
gingival junction, there is freedom of mobility of the
lip and an anti-aesthetic situation not seen, achiev-
ing the comfort of the patient from the immediate
postoperative period. On the palatal side there is
a zone of exposed connective tissue that regen-
erates by second intention (fig 7). Following sur-
gery, patient was instructed to rinse with 0.12%
chlorhexidine-digluconate two times daily for at
least 3 weeks. To reduce swelling, naproxen sodic
550 mg was prescribed. A follow-up exam per-
formed at 5 months, observing good stability
and healing of all the flaps (figs 8a and fig 8b).
DISCUSSION
Management of horizontal alveolar ridge defects
has greatly evolved over the last few years, allow-
ing for implant placement under predictable condi-
tions.1 One of the key factors in the final outcome
is the maintenance of primary closure of the flaps
with tension-free for the entire healing period.
Greenstein et al. concluded that the tension-free
primary closure is attainable so long as the flap
is advanced.5 Therefore, the flap design will be
directed at the primary tension-free closure after
the bone grafting procedure despite the increased
size of the ridge.12 Flap advancement in the pos-
terior maxilla is a relatively safe procedure that
can be accomplished with minimal complications,
but in large displacements you must have exten-
sive knowledge of the anatomy to avoid damag-
ing vessels and nerves that run through this area.5
Various conventional technical approaches
The Journal of Implant & Advanced Clinical Dentistry • 39
Falcón-Guerrero
Figure 8a: Healing at 12 days.
are available to provide coverage of regenera-
tion procedures. When there is insufficient tis-
sue to cover the surgical area, studies suggest
cutting deeply in the muscle layer, entering again
in the first incision, or performing a new perios-
teal release parallel to the first and with the same
modalities to achieve elasticity of the flap.13 In
extreme cases, the internal preparation of the flap
under the periosteum can be carried out anteri-
orly close to the lip below the orbicularis muscle
without damaging its fibers. With this flap, coro-
nal manipulation is called the “suborbicularis
preparation”14 and requires suturing the flap in
two layers to avoid tearing by the tension.12 A
flap that is too small is difficult to manage and
is often responsible for early membrane or graft
exposure that leads to poor clinical outcomes.14
These approaches are effective but have
some limitations: deep linear cuts in the muscle
layers are performed without a direct visual con-
trol and can interrupt blood vessels and nerve
fibers of variable importance, increasing the
incidence of intraoperative and postoperative
complications (eg, immediate or delayed bleed-
ing, hematoma, edema, neurological injuries).15
Urban et al. proposed four clinical condi-
tions when considering tension-free primary
40 • Vol. 10, No. 3 • April 2018
Figure 8b: Healing at 5 months.
closure: 1) shallow vestibule with healthy perios-
teum; 2) deep vestibule with healthy periosteum;
3) shallow vestibule with scarred periosteum,
and; 4) deep vestibule with scarred periosteum.
Tension-free closure allows clinicians to achieve
more predictable vertical bone gain. But there is
always a change of soft tissue shift after closure,
often resulting in a severe apical translocation of
the muco-gingival junction and loss of the ves-
tibule and keratinized mucosa. This may lead to
esthetic and phonetic problems as well as higher
peri-implant plaque accumulation, inflammation,
and attachment loss.14 Considering the thick-
ness of the gingival and palatal epithelium that is
0.3 mm - 0.8 mm and sub-epithelial tissue width
that varies from 1.25 mm to 3 mm (together,
having a thickness ranging from 2.5 mm to 3.7
mm, with a mean of 2.8 mm),16,17 that provides
a good amount of tissue that is used to achieve
the extension of a palatal flap with apical repo-
sitioning to help cover the regeneration zone,
without any tension when repositioning the flap.
The case report in this article demonstrates a
simple approach (Waya technique) that allowed
for improved guidance to achieve a flap that
allows covering in a more predictable way to
the operated area, achieving a total tension-

free closure that remains stable throughout the
regeneration time and avoiding the undesired
results of traditional techniques. Advantages
of the Waya technique include the follow-
ing: 1) there is no risk of producing neural or
blood vessel damage because it is not neces-
sary to go deep into the vestibule, reducing the
possibility of hematoma, edema and inflamma-
tion; 2) the muco-gingival junction and the bot-
tom of the vestibule are conserved, avoiding the
limitation of lip movement, phonetic problems
and the patient’s anti-aesthetic appearance;
3) the keratinized gingiva is preserved, which
avoids plaque retention problems, attachment
loss, peri-implant plaque accumulation and; 4)
allows greater patient comfort from the immedi-
ate postoperative period. It can become a viable
alternative that can be well accepted within the pro-
tocols of regenerative treatments in Implantology.
CONCLUSION
This preliminary report describes a new surgical
technique that uses a palatal flap of apical repo-
sitioning (Waya technique) for primary tension-
free closure in maxillary bone augmentation that
eliminates the secondary effects of traditional
techniques. This technique shows satisfactory
clinical results, both for the surgical procedure
and for the patient, being a new alternative to take
into account in the regenerative procedures of
the maxilla. In contrast, it is a delicate procedure
and if do not have much practice you can lacer-
ate the flap, so it demands more execution time. l
Correspondence:
Dr. Britto Falcón-Guerrero
artdent2000@hotmail.com
The Journal of Implant & Advanced Clinical Dentistry
Falcón-Guerrero
Disclosure
The authors report no conflicts of interest with anything in this article.
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• 41