Types of Flap Positioning
Replaced
Apically positioned
Coronally positioned
Laterally positioned
Replaced flap
returned to its original position -like in the modified Widman flap
Apically Positioned Flap
eliminates pocket by apically displacing the soft tissue wall of the pocket
thus is preserves/increase width of attached gingiva by transforming previously unattached keratinized pocket wall into attached gingiva tissue
Coronally and Laterally Positioned Flaps
Used to cover areas of recession
6 Goals of Suturing
Provide adequate tension of wound closure w/out dead space but loose enough to prevent tissue ischemia/necrosis
Maintain hemostasis
Permit healing by Primary Intention
Reduce postoperative pain
Prevent bone exposure–>delayed healing and bone resorption
Permit proper flap position
Nonresorbable Suture Materials
Silk
Polyester- nylon
- PTFE
Resorbable Suture Materials
Natural - plain gut
- Chromic gut
Synthetic - Coated Vicryl
Chromic Gut
Resorp Rate: 7-10 days by proteolytic enzymatic processes
Tensile strength: +
Tissue rxn: Moderate
Uses: Rapidly healing mucosa, avoiding suture removal
Coated Vicryl (polyglactin 910)
Resorp Rate: 56-70 days by slow hydrolysis
Tensile strength: +++
Tissue rxn: Minimal
Uses: To resist muscle pull; subepithelial mucosal surfaces, resorbable
Surgical Silk
Resorp Rate: Nonresorbable, Gradual encapsulation by fibrous CT- lost after 2 years
Tensile strength: ++
Tissue rxn: Moderate
Uses: Mucosal surfaces, nonresorbable
ePTFT, Gore-Tex (monofilament)
Resorp Rate: Nonresorbable
Tensile strength: +++
Tissue rxn: Extremely low
Uses: All types of soft tissue approximation
6 Qualities of Ideal Suture Material
Pliability- ease of handling Knot Security Sterilizable Appropriate elasticity Nonreactivity Adequate tensile strength
Suture Material used most often
Silk and synthetics
Suture Material used when retrieval is difficult
Gut sutures
Recommended Suture Material for bone augmentation
Monofilament sutures- to prevent “wicking”, reduce inflammation, and permit longer retention
Recommended Suture Material for GTR
Gore-Tex and Coated Vicryl Sutures
Direction Suturing Should Take Place
From movable to a nonmovable tissue
Where to grasp the needle
1/4 to 1/2 the length from the swaged area
To avoid wicking of bacteria, Knots should not be placed…
in incision lines
What are the ears of a knot?
The cut ends of the suture
Types of Knots
Square, Slip, Surgeon’s
Square Knot
Two overhand knots in opposite directions, one above and one below the jaws of the needle holder
May loosen if made of synthetic or monofilament
Slip Knot
Two overhand knots in same direction, both above needle holder and in same direction
Surgeon’s Knot
Most common in dentistry
Modified Square Knot
Double the loop above the needle holder, and then one loop under the needle holder in opposite direction
5 Common Suturing Techniques
Interrupted Sutures - Simple loop mod, figure 8 mod
Mattress Sutures - Vertical, Horizontal
Periosteal Sutures
Continuous Sutures - Locking, Horizontal Mattress
Sling Sutures - Independent, Continuous
Interrupted Sutures - Uses
Vertical incision tuberosity and retromolar Bone regeneration Widman flap, open flap debridment, replaced flap, apically positioned flap Edentulous spaces Partial or split-thickness flaps Dental implants
Interrupted Suture - Simple Loop Mod
Most used suture in dentistry
For when facial and lingual flaps have been elevated
Pass needle thru facial, under contact, thru lingual on inner, under contact, tie on facial
Interrupted Suture - Figure 8 Mod
For very restricted areas (lingual 2nd molar)
Interposes suture material between edges of the flaps- usually a 4-0 size thread allows primary closure still
Pass needle thru facial, under contact, reverse and enter lingual from outer, under contact, tie on facial side
Single Interrupted Sling Suture
For when flap has been elevated on one side or when facial and lingual flaps are positioned at different levels
For 2 papillae
Pass needle thru outer surface of mesial papilla, move around tooth, pass under distal contact, pentrate flap from inner, pass back under distal around tooth, under mesial and tie knot
Continuous Independent Sling Suture Technique
For a flap with 3 or more papillae on only one surface
Tie interrupted suture on distal, pass needle under contact point to opposite side, look needle and thread around tooth, pass needle through the next interdental area below contact, repeat procedure until the last interdental area
Perio Dressing
No curative properties
Assist healing by protecting tissues during the healing stage
Reasons to use Perio Dressing
- To protect the wound postsurgically
- To obtain and maintain a close adaptation of mucosal flaps to underlying bone
- Patient comfort
Disadvantage to Perio Dressing
Antibacterial rinses cannot work under the dressing
CoePak ingredients
Oxides of metals (zinc oxide), lorothidol (fungicide), non-ionizing carboxylic acids, and chlorothymol (bacteriostatic)
Most important variable in determining long-term result of perio surgery
Post Operative Plaque Control - rinse w/ Chlorhexidine
Another important variable is postsurgical wound stability
Suture Removal Techniques
Cut suture as close to tissue as possible to avoid dragging “dirty suture”
Healing Phases (3)
Inflammation
Fibroblastic-granulation
Matrix formation and remodeling
Primary Intention Healing
By clean surgical incision w/ flap surgery
Primary Intention Healing Immediate Response (1)
Blood clot forms between flap and tooth/bone- containing fibrin reticulum, neutrophils, erythrocytes, platelets, debris, capillaries
Primary Intention Healing w/in 24 hours (2)
Neutrophils invade CT
Epithelium migrates from wound margin to cover wound
Primary Intention Healing 1-3 days (3)
Space between flap and tooth/bone thins
Epithelial cells migrate over border of flap contacting tooth
Primary Intention Healing 3-7 days (4)
Epithelial migration continues
Neutrophils replaced by macrophages
Incision space fills with granulation tissue
Revascularization under way
Primary Intention Healing 1 week (5)
Epithelial attachment to roots formed by hemidesmosomes and basal lamina
Clot replaced by granulation tissue from CT, bone marrow, and PDL
Primary Intention Healing 2 weeks (6)
Collagen fibers appear parallel to tooth
Weak union of flap to tooth due to immature collagen
Primary Intention Healing 1 month (7)
Inflammatory cells are gone
Fibroblasts proliferate and collagen accumulates
Revascularization process regresses
Fully epithelialized gingival crevice w/ well-defined attachment
Supracrestal fibers assume functional arrangement
Primary Intention Healing w/in 6-8 weeks (8)
Wound gains tensil strength
Secondary Intention Healing differs from Primary in that (3)
- More inflammation
- More granulation tissue
- Wound contraction is much more pronounced
Summary of Wound Healing
Wound debrided by inflammatory cells
Parenchymal cells regenerate
Parenchymal and CT cells migrate and proliferate
Extracellular matrix proteins (collagen) synthesized
CT and parenchymal components remodel
Wound gains strength
Repair
Damaged tissues replaced by tissues that don’t duplicate original function or architecture
The usual outcome of therapy
Regeneration
Damaged tissues replaced by tissues that duplicate structure and function of original tissues
Involves formation of new cementum, PDL, alveolar bone
Rare but most desirable
Factors affecting Regeneration
Contamination by bacteria
Requires concerted action of many cells (cemento, osteo, fibro -blasts, JE cells, etc)
Requires formation of specialized junctional complexes
Root surface is avasclar and cant contribute new vessels
Requires complex interactions between ECM and cells