Successful membrane coverage is determined by tension free flap closure and is significant for desirable clinical outcomes. Hence, proper tension release on the overlying flap to achieve passive tension flap closure remains to be the most important factor for achieving predictable bone augmentation outcomes. Flap openings have been associated with postsurgical complications including infections and graft failure. Therefore, gaining flap flexibility for the coverage of small to high volume augmentation is an important component for predictable outcomes. Several techniques have been described in the literature for flap advancement. Vertical releasing incision and periosteal scoring are common techniques to obtain flap flexibility and are commonly applied. Also, it is known that the incision into submucosa and even some muscularly incision will provide major flap advancement. Furthermore, the application of these advancement methods is often limited to the presence of sufficient gingival tissue thickness.

The determination of periodontal phenotype is relevant to determine mucogingival surgical management. For thin gingival tissue it has been advocated to perform a full thickness flap (periosteum within the flap) rather than a partial-thickness flap (leaving the periosteum over the bone as tissue thickness decreases wound dehiscence occurs. This is leading to flap tearing and subsequent graft exposure. Similar to flap advancement, split thickness flaps are surgical demanding to be performed in thin tissue as perforation may occur. So far, no specific surgical technique has been proposed for major flap advancement in the thin tissue phenotype (≤1.5mm). Therefore, this lecture introduces a surgical technique – The Mucosal Detachment Technique – that is separating the mucosal insertion from the periosteum which is aimed at achieving adequate dimensions of flap flexibility to cover high volume augmentation.

Learning objectives

• Explain the importance of tension-free flap closure for predictable membrane coverage and bone augmentation success.
• Identify causes and consequences of flap opening and graft exposure following augmentation procedures.
• Compare conventional flap advancement techniques and their limitations in thin periodontal phenotypes.
• Assess periodontal phenotype to guide appropriate mucogingival surgical management.
• Understand the principles and indications of the Mucosal Detachment Technique for achieving flap advancement in thin tissue cases.