Comparison of Double-Flap Incision to

Periosteal Releasing Incision for Flap Advancement:

A Prospective Clinical Trial
Yumi Ogata, DDS, MS1/Terrence J. Griffin, DMD2/Alexander C. Ko, DMD3/Yong Hur, DDS, DMD, MS4

Purpose: The aim of this study was to evaluate the efficacy and morbidity of two periodontal releasing incision
techniques in vertical ridge augmentation. Materials and Methods: Twenty-three vertical and horizontal
defects (Seibert Class III) were selected to compare the double-flap incision (DFI) to the conventional periosteal
releasing incision (PRI). An incision technique was randomly assigned for flap advancement. The amount of flap
advancement, the incidence of postsurgical complications, and the level of patient discomfort were compared.
Flap advancement was measured with a UNC-15 probe as the difference between the initial elevated flap
and the final advanced flap. Postsurgical complications including premature membrane exposure, infection,
paresthesia, and continuous discomfort were noted at follow-up visits. A visual analog scale (VAS) was used
to quantify the amount of pain, swelling, and bleeding in the patients. Results: An average of 9.64 ± 0.92 mm
flap advancement was accomplished for DFI, whereas PRI advancement averaged 7.13 ± 1.45 mm (P < .001).
Premature membrane exposures occurred in two sites in the PRI group and one site in the DFI group.
Paresthesia, infection, and continuous discomfort were noted in one site each in the PRI group. The difference
between groups in the incidence of postoperative complications (PRI, 5; DFI, 1) was not significant (P < .082).
The mean pain, swelling, and bleeding scores for DFI (1.55 ± 1.21, 1.91 ± 0.94, and 0.40 ± 0.12, respectively)
were lower than those of the PRI group (3.75 ± 2.63, 3.25 ± 1.29, and 1.16 ± 0.34, respectively) (P = .019,
P = .010, and P = .061, respectively). Conclusions: Flap advancement was facilitated and morbidity was
decreased in the DFI group. The technique may have potential to serve as an alternative to PRI to overcome
some of the latter’s limitations. Int J Oral Maxillofac Implants 2013;28:597–604. doi: 10.11607/jomi.2714

Key words: alveolar ridge augmentation, bone transplantation, dental implants, surgical flaps, wound healing

V ertical alveolar bone augmentation procedures are

considered a major challenge in dentistry.1 These
procedures enable the placement of dental implants
and more functional and esthetic prostheses. A few
techniques exist: guided bone regeneration (GBR),
distraction osteogenesis, and onlay bone grafting.
Among these, GBR with a titanium-reinforced expand-
ed polytetrafluoroethylene (e-PTFE) membrane is the
most frequently used. Multiple clinical and histologic
1Instructor, Department of Periodontology, Tufts University
School of Dental Medicine, Boston, Massachusetts, USA.
2Private practice, Boston, Massachusetts, USA.
3 Postgraduate Resident, Tufts University School of Dental
Medicine, Boston, Massachusetts, USA.
4 Assistant Professor, Tufts University School of Dental
Medicine, Boston, Massachusetts, USA.
Correspondence to: Dr Yong Hur, Department of
Periodontology, Tufts University School of Dental Medicine,
1 Kneeland Street, Boston, MA 02111. Fax: +617-636-0911.
Email: Yong.Hur@tufts.edu
©2013 by Quintessence Publishing Co Inc.
studies have reported its ability to regenerate new
bone with decreased patient morbidity.2–7 However,
despite the possible benefits, the procedure remains
technique-sensitive; therefore, the ideal technique for
predictable outcome has yet to be defined.
Maintenance of primary closure during the heal-
ing period is paramount when an e-PTFE membrane
is used for GBR.8 Premature membrane exposure may
result in delayed healing, pain/discomfort, and in-
flammation/infection of the graft site, resulting in de-
creased regenerative potential. An understanding of
the anatomy of the defect, in combination with proper
surgical technique, is required for a successful out-
come. Adequate flap advancement is crucial for ten-
sion-free primary closure. Excessive tension may result
in flap dehiscence and premature membrane expo-
sure. The periosteal releasing incision (PRI) is common-
ly used to relieve flap tension and involves severing
the periosteum along with the underlying submucosa.
However, the deep incisions into the submucosa that
are required for major flap advancement often result
in increased swelling, bleeding, and failure to obtain
primary closure.9

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Ogata et al

Fig 1   The DFI technique. (Left) The mucosal layer is elevated, leaving the periosteal layer on the alveolar bone. (Center) The perios-
teal layer of the double flap is reflected from the alveolar bone. (Right) The periosteal layer is used to stabilize the membrane using
periosteal sutures.

The double-flap incision (DFI) design was devel-
oped by the authors as an alternative to PRI for flap
advancement.10 In brief, the technique involves the
separation of the mucosa and periosteum of the flap
to relieve tension. The isolation of the periosteum from
the flap enables tension-free primary closure. In addi-
tion, the DFI technique appears to reduce the amount
of soft tissue trauma, such as swelling, excessive bleed-
ing, and dehiscence, as well as patient morbidity. How-
ever, to date, no studies have investigated its clinical
performance and patient comfort.
The purpose of the study is to compare the effica-
cy and morbidity of DFI to PRI for flap advancement.
The efficacy of the two techniques was determined by
comparing the amount of flap advancement. Quan-
titative comparison of morbidity was performed by
evaluating postoperative surgical complications and
patient pain and discomfort.
MATERIALS AND METHODS
Between July 2009 and January 2011, a prospective,
randomized, controlled clinical trial was conducted to
compare releasing incision techniques in GBR. Sixteen
patients with a total of 23 surgical sites were selected for
vertical and horizontal augmentation (Seibert Class III
ridge deformity)11 at the Department of Periodontol-
ogy at Tufts University School of Dental Medicine. The
age of the patients ranged from 43 years to 71 years,
and each had good general health without any con-
tributing systemic diseases. Smokers and those with
uncontrolled diabetes were excluded from this study.
Most defects were located in the posterior mandible in
an area with two or three missing teeth (Table 1). The
releasing incision technique (PRI or DFI) was randomly
assigned. PRI was performed in 12 sites and DFI was
performed in 11 sites by a single operator. An indepen-
dent examiner reviewed each of the following param-
eters between the two techniques:
• The amount of flap advancement (in millimeters)
• The frequency of surgical complications, including
membrane exposure, infection, and paresthesia
• The level of patient discomfort (pain, swelling,
bleeding)
The study protocol was approved by the Tufts
Health Science Campus Institutional Review Board.
Written informed consent was given by all subjects.
DFI Technique
The double-flap technique was implemented to re-
lieve tension to gain flap advancement in the test (DFI)
group. A partial-thickness incision is used to separate
the mucosal layer of the flap from the periosteal layer
on the alveolar ridge (Fig 1). The periosteal layer is su-
tured first using periosteal sutures to stabilize the re-
generative site (Fig 1). Primary closure is achieved by
suturing the mucosal layer.

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 Ogata et al

Table 1   Clinical Data of the Surgical Sites Treated in the Study
Patient no. (site no.) Age (y) Sex Arch Method Extraction Defect size (no. of teeth)
1 (1) 57 M Mandible DFI N 2
2 (2) 43 F Mandible PRI Y 3
3 (3) 71 F Mandible DFI N 4
3 (4) Mandible PRI N 3
4 (5) 69 M Mandible PRI N 4
5 (6) 61 F Mandible PRI N 1
5 (7) Mandible DFI N 1
6 (8) 54 F Mandible DFI N 3
6 (9) Mandible PRI N 1
7 (10) 63 F Mandible PRI N 2
8 (11) 64 M Mandible DFI N 2
9 (12) 60 F Mandible PRI Y 3
10 (13) 66 F Maxilla DFI N 2
10 (14) Mandible PRI N 2
11 (15) 65 M Mandible PRI N 3
12 (16) 68 F Mandible DFI N 2
13 (17) 58 M Mandible DFI Y 3
13 (18) Mandible PRI N 2
14 (19) 61 M Mandible PRI N 3
15 (20) Mandible DFI N 3
15 (21) 65 F Mandible PRI N 3
15 (22) Mandible DFI N 3
16 (23) 53 F Mandible DFI N 2

a b c
Fig 2  The PRI technique. (a) A periosteal incision is made 1 mm deep into the mucoperiosteal flap, severing the periosteum.
(b) Deeper incisions into the alveolar submucosa are made at a 60-degree angle up to 3 mm to achieve additional flap advancement.
(c) Clinical view of PRI.

PRI Technique
A PRI was used for flap advancement in the control
group. The periosteal releasing incision was made ap-
proximately 1 mm deep into the mucoperiosteal flap,
severing the periosteum (Fig 2a). Further incisions
were made at a 60-degree angle up to 3 mm as neces-
sary to achieve primary wound closure (Figs 2b and 2c).
Surgical Procedure
Local anesthesia was obtained with two to three car-
pules of lidocaine with 1:100,000 epinephrine. A crestal
incision was made over the edentulous ridge. Vertical
releasing incisions were placed on the buccal and lin-
gual as needed. Mucoperiosteal flaps were reflected
with the DFI technique or the PRI technique, depend-
ing on patient assignment. In the DFI group, a partial-
thickness flap was raised first to separate the mucosal
layer from the overlying periosteum. Subsequently, the
periosteal layer was elevated to expose the underlying
alveolar process (Fig 1). In the PRI group, a buccal and
lingual mucoperiosteal full-thickness flap was raised.
Incremental incisions of 1 mm, up to 3 mm into the
periosteum and submucosa, were used to advance the
mucoperiosteal flap (Fig 2).

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Ogata et al

Pain—Severity (0–10):
• Slight (0–3): No or little discomfort
• Moderate (4–6): pain that bothered you or mildly affected your daily functions
• Severe (7–10): pain that could not be tolerated or that disrupted your daily
functions (eg, difficult to eat, difficult to speak)
Swelling—Severity (0–10):
• Slight (0–3): No abnormal feeling or slightly visible change in appearance to a
feeling of “fat” that you could not recognize at a glance
• Moderate (4–6): moderate visible change that you could recognize apparently
or easily in size and shape, in addition to a “fat” feeling
• Severe (7–10): very noticeable change in size and shape
Bleeding—Severity (0–10):
• Slight (0–3): No to minimal bleeding ranging from no detectable bleeding to a
trace of blood clot not requiring any care
• Moderate (4–6): oozing or mild bleeding that stopped with home care
• Severe (7–10): bleeding that could not be stopped with home care or
telephone instructions

Fig 3  Schematic of the measurement method Fig 4   The patient discomfort questionnaire.12
for flap advancement.

Freeze-dried bone allograft (MinerOss, Osteotech)
and titanium-reinforced e-PTFE membrane (Gore-Tex
Regenerative Membrane, W.L. Gore & Associates) were
used to augment the alveolar bone defects. The mem-
brane was shaped to the desired contours and trimmed
1 mm from the adjacent teeth surfaces to minimize the
risk of infection. The freeze-dried bone allograft was
hydrated with sterile saline and placed into the defect.
The membrane was placed over the graft material and
secured with bone tacks (ACE Surgical).
In the DFI group, the periosteal flap was sutured
first, with periosteal sutures securing the regenerative
site. Then the mucosal flap was closed with horizon-
tal mattress and simple interrupted sutures. In the PRI
group, the mucoperiosteal flap was closed with hori-
zontal mattress and simple interrupted sutures.
The patients were instructed to take amoxicillin
500 mg/clavulanic acid 125 mg starting 1 day prior to
the surgery and continuing for 10 days. Clindamycin
was prescribed for patients with penicillin allergy. An
anti-inflammatory agent (ibuprofen) was prescribed
to the patients for 3 days after surgery. Patients were
instructed not to brush or floss in the surgical area for
3 weeks. Patients were instructed to rinse three times a
day with 0.12% chlorhexidine gluconate solution until
the sutures were removed. Interrupted sutures were
removed 14 days after surgery and horizontal mattress
sutures were removed 21 days after surgery.
Study Measurements
Flap advancement was measured by a blinded inves-
tigator. The center of the flap was grasped approxi-
mately 3 mm from the margin and advanced by a pair
of periodontal forceps. The advancement was stopped
if there was noticeable blanching or tension in the flap.
Measurements were made from the base to the coro-
nal end of the flap with a UNC-15 periodontal probe
placed at the center of the flap (Fig 3). The differences
in measurements, before and after DFI or PRI, were re-
corded in millimeters. Intraexaminer calibration exer-
cises were performed prior to the study to minimize
measurement discrepancies. All measurements were
repeated a total of two times and the average was used.
Postoperative complications were evaluated at 1, 2,
4, 12, and 24 weeks following GBR. These complications
included membrane exposure, infection, paresthesia,
and continuous discomfort. Premature membrane ex-
posure was defined as any type of loss of primary clo-
sure during the 6-month healing period. Postsurgical
infection was defined as any redness, swelling, pain,
heat, or drainage that required an additional course
of antibiotics (infection associated with membrane ex-
posure was classified as a membrane exposure). Pares-
thesia was defined as altered sensation in the patient,
which ranged from a tickling sensation to numbness.
Continuous discomfort was defined as chronic pain ex-
perienced by the patient after suture removal, which
ranged from a dull aching to sporadic sharp pain.
A patient discomfort questionnaire12 was adminis-
tered 7 days postoperatively. A visual analog scale (VAS)
was used to quantify the amount of pain, swelling, and
bleeding the patient experienced on the questionnaire
(with a range of 0 to 10 for each symptom [pain, swelling,
and bleeding]). Regarding pain, the scale ranged from
0 (no pain) to 10 (unbearable pain). Swelling ranged
from 0 (no noticeable visible and palpable difference)
to 10 (very noticeable change in size and shape). Bleed-
ing ranged from 0 (no bleeding and no taste of blood) to
10 (uncontrolled bleeding requiring office visit) (Fig 4).
Statistical Analysis
Clinical measurements of 23 surgical sites were com-
pared between the DFI and PRI groups using SPSS 15.0
(IBM) statistical software. Means and medians were

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 Ogata et al

Table 2   Amount of Flap Advancement (mm)

Group Mean Median SD Range Interquartile range
DFI (n = 11) 9.64 10.0 0.92 8–11 (9, 10)
PRI (n = 12) 7.13 7.0 1.45 4–10 (7, 8)
SD = standard deviation.

Table 3   Incidence of Postoperative Complications

Group Membrane exposure Paresthesia Infection Continuous discomfort Total
DFI (n = 11) 1 (9.1%) 0 0 0 1 (9.1%)
PRI (n = 12) 2 (16.7%) 1 (8.3%) 1 (8.3%) 1 (8.3%) 5 (41.7%)

calculated for the amount of flap advancement in the Table 4   Results of Patient Discomfort Survey
two groups. Subsequently, the independent samples
Pain score* Swelling score* Bleeding score*
t test (significant at P < .05) was used to determine
whether there were statistically significant differences DFI 1.55 (± 1.21) 1.91 (± 0.94) 0.40 (± 0.12)
in the amount of flap advancement, the frequency of PRI 3.75 (± 2.63) 3.25 (± 1.29) 1.16 (± 0.34)
postoperative complications, and the levels of patient *VAS with a range of 0 to 10.
discomfort.

RESULTS

Flap Advancement
Flap advancement was measured as the difference
in flap height before and after the incision. The flap
was measured from its apical margin to its coro-
nal edge. The average advancement attained was
9.64 ± 0.92 mm in the DFI group (range, 8 to 11 mm)
and 7.13 ± 1.45 mm (range, 4 to 10 mm) in the PRI
group. The DFI technique therefore resulted in a mean
of 2.51 mm more advancement than the PRI technique.
This difference between the groups was statistically
significant (P < .001), indicating that, on average, the
DFI technique resulted in greater flap advancement
(Table 2).
Incidence of Postoperative Complications
In the DFI group, one site (9.1%) showed a membrane
exposure. In comparison, the PRI group showed a total
of five sites (41.7%) with postoperative complications:
membrane exposure (n = 2), paresthesia (n = 1), infec-
tion (n = 1), and continuous discomfort (n = 1). Never-
theless, the incidence of postoperative complications
was not statistically significantly different between the
two groups (P = .082) (Table 3).
Patient Discomfort Survey Results
Overall, the patient response on the VAS questionnaire
was more favorable to the DFI technique. The survey
revealed there was less patient discomfort in the DFI
group as compared to the PRI group, with statistically
significant differences in pain and swelling scores. The
average pain score was 1.55 (± 1.21) in the DFI group
and 3.75 (± 2.63) in the PRI group (P = .019). The aver-
age swelling scores for DFI and PRI were 1.91 (± 0.94)
and 3.25 (± 1.29), respectively (P = .010). The average
bleeding score was 0.40 (± 0.12) in the DFI group and
1.16 (± 0.34) in the PRI group (P = .061) (Table 4).
DISCUSSION
Past research has shown that, to achieve success in
GBR, primary closure during the healing phase must
be maintained.8,13,14 The first step to attain primary clo-
sure is adequate flap release. The PRI, with or without
vertical releasing incisions, is the most common tech-
nique for flap advancement.15 However, clinical obser-
vations have shown that PRI may result in increased
bleeding, swelling, and inadequate flap advancement.
This has led to the development of other approaches
to achieve the fundamental goal of primary closure
while limiting sequelae.

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Ogata et al
Fig 5a   Premature membrane exposure at site 10, treated with
PRI. It presented with a 7-mm soft tissue dehiscence after 3
months of healing.
Langer and Langer proposed the use of an over-
lapped flap to achieve primary closure over implants.16
A beveled incision provides an increased surface area,
which allows some overlapping of the soft tissue to en-
sure coverage of the implant. Buser and coworkers em-
ployed a reverse beveled incision for GBR with a similar
effect.17,18 Tinti and Parma-Benfenati suggested a pala-
tal sliding flap advancement, which offers preserva-
tion of the masticatory mucosa.19 Fugazzotto rotated
palatal connective tissue and periosteum to cover the
regenerative site to achieve passive soft tissue cover-
age.20,21 Recently, Ronda and Stacchi used a lingual flap
for advancement.22
While the aforementioned approaches may be ad-
vantageous for practitioners to achieve primary clo-
sure, none has been studied through a clinical trial, ie,
no objective comparison with a control group has yet
been published. A comparison is necessary to deter-
mine the efficacy and validity of the two surgical tech-
niques. To the best of the authors’ knowledge, the DFI
design described in this paper is one of the first to com-
pare its efficacy and morbidity versus the conventional
PRI approach.
The result of the study showed that DFI provided a
mean increase in flap advancement of 2.51 mm versus
the conventional PRI technique (P < .001). The authors
postulate that the difference between the two groups
is related to the amount of periosteum that is left at-
tached to the flap that is being advanced. The mucosal
layer of the DFI is devoid of the periosteum, whereas
the mucoperiosteal flap with the PRI technique still
contains the majority of the periosteum. The inelas-
ticity of mucoperiosteal flaps is derived from the peri-
osteum, which is composed mainly of dense fibrous
connective tissue.23,24
Patients were monitored for postoperative com-
plications of premature membrane exposure, par-
esthesia, infection, and continuous discomfort for 6
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Fig 5b   When accessed surgically, the site showed dislocation
of the membrane with inflammatory granulation tissue from the
buccal aspect.
months. Primary closure of the regenerative site was
maintained during the 6-month healing period in
20 of the 23 treated sites (87%). Premature membrane
exposure was observed at sites 10 (PRI), 14 (PRI), and
20 (DFI) (Table 1). All membranes were removed 3 to
4 months after the procedure. Significant bone loss
was noticed at sites 10 and 14 and was related to in-
fection and membrane dislocation (Fig 5). Site 20
showed exposure on the lingual margin of the mem-
brane, but the membrane remained stable (Fig 6). The
patient with site 2 (PRI) reported altered sensation in
the lower left lip. However, the tickling, dull sensation
reported by the patient gradually improved during
the healing period. An infection without membrane
exposure was noticed at site 15 (PRI). The infection
was controlled with an additional course of antibiotics
(amoxicillin 500 mg/clavulanic acid 125 mg). Patient 3,
who received both techniques, reported constant dull
pain and discomfort at the PRI site. Membrane mobil-
ity was noted upon re-entry during dental implant
placement.
The main role of the membrane is to exclude soft
tissue and stabilize the regenerative site.25 Bone regen-
eration is expected with initial blood clot formation
and immobilization of the graft site during the course
of healing.26 The internal periosteal layer of the double
flap appears to add stability to the membrane versus
the PRI technique. With the DFI, the continuity of the
dense periosteum is maintained throughout the flap.
The periosteal suture on the periosteal layer is able to
anchor the graft site during the initial healing period
(Fig 7). On the other hand, the PRI severs the perios-
teum at the base of the flap, creating a segment that
is devoid of periosteum. This can potentially allow mo-
bilization of the graft site. No incidence of membrane
dislocation, loose tack, and mobilization of graft was
reported in the DFI group. A clinical impression from
follow-up examinations suggests that the decreased

Fig 6a   Premature membrane exposure at site 20, treated with
DFI. A 6-mm soft tissue dehiscence was seen after 4 months
of healing.
Fig 7   The periosteal suture on the periosteal layer is able to
anchor the graft site toward the flap base in the DFI technique.
incidence of continuous discomfort, premature mem-
brane exposure, and infection in the DFI group could
be explained by the extra stabilization of the graft with
the periosteal layer (Fig 8).
The study attempted to measure the level of pa-
tient discomfort using a VAS.12,27 The VAS is based on
self-report and psychometric responses. The surgical
procedure in the study required significant flap ad-
vancement (over 7 mm), which may result in increased
discomfort. However, less pain and swelling were re-
ported by the DFI group than the PRI group (average of
1.55 versus 3.75 for pain, 1.91 versus 3.25 for swelling).
The authors speculate that the DFI has enhanced heal-
ing potential over the PRI for the following reasons:
(1) The DFI maintains the blood supply in the perios-
teal layer versus PRI, which severs its blood supply at
the base of the flap; and (2) the DFI avoids deep inci-
sion into the submucosa, which may be the cause of
swelling and bleeding with the PRI technique.
The DFI technique has been used in the Depart-
ment of Periodontology at Tufts University School of
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Ogata et al
Fig 6b   When the site was accessed, an intact membrane with-
out further complications was noted.
Fig 8   Schematic of extra stabilization by the periosteal layer
with the DFI technique.
Dental Medicine for the past 4 years. The present find-
ings show that the DFI technique is advantageous
over the PRI technique with regard to flap advance-
ment and patient morbidity. Limitations of this study
include the subjective nature of patient discomfort,
difficulty in objectively measuring flap advancement,
and the small sample size. The clinical benefits of the
technique need to be confirmed with additional ran-
domized controlled clinical studies.
CONCLUSIONS
In the present study, the double-flap incision tech-
nique facilitated greater flap advancement with less
patient morbidity than the conventional periosteal
releasing incision technique. The technique may have
potential to serve as an alternative to the periosteal
releasing incision to overcome some of its limitations.
The International Journal of Oral & Maxillofacial Implants 603
Ogata et al
Acknowledgments
The authors reported no conflicts of interest related to this study.
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