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

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

Moderate

Rapidly healing
mucosa
Avoid suture
removal

Coated Vicryl

56-70 days, by
slow hydrolysis

+++

Minimal

Resist muscle
pull, subepithelial
mucosal
surfaces,
resorbable

Surgical Silk

Non-resorbable
(gradual
encapsulation by
fibrous CT)

++

Moderate

Mucosal surfaces
Non-resorbable

ePTFE
(Gore-Tex)

Non-resorbable

+++

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 nonionizing 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