Periodontal Flap Surgery

-Flap Positioning -Suturing -Healing after Flap Surgery

Flap Positioning

Replaced Positioned - Apically positioned - Coronally positioned - Laterally positioned

Flap Positioning

Replaced Flap

Apically Positioned Flap

Flap Positioning

Coronally Positioned Flap

Flap Positioning

Laterally Positioned Flap

Suturing
The term suture describes any strand of material utilized to ligate blood vessels or approximate tissues. The primary objective of dental suturing is to position and secure surgical flaps in order to promote optimal healing.

Suturing
The goals of suturing are as follows: Provide adequate tension for wound closure, but loose enough to prevent tissue ischemia and necrosis Maintain hemostasis Permit healing by primary intention Reduce postoperative pain Prevent bone exposure resulting in delayed healing and bone resorption Permit proper flap position

Needle design

Silverstein LH. Principles of Dental Suturing

Conventional Cutting Suture Needle

Silverstein LH. Principles of Dental Suturing

Reverse Cutting Suture Needle

Silverstein LH. Principles of Dental Suturing

Tapercut Suture Needle

Silverstein LH. Principles of Dental Suturing

Suturing instruments
A B C D

A. Corn suture pliers

B. Adson tissue pliers C. Castroviejo needle holder

D. Scissors

Suturing instruments

Types of suture materials

Nonresorbable Silk Polyester Nylon PTFE Resorbable Natural Plain gut Chromic gut Synthetic Coated Vicryl

Types of suture materials

Suture Type Resorption Rate Tensile strength Tissue reaction Uses

Chromic Gut

7-10 days by proteolytic enzymatic digestive process

56-70 days, by slow hydrolysis

Moderate

Rapidly healing mucosa Avoid suture removal

Resist muscle pull, subepithelial mucosal surfaces, resorbable Mucosal surfaces Non-resorbable

Coated Vicryl

+++

Minimal

Surgical Silk

Non-resorbable (gradual encapsulation by fibrous CT) Non-resorbable

++

Moderate

ePTFE (Gore-Tex)

+++

Extremely low

All types of tissue approximation

Suturing techniques
Some common methods:

Interrupted sutures Simple loop modification Figure 8 modification Sling sutures Independent sling suture Continuous sling suture

Suturing techniques

Sutures, inserted through the more mobile flap first Should be placed no closer than 2-3 mm from the edge of the flap In the interdental papilla should enter and exit the tissue at a point located below the imaginary line that forms the base of the triangle of the interdental papilla

Simple Loop Modification of Interrupted Suture Technique

Silverstein LH. Principles of Dental Suturing

Simple Loop Modification of Interrupted Suture Technique

Figure 8 Modification of Interrupted Suture Technique

Single Interrupted Sling Suture Technique

Silverstein LH. Principles of Dental Suturing

The continuous, independent sling suture

The continuous, independent sling suture

Photo courtesy: Dr. Claman

Surgical knotting techniques

Silverstein LH. Principles of Dental Suturing

Square Knot

Silverstein LH. Principles of Dental Suturing

Slip Knot

Silverstein LH. Principles of Dental Suturing

Surgeons Knot

Silverstein LH. Principles of Dental Suturing

Periodontal Dressings
To protect the wound postsurgically To obtain and maintain a close adaptation of the mucosal flaps to the underlying bone For patient comfort

Periodontal Dressings

Coe-Pak, commonly used One tube contains oxides of various metals (mainly zinc oxide ) and lorothidol (a fungicide). The second tube contains non-ionizing carboxylic acids and chlorothymol (a bacteriostatic agent). Equal parts from both tubes are mixed together immediately prior to insertion.

Post-operative care

Post operative plaque control - 0.12% chlorhexidine (Peridex, Periogard) Maintaining good postsurgical wound stability - adequate suturing technique - protection from mechanical trauma to the marginal tissues during the healing phase.

Suture Removal
Use a disinfecting mouthwash to clean the wound of all debris. The suture knot is elevated off the tissue utilizing cotton pliers. The suture is cut as close to the tissue as possible in order to avoid dragging bacteria through the wound. When removing continuous sutures, each section should be cut and pulled out individually.

Suture Removal