Fig. 5 Fig. 7 Fig. 6 is deficient 3.28 mm in bone width, and in site #10 the patient is deficient 1.91 mm in bone width. Note the labial bone concavities present in both sites (Figs.4 and 5-A and B). When I perform GBR, the goal is to convert the labial bone concavity into a labial bone convexity (Fig. 6). If this is achieved the bone width will increase significantly. Fig. 8 ᕤ The horizontal incision is a floating one with a 15 C blade. ᕥ Start apically on vertical releasing incisions. Once the MGJ is reached, bevel the flap 45°, and as you approach the tooth, finish with a hockey stick curve design (Fig. 9). ᕦ The anterior lingual releasing incision should be 4mm long. Use the tooth adjacent to the hori-zontal incision line (Fig. 7). ᕧ Retrace all incisions deep through the perios-teum with a 15 C blade. ᕨ With a ball scaler (SB2/3) trace deep through the incision lines. The vertical releasing incisions were placed at the distal of the first bicuspids (two teeth away from sites 7 and 10) (Fig. 8). Using the principles described above, the flap was reflected. The bone in sites 7 (Fig. 10-A) and 10 (Fig. 11-A) was exposed. Labial decortications (perforations through the cortical bone) were performed in the sites to stimulate bleeding into the graft mixture to be placed (Figs. 10-B and 11-B). What Flap Design Should be Used When Performing Guided Bone Regeneration? Dr. Urban states, "Flap design should account for the fact that primary tension-free closure will need to be achieved over an increased dimension after the bone graft has been applied to the defect.” The safety flap should be utilized. The rationale behind the flap design is to have enough soft tissue to accommodate the increased dimension of the grafted ridge.” 16 Safety flap requirements: 6, 16 ᕡ The safety flap is full thickness. ᕢ Design a safety (remote) flap at least two teeth away (Figs. 7 and 8). If there are any anticipated problems with flap closure, design the safety flap such that it is at least three teeth away from the edentulous area. ᕣ The horizontal incision should be mid-crestal in keratinized tissue. It is imperative to finish with keratinized tissue on the lingual. 34 Winter 2018 JAOS
Journal of the American Orthodontic Society Winter 2018: Page 34
