Periodontal Flap Surgery: Closure and Suturing Flashcards
What are the two types of flap positions?
Replaced
Positioned (apical, coronal, lateral, etc)
Replaced Flap
Returned to its original positions
Seen in a modified Wideman flap
Apically Positioned Flap
Eliminates the pocket by apically displacing the soft tissue wall of the pocket
In doing so, it preserves or increases the width of the attached gingiva tissue by transforming the previously unattached keratinized pocket wall into the attached gingiva tissue
Coronally and laterally positioned flaps are useful for what?
Cover areas of gingival recession
Suture definition
Any strand o material utilized to ligate (tie) blood vessels or approximate tissues
What is the primary objective of dental suturing?
Position and secure surgical flaps in order to promote optimal healing
What are the overall goals of suturing?
Provide adequate tenison of wound closure without dead space, but loose enough to prevent ischemia and necrosis Maintain homeostasis Permit healing via primary intention Reduce post-op pain Prevent exposure
What are the different types of non-resorbable sutures?
Silk
Polyester (nylon, PTFE)
Silk suture resorption rate
Gradual encapsulation by fibrosis CT
Usually cannot be found after 2 years
Silk suture tensile strength
Moderate
Silk suture tissue reaction
Moderate
Silk suture uses
Mucosal surfaces
PTFE suture resorption rate?
Non-resorbable
PTFE suture tensile strength
Low
PTFE suture tissue reaction
Extremely low
PTFE suture uses?
All types of soft tissue approximaiton
What are the different types of Natural Resorbable sutures?
Plain Gut
Chromatic Gut
Chromatic Gut suture resorption rate
Resorbed by proteolytic enzymatic digestive processes in 7-10 days
Chromatic Gut suture tensile strength
Low
Chromatic Gut suture tissue reaction
Moderate
Chromatic Gut suture uses
Rapidly healing mucosa
What is an example of a synthetic suture?
Coated vicryl
Coated vicryl suture resorption rate
Resorbed slowly by hydrolysis between 56-70 days
Coated vicryl suture tensile strength
High
Coated vicryl suture tissue reaction
Minimal
Coated vicryl suture uses
Used to resist muscle pull
Subepithelial mucosal surfaces
What are qualities of ideal suture material?
Pliable for ease of handling Knot security Sterilizable Appropriate elasticity Nonreactive Adequate tensile strength for wound healing
What sutures are used the most often?
Silk
Synthetic (Coated vicryl)
When are gut sutures used?
Only when retrieval is difficult
When are monofilament (PTFE) sutures used?
They’re recommended for bone augmentation procedures to prevent the “wicking” and to reduce inflammation response and permit longer reaction
What sutures are recommended for Guided Tissue Regeneration?
Gore-Tex
Coated Vicryl
Suturing force should be applied in what direction?
A direction that follows the curvature of the needle
Suturing should always be done from ____________ to ___________
Movable to non-movable tissue
Where should a needle be grasped?
1/4 - 1/2 the length from the swaged area
Why should you not grab or retrieve the needle from the tip?
It will damage or dull the needle
What type of tissues should sutures be placed?
Keratinized tissue (whenever possible)
Why do we need adequate tissue bite when suturing?
Prevent the tissue form tearing
Where do we want to make sure NOT to place sutures?
Incision lines - otherwise, wicking of bacteria can occur
How far should suture ends be tied from the knot?
2-3mm
What are the 3 components of a knot?
The loop created by the knot
The knot itself
The ears (the ends that get cut)
What are the 3 parts of a surgical needle?
Eye
Body
Point
Eye of a needle
Swaged area that permits the suture and needle to act as a single unit to decrease trauma
Body of a needle
The widest point
Also referred to as the grasping point
Comes in a number of shapes (round, oval, rectangular, etc)
Point of a needle
Runs from the top to the maximum cross-sectional area of the body
How to hold the needle
The smaller the needle, the smaller the holder require
Grasp 1/4-1/2 distance from swagged point to tip
The needle should be placed securely in the tips of the jaws, and should not rock, twist, or turn
Do not over close the needle holder to avoid causing damage to the needle
When are Simple loop modification of interrupted sutures used?
When facial and lingual flaps have been elevated
Most commonly used suturing technique used in dentistry
What is the technique/steps used to do a simple loop modification of interrupted suture?
Pass the needle through the facial flap on the outer (epithelial) side
Pass the needle under the contact
Pass the needle through the lingual flap on the inner surface
Pass the needle under the contact again
Tie the facial surface of the tooth so that the knot is not on the incision line
Cut the suture material 2-3mm from the knot
When are Figure 8 Modification of Interrupted Sutures used?
In very restricted areas (ie lingual of second molars)
What is the technique/sutures of Figure 8 Modification of Interrupted Sutures?
Pass the needle through the facial flap from the outer (epithelial) surface
Pass the needle under the contact
Reverse the needle and enter the lingual flap from the epithelial (outer) surface
Pass it back under the contact
Tie off the facial surface of the tooth so that the knot is not on the line of incision
Cut the suture material 2-3mm from the knot
When is a Single Interrupted Sling suture indicated?
When a flap has been elevated on only one side of the arch
OR
When the facial and lingual flaps are to be positioned on different levels
It involves 2 papillae
What is the technique/Steps for a Single Interrupted Sling Suture technique?
Pass needle through outer surface of the most mesial papilla
Move the suture around the tooth
Pass the suture under the distal contact point of the same tooth
Penetrate the flap with the suture needle from its inner side
Pass the needle back under the distal contact, around the tooth, under the mesial contact, and tie a knot
Tie and cut
When is a Continuous Independent sling suture technique indicated?
Flap with three or more papillae on only one surface
Continuous Independent sling suture technique/steps
Begin at the distal aspect by tying an interrupted suture and cutting the short end only
Pass the needle under the contact point to the opposite side
Loop the needle and threat around the tooth
Pass the needle through the next interdental area below the contact point w/o penetrating the tissue
Penetrate the flap from the outer surface
Repeat the procedure until the last interdental area with the needle ending on the opposite side of the flap
Prior to tying the suture, adjust the tension in order to obtained desired flap positioned
How do you tie a Continuous independent sling suture?
Leave a loop 15-20 mm in length on the flap side of the last tooth during the final pass through
The slack suture is handled as if it were a free end suture and tied in the usual manner on the opposite side of the elevated mucoperiosteal flap
T/F - Periodontal dressing provide curative properties
False - they provide no curative properties
They assist in healing by protecting the tissues during the healing stage
Why are periodontal dressings used?
Protect the wound postsurgically
To obtain and maintain a close adaptation of the mucosal flaps to the underlying bone
For patient comfort
What is a disadvantage of Periodontal Dressing?
Mouth rinsing with antibacterial agents does not prevent the formation of plaque under the dressing
Data shows dressings may be unnecessary after flap procedures and may be usefully replaced by rinsing with chlorohexidene
CoePak
Commonly used Perio Dressing
Comes in 2 tubes that are mixed together
What is the most important variable in determining the long-term result of periodontal surgery
Plaque control
How are patients expected to do plaque control post-surgically?
Rinse with 0.12% Chlorohexidene 2x a day during the post-op period until normal plaque control techniques can be resumed
After that it is important to maintain good mechanical measures
What provides post-op wound stability
Good suturing technique
How do you remove sutures?
Pt rinses with chlorohexidene to clean wound of all debris
Knot is elevated off tissue with cotton pliers
Cut the suture as close to the tissues as possible in order to avoid dragging dirty suture through tissues
What are the stages of healing
1) Inflammation
2) Fibroblastic-granulation
3) Matrix formation and remodeling
Immediate response of Primary Intention
Blood clot forms between the flap and tooth/boneThe clot contains fibrin reticulum, neutrophils, erythrocytes, platelets, debris of injured cells, and capillaries at the edge of the wound
Primary Intention within 24 hours
Neutrophils infiltrate the CT
Epithelium migrates from the wound margin and begins to cover the wound
1-3 Days of Primary Intention
The space between the flap and the tooth or bone thins
Epithelial cells migrate over the border of the flap, usually contacting the tooth
3-7 Days of Primary Intention
Epithelial migration continues
Neutrophils are replaced by macrophages, which eliminate dead or damaged tissue elements
The incision space begin to fill with granulation tissue
Revascularizaiton begins
1 Week of Primary Intention
Epithelial attachment to the root forms by means of hemidesmosomes and basal lamina
Blood clot has been replaced by granulation tissue derived from the gingival Ct, bone marrow, and PDL
2 Weeks of Primary Intention
Collagen fibers begin to appear parallel to tooth surface
Union of the flap to the tooth is weak because collagen fibers are immature
How does secondary intention differ from primary intention
There is more necrosis, therefore the inflammatory response is more intense
More granulation tissue forms to fill the larger void
Wound contraction is much more pronounced
Repair
Damaged tissues are replaced by tissues that do not duplicate the original function or architecture of the original tissues
This is the usual outcome of therapy
Regeneration
Damaged tissues are replaced by tissues that duplicate the structure and function of the original tissues
Ideally, this should involve the formation of new cementum, PDL, and alveolar bone
Rare, but most desirable outcome
What factors make periodontal regeneration unpredictable?
Wound is contaminated by many types of bacteria
Regeneration requires action by many specialized types of cells
Requires the formation of several specialized junctional complexes
Root surface is avascular - can’t provide new blood
Requires complex interactions between the ECM and cells
