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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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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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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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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
fo r
nective
n
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
n
of 3-0 sutures led to tissue breakage in
ot
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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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