Modified Periosteal Fenestration (MPF) Technique for Flap Advancement

Objectives: Tensionless flap adaptation is required for all surgical procedures. This may prove problematic with guided bone regeneration (GBR) procedures where extreme flap advancement is needed to gain tensionless primary closure. This case report explores the potential of a new flap design, the modified periosteal fenestration technique (MPF), in regards to the amount of advancement and the morbidities.

Methods:  A 63 year old non-smoking Caucasian man presented with missing #30 and recently extracted #31.  A comprehensive oral evaluation revealed that the patient had both vertical and horizontal ridge deformity (Seibert Class III). It was deemed necessary that ridge augmentation of the defect was needed prior to the placement of implants.  MPF was chosen as the flap design to facilitate the flap advancement to achieve tensionless primary closure.

Results: During the surgery, over 10 mm of advancement was gained through MPF. This allowed tensionless closure of the flap margins.   The proximity of the mental nerve was of concern, however the nerve trunk was not severed while using this technique and thus paresthesia was not reported by the patient. There was no premature exposure of the non-resorbable membrane which was removed at time of implant placement. The amount of post-operative swelling and pain appears to be less than the conventional periosteal fenestration technique.

Conclusions: While the scope of the study is limited, the preliminary findings may warrant further studies in the MPF technique. The modified periosteal fenestration technique, can achieve extreme flap advancement that is needed for tensionless flap closure required in GBR techniques.  It appears to have the benefits of decreased morbidity such as post-operative swelling and pain as well as decreased likelihood of paresthesia resulting from inadvertent severance of the mental nerve.