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After passing the interdental area, the needle will re-emerge on the buccal side right underneath the tip of the papilla. (Fig 6a). Thereon the needle will be led.
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Otto Zuhr, DDS, Dr med dent Private practice, Munich, Germany

Stephan F Rebele, DDS Private practice, Munich, Germany

Tobias Thalmair, DDS, Dr med dent Private Institute for Periodontology and Implantology, Munich, Germany

Stefan Fickl, DDS, Dr med dent Department for Periodontology and Implant Dentistry, Arthur Ashman College of Dentistry, New York University, New York, USA

Markus B Hürzeler, DDS, PhD, Prof Dr med dent Department of Operative Dentistry and Periodontics, School of Dental Medicine, Albert-Ludwigs-University Freiburg, Germany Department of Endodontics and Periodontics, Dental Branch, University of Texas at Houston, USA and Private practice, Munich, Germany

Correspondence to: Dr Otto Zuhr Huerzeler/Zuhr Praxis für Zahnheilkunde, Rosenkavalierplatz 18, 81925 München, Germany e-mail: [email protected]

338 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 4 • NUMBER 4 • WINTER 2009

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A Modified Suture Technique for Plastic Periodontal and Implant Surgery – the Double-Crossed Suture

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CLINICAL APPLICATION

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aims to improve

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Abstract

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ZUHR ET ALopyrig No C t fo rP ub lica tio n wound adaptationt eand ss e n c e

soft tissue stabilization after surgical treatTo enable uneventful and accelerated heal-

ment with tunneling flap preparation tech-

ing processes to occur, common tech-

niques. Anchored at the incisal contact

niques in plastic periodontal and implant

points of the affected teeth, the suture is

surgery focus on stable postoperative flap

crossed through the buccal as well as

positions. Flap stability is, in particular,

through the palatal aspect. In this manner,

positively influenced by an adequate sutur-

the suture maintains the surgically estab-

ing technique, which therefore represents

lished coronal displacement of the buccal

one important factor with regard to the pre-

flap and provides a stable and intimate

dictability of successful treatment out-

contact to the underlying tissues.

comes. The following article illustrates the use of a modified suturing technique, which

(Eur J Esthet Dent 2009;4:338–347)

339 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 4 • NUMBER 4 • WINTER 2009

CLINICAL APPLICATION

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Preoperative situation in the anterior maxilla

Fig 2

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Fig 1

After having undermined the buccal tissues

showing the right lateral incisor designated for ortho-

and inserted the connective tissue graft in the prepared

dontic treatment. The treatment plan proposes surgical

tunnel, the suturing will be performed. Starting from the

thickening of the buccal gingiva prior to orthodontic

buccal aspect, the needle is guided through the com-

movement in order to prevent gingival recession for-

plete soft tissue complex.

mation. Surgery will be performed on the basis of a minimal invasive and incision-free approach.

Introduction

when an uneventful and fast healing process is guaranteed. The suturing tech-

Increased patient expectations are contin-

nique is of certain importance in this con-

uously leading to the refinement of surgi-

text as it should meet the following two

cal techniques to improve their predictabil-

principal prerequisites needed for opti-

ity and overall esthetic outcome. However,

mized healing: an intimate contact of the

satisfying esthetic results in plastic peri-

affected tissues and a proper wound stabi-

odontal surgery can only be achieved

lization.1 With particular respect to coronal repositioning techniques, the suture should also be able to secure the flap coronally and to maintain its position during the entire period of initial healing. To accomplish these goals, interrupted sutures are the most commonly used suturing technique in this context.2–4 In addition to interrupted sutures, so-called sling sutures have also regularly been applied to advance periodontal flaps over exposed root surfaces and to connect the papillae to the interdental connective tissues.5–8 As a further alternative, a modified sling and tag suturing

Fig 3

The needle will reappear at the palatal aspect.

technique combining double sling with interrupted sutures has been also previously reported.9

340 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 4 • NUMBER 4 • WINTER 2009

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Anchorage sutures were described as a

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further modification to better maintain the

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ZUHR ET ALopyrig No C t fo rP ub lica tio n te ss e n c e

coronal position of a flap. One option for anchoring such sutures are the incisal contact points of the affected teeth, that are splinted with composite material prior to surgery.10 Aside from a maximum coronal stabilization of the flap, an additional compression to the underlying tissues would make a further contribution to improved initial healing. Hence, a suture being an-

a

chored and crossed coronal to the desired wound margin may be beneficial to attain complete and durable tissue repositioning. This article presents a modified suturing technique to immobilize and coronally reposition periodontal and peri-implant flaps.

The double-crossed suture Basic considerations of the following suturing technique are the coronal positioning as well as the compression of the flap. With

b

the help of an anchorage point, which is located coronal to the wound margin, the buccal flap is secured and stabilized in the desired coronal position. The additional crossing of the suture under that anchorage point applies pressure of the flap to the underlying tissues. Prior to suturing, the contact points of the affected teeth need to be temporarily splinted with a flowable, light-curing resin material. Due to undercuts in the interproximal areas, no additional etching or bonding needs to be applied. Starting at the buccal aspect (Fig 1), the needle is guided through the buccal soft tissue complex approximately 5 mm apical to the tip of the papilla, but never apical to the muco-gingival junction (Fig 2). The su-

c Fig 4

The needle is guided from the palatal side over

the contact point (a), wrapped around it (b), and passed underneath the contact point back to the palatal side without pinching the soft tissue (c).

341 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 4 • NUMBER 4 • WINTER 2009

CLINICAL APPLICATION

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pyrig No Co t fo rP ub lica ti tepalatal on ture will reappear in the base of the ss e n c e

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papilla area (Fig 3). Consecutively, the nee-

dle will be wrapped around the splinted contact region and slid underneath the contact point to re-appear at the palatal side again without pinching any soft tissue (Fig 4). The same procedure is repeated once again, now starting from the palatal aspect. Therefore the needle is guided through the palatal tissue also approximately 5 mm apical to the tip of the papilla Fig 5

The needle is guided from the palatal side

back to the buccal aspect.

(Fig 5). After passing the interdental area, the needle will re-emerge on the buccal side right underneath the tip of the papilla (Fig 6a). Thereon the needle will be led over and placed underneath the contact point to re-appear at the buccal aspect again without pinching any soft tissue (Fig 6 b and c). By placing the knot at the buccal side the suture is closed with gentile pressure (Fig 7). Each interdental area is dressed with this double-crossed suture in order to stabilize the entire buccal soft tissue complex in the desired coronal position (Fig 8). The crossing of the suture

a

around the contact point in the interproxi-

b Fig 6

c The needle reappears at the buccal side (a), is led over the contact point (b), wrapped around it and

passed underneath the contact point back to the buccal side again without any pinching of the soft tissue (c).

342 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 4 • NUMBER 4 • WINTER 2009

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b

a Fig 7

The suture is tied with gentile pressure (a) at the buccal side (b).

Fig 8

Postoperative situation. The mesial and distal

Fig 9

The two basic advantages of this suture are the

contact points of the affected tooth are splinted and the

coronal positioning and the compression to the under-

suture is crossed around them.

lying tissues.

Fig 10

Fig 11

Healing situation after 1 week, prior to re-

Situation after 5 months.

moval of the sutures. Uneventful healing is noticed.

343 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 4 • NUMBER 4 • WINTER 2009

CLINICAL APPLICATION

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pyrig No Co t fo rP ub lica tio n te with tunneling flap preparation techniques ss e n c e

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the underlying connective tissue graft.

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mal area applies pressure in particular to

is indicated. These situations may include:

This enhances stability and nourishment

surgical thickening of the gingiva (Figs 1 to

during the early wound healing period

11), gingival recession coverage11 (Figs 12

(Figs 9 to 11).

to 15), implant second-stage surgery (Figs 16 to 19), and soft tissue ridge augmentation (Figs 20 to 23).

Discussion

The double-crossed suture meets a series of important demands in this context.

The double-crossed suture can be regard-

With the anchoring area being situated

ed as a suitable suturing technique in a va-

coronally and in the bucco-lingual center

riety of clinical situations where treatment

of the alveolar ridge, a maximum coronal

Fig 12

Fig 13

Postoperative situation.

Fig 15

Situation after 4 months.

Preoperative view of the anterior maxilla

showing a shallow recession defect on the right lateral incisor. The treatment plan designated recession coverage with the modified tunnel technique.11

Fig 14

Healing situation after 1 week, prior to re-

moval of the sutures.

344 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 4 • NUMBER 4 • WINTER 2009

ed

tissue

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nective

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mobilization and stabilization of the elevatbe

crossed design of this anchorage suture is

achieved. The crossing of the suture does

not only able to shift the tissue coronally,

not only ensure further wound stabilization,

but is also able to compress the periodon-

but also adapts the flap and any connec-

tal flap and the connective tissue graft to its

tive tissue graft to the underlying tissues.

underlying nourishing tissues. This results

Anchorage sutures without interdental

in enhanced healing and revasculariza-

crossing, on the other hand, would dis-

tion of the connective tissue graft as it has

lodge the elevated flap from the underly-

been demonstrated that the initial adhe-

ing tissues. This might be crucial with re-

sion of the blood clot is of critical impor-

gard

the

tance for the healing process. A thin clot

elevated buccal soft tissue and the con-

promotes tensile strength and stability of

Fig 16

Fig 17

gingivo-papillary

to

nutrition

complex

and

survival

can

of

Preoperative situation in the anterior maxilla

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ZUHR ET ALopyrig No C t fo rP ub lica tio n graft. Conclusively,t e sthe se nc e

Postoperative situation following implant sec-

showing the right lateral incisor needed to be extract-

ond-stage surgery. After having undermined the buc-

ed due to vertical root fracture. The treatment plan pro-

cal soft tissues the implant was uncovered by applica-

posed implant-assisted tooth replacement on the ba-

tion of a modified roll flap.

sis of a staged approach.

Fig 18

Healing situation after 1 week, prior to re-

moval of the sutures.

Fig 19

Situation 11 months after final implant crown

cementation (dental technician: Uli Schoberer, Seehausen, Germany).

345 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 4 • NUMBER 4 • WINTER 2009

CLINICAL APPLICATION

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Preoperative view of the anterior maxilla with

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Fig 20

Fig 21

Postoperative situation.

Fig 23

Situation 6 months after cementation of a full

a congenitally missing left lateral incisor designated for soft tissue ridge augmentation.

Fig 22

Healing situation after 1 week, prior to re-

moval of the sutures.

ceramic resin-bonded bridge (dental technician: Uli Schoberer, Seehausen, Germany).

the wound.12 The capillary proliferation and

tension and the fragile buccal soft tissues

ingrowth may also be accelerated. The

are prevented from disruption. Moreover, it

disrupted vascular vessels may be re-

has also been reported that a tension-free

stored earlier and anastomose freely with

wound closure seems to be another rele-

the surrounding vessels, reestablishing the

vant factor for uneventful healing process-

vascular network.13

es and predictable treatment outcomes.14

The proposed suture design provides a

The use of refined suture materials is of

further advantage with the suture passing

certain importance in this context. Burk-

the flap twice in the papilla area. When the

hardt et al evaluated the influence of vari-

knot is tightened, the tension of the suture

ous suture and needle attributes on flap

is not intensified at one distinctive spot.

tension and soft tissue tearing characteris-

This results in a more equally distributed

tics. The results documented that the use

346 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 4 • NUMBER 4 • WINTER 2009

only caused breakage of the thread. The authors concluded that tissue trauma and flap tension can be reduced by choosing finer suture diameters.15 Considering these findings, a thin suture material (6-0/7-0) may be suitable to achieve passive wound adaptation and to lower the risk of tissue trauma.16 Furthermore, finer suture material, in combination with the implementation of a microsurgical concept, has been demonstrated

to

significantly

improve

postoperative revascularization of connective tissue grafts during the initial healing phase.17 In conclusion, the proposed suturing technique offers, in a variety of clinical situations, the opportunity to stabilize the buccal-soft tissue complex in a coronal position and to enhance the adaptation of the buccal flap and any connective tissue graft to the underlying nourishing tissues.

References 1.

2.

3.

4. 5.

Wong ME, Hollinger JO, Pinero GJ. Integrated processes responsible for soft tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:475–492. Baldi C, Pini Prato G, Pagliaro U et al. Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. J Periodontol 1999;70:1077–1084. Bernimoulin JP, Lüscher B, Mühlemann HR. Coronally repositioned periodontal flap. Clinical evaluation after one year. J Clin Periodontol 1975;2:1–13. Restrepo OJ. Coronally repositioned flap: report of four cases. J Periodontol 1973;44:564–567. Harris RJ. Root coverage with a connective tissue with partial thickness double pedicle graft and an

fo r

contrast to the use of 7-0 sutures, which

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of 3-0 sutures led to tissue breakage in

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ZUHR ET ALopyrig No C t fo rP ub lica tio acellular dermal matrix graft: a clinical and thistoess c e n logical evaluation of a case report. J Periodontol e n 1998;69:1305–1311. 6. Zucchelli G, Cesari C, Amore C, Montebugnoli L, De Sanctis M. Laterally moved, coronally advanced flap: a modified surgical approach for isolated recession-type defects. J Periodontol 2004;75:1734–1741. 7. Zucchelli G, De Sanctis M. The coronally advanced flap for the treatment of multiple recession defects: a modified surgical approach for the upper anterior teeth. J Int Acad Periodontol 2007;9:96–103. 8. De Sanctis M, Zucchelli G. Coronally advanced flap: a modified surgical approach for isolated recession-type defects: three-year results. J Clin Periodontol 2007;34:262–268. 9. Huang LH, Wang HL. Sling and tag suturing technique for coronally advanced flap. Int J Periodontics Restorative Dent 2007;27:379–385. 10. Azzi R, Etienne D, Takei H, Fenech P. Surgical thickening of the existing gingiva and reconstruction of interdental papillae around implant-supported restorations. Int J Periodontics Restorative Dent 2002;22:71–77. 11. Zuhr O, Fickl S, Wachtel H, Bolz W, Hürzeler MB. Covering of gingival recessions with a modified microsurgical tunnel technique: case report. Int J Periodontics Restorative Dent 2007;27:457–463 12. Wikesjö UM, Nilveus RE, Selvig KA. Significance of early healing events on periodontal repair: a review. J Periodontol 1992;63:158–165. 13. Kon S, Caffesse RG, Castelli WA, Nasjleti CE. Revascularization following a combined gingival flap-split thickness flap procedure in monkeys. J Periodontol 1984;55:345–351. 14. Pini Prato G, Pagliaro U, Baldi C et al. Coronally advanced flap procedure for root coverage. Flap with tension versus flap without tension: a randomized controlled clinical study. J Periodontol 2000;71:188–201. 15. Burkhardt R, Preiss A, Joss A, Lang NP. Influence of suture tension to the tearing characteristics of the soft tissue: an in vitro experiment. Clin Oral Impl Res 2008;19:314–319. 16. Pini Prato GP, Baldi C, Nieri M et al. Coronally advanced flap: the post-surgical position of the gingival margin is an important factor for achieving complete root coverage. J Periodontol 2005;76:713–722. 17. Burkhardt R, Lang NP. Coverage of localized gingival recessions: comparison of micro- and macrosurgical techniques. J Clin Periodontol 2005;32:287–293.

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