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A Modified Suture Technique

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ss e n c e
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for Plastic Periodontal and Implant


Surgery – the Double-Crossed
Suture
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: o.zuhr@huerzelerzuhr.com

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wound adaptationt eand
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Abstract aims to improve ss e n c e
fo r
soft tissue stabilization after surgical treat-
To 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)

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Fig 1 Preoperative situation in the anterior maxilla Fig 2 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 en-
tire 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 peri-
odontal flaps over exposed root surfaces
and to connect the papillae to the interden-
tal connective tissues.5–8 As a further alter-
native, a modified sling and tag suturing
Fig 3 The needle will reappear at the palatal aspect.
technique combining double sling with in-
terrupted sutures has been also previous-
ly reported.9

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Anchorage sutures were described as a ss e n c e fo r
further modification to better maintain the
coronal position of a flap. One option for
anchoring such sutures are the incisal con-
tact 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 com-
pression 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 sutur-
ing technique are the coronal positioning
as well as the compression of the flap. With
b
the help of an anchorage point, which is lo-
cated 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 anchor-
age point applies pressure of the flap to the
underlying tissues.
Prior to suturing, the contact points of the
affected teeth need to be temporarily splint-
ed with a flowable, light-curing resin mate-
rial. Due to undercuts in the interproximal
areas, no additional etching or bonding
needs to be applied.
Starting at the buccal aspect (Fig 1), the
c
needle is guided through the buccal soft
Fig 4 The needle is guided from the palatal side over
tissue complex approximately 5 mm apical
the contact point (a), wrapped around it (b), and
to the tip of the papilla, but never apical to passed underneath the contact point back to the palatal
the muco-gingival junction (Fig 2). The su- side without pinching the soft tissue (c).

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ture will reappear in the base of the ss e n c e
fo r
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 approxi-
mately 5 mm apical to the tip of the papilla
Fig 5 The needle is guided from the palatal side (Fig 5). After passing the interdental area,
back to the buccal aspect. 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 buc-
cal 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 tis-
sue complex in the desired coronal posi-
tion (Fig 8). The crossing of the suture
a
around the contact point in the interproxi-

b c

Fig 6 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).

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a b

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 Healing situation after 1 week, prior to re- Fig 11 Situation after 5 months.
moval of the sutures. Uneventful healing is noticed.

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mal area applies pressure in particular to with tunneling flap preparation techniques
ss e n c e
fo r
the underlying connective tissue graft. 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 augmenta-
tion (Figs 20 to 23).
Discussion The double-crossed suture meets a se-
ries 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 Preoperative view of the anterior maxilla Fig 13 Postoperative situation.


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

Fig 14 Healing situation after 1 week, prior to re- Fig 15 Situation after 4 months.
moval of the sutures.

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graft. Conclusively,t e sthe
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mobilization and stabilization of the elevat- nective tissue
se nc e
fo r
ed gingivo-papillary complex can be 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 to nutrition and survival of the tance for the healing process. A thin clot
elevated buccal soft tissue and the con- promotes tensile strength and stability of

Fig 16 Preoperative situation in the anterior maxilla Fig 17 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- Fig 19 Situation 11 months after final implant crown
moval of the sutures. cementation (dental technician: Uli Schoberer, See-
hausen, Germany).

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Fig 20 Preoperative view of the anterior maxilla with Fig 21 Postoperative situation.
a congenitally missing left lateral incisor designated for
soft tissue ridge augmentation.

Fig 22 Healing situation after 1 week, prior to re- Fig 23 Situation 6 months after cementation of a full
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

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acellular dermal matrix graft: a clinical and thisto-
ot

n
of 3-0 sutures led to tissue breakage in
logical evaluation of a case report. J Periodontol e n
fo r
contrast to the use of 7-0 sutures, which
1998;69:1305–1311.
only caused breakage of the thread. The 6. Zucchelli G, Cesari C, Amore C, Montebugnoli L,
authors concluded that tissue trauma and De Sanctis M. Laterally moved, coronally
advanced flap: a modified surgical approach for
flap tension can be reduced by choosing isolated recession-type defects. J Periodontol
finer suture diameters.15 Considering these 2004;75:1734–1741.
7. Zucchelli G, De Sanctis M. The coronally
findings, a thin suture material (6-0/7-0)
advanced flap for the treatment of multiple reces-
may be suitable to achieve passive wound sion defects: a modified surgical approach for the
adaptation and to lower the risk of tissue upper anterior teeth. J Int Acad Periodontol
2007;9:96–103.
trauma.16 Furthermore, finer suture materi- 8. De Sanctis M, Zucchelli G. Coronally advanced
al, in combination with the implementation flap: a modified surgical approach for isolated
recession-type defects: three-year results. J Clin
of a microsurgical concept, has been
Periodontol 2007;34:262–268.
demonstrated to significantly improve 9. Huang LH, Wang HL. Sling and tag suturing tech-
postoperative revascularization of connec- nique for coronally advanced flap. Int J Periodon-
tics Restorative Dent 2007;27:379–385.
tive tissue grafts during the initial healing 10. Azzi R, Etienne D, Takei H, Fenech P. Surgical
phase.17 thickening of the existing gingiva and reconstruc-
tion of interdental papillae around implant-sup-
In conclusion, the proposed suturing
ported restorations. Int J Periodontics Restorative
technique offers, in a variety of clinical sit- Dent 2002;22:71–77.
uations, the opportunity to stabilize the 11. Zuhr O, Fickl S, Wachtel H, Bolz W, Hürzeler MB.
Covering of gingival recessions with a modified
buccal-soft tissue complex in a coronal microsurgical tunnel technique: case report. Int J
position and to enhance the adaptation of Periodontics Restorative Dent 2007;27:457–463
12. Wikesjö UM, Nilveus RE, Selvig KA. Significance
the buccal flap and any connective tissue
of early healing events on periodontal repair: a
graft to the underlying nourishing tissues. 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
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