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ORIGINAL ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 29-32

Vascularized interpositional periosteal connective tissue flap in implant dentistry


1 Department of Oral and Maxillofacial Surgery, Oral and Maxillofacial Diseases Research Center, Mashhad, Iran
2 Department of Oral and Maxillofacial Pathology, Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran

Date of Web Publication19-Apr-2014

Correspondence Address:
Saeedeh Khajehahmadi
Department of Oral and Maxillofacial Pathology, Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, Vakilabad Boulevard, P.O. Box 91735 984, Mashhad
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-6781.130952

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   Abstract 

Background: Due to the morphologic alteration, that occur following tooth extraction, augmentation procedures are often necessary. In the upper jaw, submucosa of palate can be used for soft-tissue reconstruction in implant dentistry. Materials and Methods: Thirty eight VIP-CT flaps in 37 patients were used for small maxillary reconstruction. In 97.3% of events, unilateral VIP-CT flap for each patient was used. Complications occur in this study include of flap necrosis in one case (2.7%), palatal sloughing in twenty four cases (63%) and donor site deformity in one patient (2.7%) respectively. Results: Patients, that VIP-CT flap was used for preparation of the mouth before implant insertion or during and after dental fixture insertion to preventing esthetic or functional problems, were selected. Indications, extension of palatal incision, donor site morbidity in the form of mucosal sloughing as well as deformity were reported. Sloughing of mucosa was evaluated at 1st week and palate was checked for deformity at 2 month after operation. The flap survival or necrosis was recorded. Conclusion: VIP-CT flap is a reliable source of soft-tissue for replacement of mucosa in the maxilla for implant dentistry.

Keywords: Dental implant, palatal submucosa, socket preservation


How to cite this article:
Rahpeyma A, Khajehahmadi S. Vascularized interpositional periosteal connective tissue flap in implant dentistry. J Dent Implant 2014;4:29-32

How to cite this URL:
Rahpeyma A, Khajehahmadi S. Vascularized interpositional periosteal connective tissue flap in implant dentistry. J Dent Implant [serial online] 2014 [cited 2019 Aug 19];4:29-32. Available from: http://www.jdionline.org/text.asp?2014/4/1/29/130952


   Introduction Top


In implant dentistry, there are some situations that need for soft/hard tissue augmentation before, during or after dental implant insertion. In the anterior maxilla, inserted implants had the most esthetic demands. Vascularized interpositional periosteal connective tissue (VIP-CT) flap is a good choice in such situations. It can be used for coverage of bone graft and socket preservation before implant insertion. [1],[2] Increasing attached gingival, ridge expansion coverage and immediate implant insertion concomitant with VIP-CT flap can be used during dental implant insertion. [3],[4],[5] Filling black space between fabricated fixed prosthesis in maxillary central incisor region is another indication of this flap after implant insertion. [6]


   Materials and Methods Top


Patients, that VIP-CT flap was used for preparation of the mouth before implant insertion or during and after dental fixture insertion to preventing esthetic or functional problems, were selected. Indications, extension of palatal incision, donor site morbidity in the form of mucosal sloughing as well as deformity were reported. Sloughing of mucosa was evaluated at 1 st week and palate was checked for deformity at 2 month after operation. The flap survival or necrosis was recorded.


   Results Top


[Table 1] shows indications of VIP-CT flap in implant dentistry. Thirty eight VIP-CT flaps in 37 patients were used for small maxillary reconstruction. In 97.3% of events, unilateral VIP-CT flap for each patient was used. Only in one case bilateral VIP-CT flap was used. This flap was used in 55.2% of events for preparation of oral cavity before implant insertion for bone graft coverage and socket preservation. In 42.1% of cases simultaneous with implant insertion this flap was used in order to increasing the width of attached gingiva, ridge expansion coverage and primary closure in immediate implant insertion into the fresh extraction socket. Only in one patient (2.7%), this flap was used for improving esthetic appearance of an anterior maxillary fixed prosthesis fabricated previously on inserted dental implants [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5] nad [Figure 6].
Figure 1: Coverage of bone graft by vascularized interpositional periosteal connective tissue fl ap: (a) Anterior jaw region. (b) Posterior maxilla

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Figure 2: Socket preservation and vascularized interpositional periosteal connective tissue flap

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Figure 3: (a) Black space under existing fi xed prosthesis. (b) Vascularized interpositional periosteal connective tissue flap

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Figure 4: Increasing attached gingival: (a) Immediately after operation. The raw surface is vascularized interpositional periosteal connective tissue flap. (b) Secondary epithelization, 1 week after surgery. (c) 1st month follow-up visit

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Figure 5: Ridge expansion coverage in anterior maxillary region

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Figure 6: Immediate implant insertion into fresh extraction socket. (a) Bone substitute was used to fi ll the space between fixture body and socket walls. (b) Vascularized interpositional periosteal connective tissue fl ap covered the socket

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Table 1: Indications for VIP-CT flap in implant dentistry for 38 cases (37 patients)

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Complications occur in this study include of flap necrosis in one case (2.7%), palatal sloughing in twenty four cases (63%) and donor site deformity in one patient (2.7%) respectively [Figure 7].
Figure 7: Palatal sloughing after harvest of vascularized interpositional periosteal connective tissue fl ap. (a) In dentate patient. (b) In edentulous patient

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   Discussion Top


Submucosa of palate is rich in blood supply. It was used as roll flap (1998) and split palatal flaps (1999) for soft-tissue augmentation in implant dentistry. [7],[8] VIP-CT flap was introduced by Sclar in 2003 as anteriorly based pediculated tissue of palatal submucosa that composed of periosteum and connective tissue. Blood supply of this flap is random pattern and its pivot point in near incisive papilla. [9]

Due to the morphologic alteration that occurs following tooth extraction, augmentation procedures are often necessary. Simultaneous hard- and soft-tissue augmentation is possible by use of this flap concomitant with bone grafting include onlay or interpositional bone grafting. It protects underlying bone graft, nourishes it and simultaneously vertically augments the region. The result of this flap is beautiful prosthesis in esthetically critical area of mouth. In immediate implant insertion into fresh extraction sockets; in socket preservation, this flap, eliminates the need for membrane and reduces costs, whereas improves the histology of ridge crest [Figure 8]. It is especially useful for maxillary implants with none existing or minimal width of keratinized gingival. It is widely accepted while has not been established that keratinized gingival tissue around dental implants is more physiologic than alveolar mucosa to withstand masticatory forces. [10] Palatally incision, implant insertion, apically repositioning flap and VIP-CT flap as intermediate tissue is needed. In most cases, periosteal surface is against the bone graft and connective tissue is exposed to the oral cavity. This raw surface undergoes secondary epithelization and keratinized tissue cover it finally. [11] Learn about clinical view of secondary wound healing is necessary. Complications of this flap include palatal sloughing in 63% of events which is similar to the donor site morbidity in free connective tissue harvest from hard palate. [12] These sloughing heal in normal manner and result in normal looking palate 2 month after operation. Survival of this flap is high (97.2%), therefore it is a reliable method for reconstruction of small maxillary defects in implant dentistry.
Figure 8: Histology feature of vascularized interpositional periosteal connective tissue fl ap, 3 month after flap elevation. The tissue was harvested with soft-tissue punch before implant

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   Conclusion Top


VIP-CT flap is a reliable source of soft-tissue for replacement of mucosa in the maxilla for implant dentistry.


   Acknowledgments Top


This study was supported by a grant from the Vice Chancellor of Research of Mashhad University of Medical Sciences. The results presented in this work have been taken from thesis.

 
   References Top

1.Khoury F, Happe A. The palatal subepithelial connective tissue flap method for soft tissue management to cover maxillary defects: A clinical report. Int J Oral Maxillofac Implants 2000;15:415-8.  Back to cited text no. 1
    
2.Artzi Z, Tal H, Dayan D. Porous bovine bone mineral in healing of human extraction sockets. Part 1: Histomorphometric evaluations at 9 months. J Periodontol 2000;71:1015-23.  Back to cited text no. 2
    
3.Nemcovsky CE, Artzi Z. Split palatal flap. II. A surgical approach for maxillary implant uncovering in cases with reduced keratinized tissue: Technique and clinical results. Int J Periodontics Restorative Dent 1999;19:385-93.  Back to cited text no. 3
    
4.Nemcovsky CE, Moses O, Artzi Z, Gelernter I. Clinical coverage of dehiscence defects in immediate implant procedures: Three surgical modalities to achieve primary soft tissue closure. Int J Oral Maxillofac Implants 2000;15:843-52.  Back to cited text no. 4
    
5.Nemcovsky CE, Artzi Z, Moses O. Rotated split palatal flap for soft tissue primary coverage over extraction sites with immediate implant placement. Description of the surgical procedure and clinical results. J Periodontol 1999;70:926-34.  Back to cited text no. 5
    
6.Mathews DP. The pediculated connective tissue graft: A technique for improving unaesthetic implant restorations. Pract Proced Aesthet Dent 2002;14:719-24;726.  Back to cited text no. 6
[PUBMED]    
7.Veisman H. "The palatal roll". Soft tissue ridge augmentation using a subepithelial connective tissue pedicle graft. Oral Health 1998;88:47, 49-51;53.  Back to cited text no. 7
    
8.Nemcovsky CE, Serfaty V. Alveolar ridge preservation following extraction of maxillary anterior teeth. Report on 23 consecutive cases. J Periodontol 1996;67:390-5.  Back to cited text no. 8
    
9.Sclar A. The vascularized interpositional periosteal-connective tissue (VIP-CT) flap. In: Sclar A, editor. Soft Tissue and Esthetic Considerations in Implant Therapy. Chicago: Quintessence Publishing; 2003. p. 163.  Back to cited text no. 9
    
10.Buyukozdemir Askin S, Berker E, Akincibay H, Uysal S, Erman B, Tezcan I, et al. Necessity of keratinized tissues for dental implants: Immunological, and radiographic a clinical, study. Clin Implant Dent Relat Res 2013;doi: 10.1111/cid.12079. [Epub ahead of print].  Back to cited text no. 10
    
11.Kim CS, Jang YJ, Choi SH, Cho KS. Long-term results from soft and hard tissue augmentation by a modified vascularized interpositional periosteal-connective tissue technique in the maxillary anterior region. J Oral Maxillofac Surg 2012;70:484-91.  Back to cited text no. 11
    
12.Harris RJ. A comparison of two techniques for obtaining a connective tissue graft from the palate. Int J Periodontics Restorative Dent 1997;17:260-71.  Back to cited text no. 12
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
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