Learning the Inverted Periosteal Graft

Left: Pre op radiograph with 8mm probing
Right: 6 week post op with 3mm probing
This patient is a healthy middle aged black male. The treatment was the inverted periosteal graft using Immediate Graft mixed with OsseoConduct βTCP granules as graft material.
6-week post op photograph buccal
6-week post op palatal
Left: Pre op radiograph, LR probing 7-8mm
Right: 6-week post op radiograph, LR probing 3mm
6-week post op photograph lower right buccal
Post op photograph, LR lingual
Pre op radiograph with probing mesial #12, 8mm
6-week pre op photograph buccal
Pre op photograph palatal
Vertical releasing incisions are made one tooth mesial and distal to the area to be regenerated. Sulcular incisions are used with no scalloping.
The gingiva is reflected to the mucogingival junction.
The roots are planed and conditioned with PrefGel.
The periosteum is dissected from the alveolus cleanly with a sharp spoon.
A small angled spoon is used to locate the edge of the periosteum.
The small spoon is inserted under the periosteum. The periosteum is dissected off the buccal flap from the mucogingival junction to the base of the flap along the full length of the flap.
After the dissection with the small spoon, a large spoon is used to complete the dissection.
The large spoon is completes the dissection throughout the full length of the flap.
La Grange scissors are used to cut the periosteum at the base of the flap.
The periosteum is dissected.
Another view of the dissected buccal periosteum. This edge of the periosteum is from the base of the flap and will be sutured to the palatal periosteum.
A palatal full thickness flap is raised and the periosteum is incised at the base of the flap. Note that the flap will relax as it is incised and the space between the edges of the periosteum where cut will widen significantly. Note where the edge of the periosteum is in preparation of dissection.
One method of dissecting the palatal periosteum is to use a miniblade. The miniblade is bent to facilitate the dissection.
Bent miniblade
The flap is grasped with tissue pickups to the left and the miniblade is beginning the dissection under the periosteum on the right. Care is taken to not cut into the flap to maintain blood supply for the flap.
The dissection continues from the base of the flap to the junction between the attached gingiva and the periosteum.
The dissection of the periosteum is complete.
This photo shows the completed dissection with the flap in the upper section of the photograph and the periosteum in the lower half of the photograph.
The buccal and lingual periosteum is sutured together, one tooth distal to the site to be regenerated. If there are multiple sites to be regenerated, care is taken to not draw the edge of the periosteum away from the mesial graft site as you are suturing from distal to mesial.
The lesion is grafted with Immediate Graft mixed with Osseoconduct βTCP Perio granules in a 1.5 to 1 ratio. The graft material must be shaped to form the ridge and allow the periosteum to be drawn interproximally and fully cover the bone graft.
A resorbable suture is placed through the buccal and lingual periosteum. A resorbable synthetic suture is advised as gut or chromic suture lacks the strength to fully close the periosteum over the graft.
The suture is tied drawing the periosteum completely over the graft, resulting in the buccal and lingual periosteum to connect interproximally. Note that in this case the periosteum was sutured both mesial and distal before closing over the graft. When the periosteum is closed, the flaps are sutured.
Day 2 post op, buccal
Day 2 post op. The patient has been pressing on the palatal tissue with his tongue and some graft material was being expressed. Final evaluation of the response to surgery is done after 6 weeks.
6 week post op. Probings within normal limits, gingiva healthy. In time, the papilla will continue to regenerate but all cases respond differently.

The inverted periosteal graft places regenerative cells over the area to be regenerated. In addition, the periosteum is an ideal barrier to unwanted cells. The attached gingiva and the periosteum will not tolerate contact with each other and therefore the periosteum is an ideal biological barrier. In the posterior, the papilla will not lay over the periosteum. In the anterior, the papilla will lay over the periosteum. A minimum of 6 weeks is required before the tissues can reorganize and the periodontal ligament can be probed. Over a few months, the tissue will fully reorganize into normal anatomy. The radiographic appearance of the bone will continue to increase in radiodensity over the following months and a periodontal ligament will appear radiographically.
This surgery is very technique sensitive. The methods and materials have been developed over a 10-year period and any alteration in technique or materials will likely lead to failure of this surgery. It is advised that the surgeon follow instructions precisely until experience is gained.


American Society for Bone and Mineral Research (ASBMR)

Tissue Engineering and Regenerative Medicine International Society (TERMIS)