Soft tissue complications: Major flap tear during a tunnel flap and graft with ADG

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Posted on By david wong In Periodontics

I thought I'd share a case about complication management. Surely I'm not the only one who has ever torn a flap while grafting. It's also one of the most frequently asked questions I get.

This patient presents with sensitivity related to recession on #11-12. A number of treatment options were presented to him, and we ultimately decided to graft #11-12 with an acellular dermal graft material (ADG). These defects were surely a "slam dunk" so I chose to tunnel the recipient site but promptly tore the flap horizontally along the mucogingival junction. The photos that follow are how I managed it and the results at 2 years.

Pre-op view #11-12
Pre-op view full arch

Severely torn flap (complete perforation)
Closure of the flap tear with 7-0 Vicryl suture


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12 Comments

Hi David,

Great case and result at 2 years. You are right, this problems do happen, and it's important to be cold minded to solve them properly. You've done a great job.

In your experience, does it make a huge difference to use ADG vs coronally advanced flap alone? I have some disappointing experiences using ADG where I have seen most or complete resorption of the graft material.

Thanks for sharing


Reply

Thank you Andoni, In my experience, it does make a difference using ADG vs. CAF alone. If you look at data on long-term root coverage for CAF, it's not that impressive. Maurice reported on this at the Dental XP Symposium a couple of years ago, I believe. With ADG, there is histology that Pat Allen shows comparing various products, Alloderm vs. Perioderm vs. Mucograft, so he is probably more qualified to expand on that. What you will commonly see with ADGs is that they often heal with a connective tissue/LJE attachment with overlying attached gingiva that on its surface is unkeratinized. There are several slides floating around that show the underlying connective tissue beneath the non-keratinized mucosal layer. While this result appears to be stable, autogenous tissue is still king... nowadays, it's a little bit of a question of practicality and comfort for the patient.


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David; Please explain exactly what you did to correct this issue. I would assume you did a CAF with ACDM underneath (THIN ACDM) and only after that did you close flap fenestration. You were blessed to get this result here...often the vascular insult does not allow for this result in y experience....regards Mo


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Great question, Maurice... so once the perforation was detected, I viewed the situation in comparison to other procedures where one would see a perforation or maybe in situations where it is done on purpose. For example, sinus perforations and vestibular approaches to soft tissue grafting. As in a sinus perforation, what I did was to continue preparing the recipient site (like elevating the sinus membrane) and mobilizing the flap to a significant distance fully circumscribing the perforation. This includes releasing the tissue/flap way more apically than typical for a non-perforated flap. As you rightfully assumed, ADG was placed over the root dehiscences and sutured. As with any appropriate soft tissue closure, care is taken to evaluate any flap tension and ensure the passive primary closure of the flap and perforation. The tunnel flap was coronally advanced and sutured with independent sling sutures (5.0 Vicryl). The perforation was sutured last with 7-0 Vicryl. After this, I sprinkled on a little luck and threw in a prayer... fortunately it worked out. It was a blessing indeed.


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Learn most from these...would you ever stage, delay or move to autologous tissue?


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Dang, Maurice... sorry for the late reply. I'm just now seeing this. I actually use a lot of autogenous tissue... mostly in the lower incisor region, but anytime I want maximum tissue thickness. Depending on the situation, I may stage my procedures... for example, place a free gingival graft first and then coronally reposition later. This is also very helpful in situations of high frenum attachments or short vestibular depth. For those worried about adequate flap release or flap tension, I would recommend starting with autologous grafting techniques first. ADGs are terrible under tension, as you know.


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Dang, Maurice... sorry for the late reply. I'm just now seeing this. I actually use a lot of autogenous tissue... mostly in the lower incisor region, but anytime I want maximum tissue thickness. Depending on the situation, I may stage my procedures... for example, place a free gingival graft first and then coronally reposition later. This is also very helpful in situations of high frenum attachments or short vestibular depth. For those worried about adequate flap release or flap tension, I would recommend starting with autologous grafting techniques first. ADGs are terrible under tension, as you know.


Reply

Dang, Maurice... sorry for the late reply. I'm just now seeing this. I actually use a lot of autogenous tissue... mostly in the lower incisor region, but anytime I want maximum tissue thickness. Depending on the situation, I may stage my procedures... for example, place a free gingival graft first and then coronally reposition later. This is also very helpful in situations of high frenum attachments or short vestibular depth. For those worried about adequate flap release or flap tension, I would recommend starting with autologous grafting techniques first. ADGs are terrible under tension, as you know.


Reply

Dang, Maurice... sorry for the late reply. I'm just now seeing this. I actually use a lot of autogenous tissue... mostly in the lower incisor region, but anytime I want maximum tissue thickness. Depending on the situation, I may stage my procedures... for example, place a free gingival graft first and then coronally reposition later. This is also very helpful in situations of high frenum attachments or short vestibular depth. For those worried about adequate flap release or flap tension, I would recommend starting with autologous grafting techniques first. ADGs are terrible under tension, as you know.


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Hi David, great surgical skill and results. Compliments. What could be the reason for this hard and soft tissue recession on that area? Patient has open bite, constricted arch from bicuspid onwards distally. Upper canines are sucked in .Did you consider occlusion? Mounting the models in CR and analysing that may reveal few reasons for this recession. If that's the reason it may relapse once again . Try to check for trauma from occlusion. Regards.


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Hi David,
grate for what U did do and will do.
You are right: we need luck and pray in and for everything, and if a luminaries like you need this a novice like me is yearning for such attributes all day long.
I sucked my education in perio.from the grates like Zander Page etc.this is way i would like you guys to publish a synopsis of abbreviations.bcause many times you change it and is confusing.

love you all



Reply

Distal radius fractures account for approximately 15% of all fractures in adults. Care of these fractures is associated with a myriad of complications. This review focuses on the soft tissue complications encountered during the management of distal radius fractures, including tendon injury, nerve dysfunction, vascular compromise, skin problems, compartment syndrome, complex regional pain syndrome, and ligament dysfunction.

having a glance at this case.It was treated well and you took the right decision


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