Professional Documents
Culture Documents
No Co
t fo
ht
rP
by N
ub
lica
Q ui
tio
te ot n
A Modified Suture Technique
n
ss e n c e
fo r
338
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
ZUHR ET ALopyrig
No C
t fo
ht
rP
by N
ub
lica
Q ui
tio
wound adaptationt eand
otn
n
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)
339
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
CLINICAL APPLICATION pyrig
No Co
t fo
ht
rP
by N
ub
lica
Q ui
tio
te ot n
n
ss e n c e
fo r
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.
340
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
ZUHR ET ALopyrig
No C
t fo
ht
rP
by N
ub
lica
Q ui
tio
te n ot
n
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
341
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
CLINICAL APPLICATION pyrig
No Co
t fo
ht
rP
by N
ub
lica
Q ui
ti
tepalatal on ot
n
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).
342
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
ZUHR ET ALopyrig
No C
t fo
ht
rP
by N
ub
lica
Q ui
tio
te n ot
n
ss e n c e fo r
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.
343
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
CLINICAL APPLICATION pyrig
No Co
t fo
ht
rP
by N
ub
lica
Q ui
tio
te otn
n
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 14 Healing situation after 1 week, prior to re- Fig 15 Situation after 4 months.
moval of the sutures.
344
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
ZUHR ET ALopyrig
No C
t fo
ht
rP
by N
ub
lica
Q ui
tio
graft. Conclusively,t e sthe
otn
n
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).
345
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
CLINICAL APPLICATION pyrig
No Co
t fo
ht
rP
by N
ub
lica
Q ui
tio
te ot n
n
ss e n c e
fo r
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
346
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
ZUHR ET ALopyrig
No C
t fo
ht
rP
by N
ub
lica
Q ui
tio
ess c e n
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
References Periodontol 1984;55:345–351.
14. Pini Prato G, Pagliaro U, Baldi C et al. Coronally
1. Wong ME, Hollinger JO, Pinero GJ. Integrated advanced flap procedure for root coverage. Flap
processes responsible for soft tissue healing. Oral with tension versus flap without tension: a ran-
Surg Oral Med Oral Pathol Oral Radiol Endod domized controlled clinical study. J Periodontol
1996;82:475–492. 2000;71:188–201.
2. Baldi C, Pini Prato G, Pagliaro U et al. Coronally 15. Burkhardt R, Preiss A, Joss A, Lang NP. Influence
advanced flap procedure for root coverage. Is of suture tension to the tearing characteristics of
flap thickness a relevant predictor to achieve root the soft tissue: an in vitro experiment. Clin Oral
coverage? A 19-case series. J Periodontol Impl Res 2008;19:314–319.
1999;70:1077–1084. 16. Pini Prato GP, Baldi C, Nieri M et al. Coronally
3. Bernimoulin JP, Lüscher B, Mühlemann HR. advanced flap: the post-surgical position of the
Coronally repositioned periodontal flap. Clinical gingival margin is an important factor for achiev-
evaluation after one year. J Clin Periodontol ing complete root coverage. J Periodontol
1975;2:1–13. 2005;76:713–722.
4. Restrepo OJ. Coronally repositioned flap: report 17. Burkhardt R, Lang NP. Coverage of localized gin-
of four cases. J Periodontol 1973;44:564–567. gival recessions: comparison of micro- and
5. Harris RJ. Root coverage with a connective tissue macrosurgical techniques. J Clin Periodontol
with partial thickness double pedicle graft and an 2005;32:287–293.
347
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
The author has requested enhancement of the downloaded file. All in-text references underlined in blue are linked to publications on ResearchGate.