The international Jouinai of Periodontics & Restorotive Dentistry

37

Functional and Esthetic

Outcome Enhancement of
Periodontal Surgery by
Application of Piastic
Surgery Principles

Morkus B. Hurzeler. DDS. Dr Meó Dent. PhD' For many yeors the goais of
Dietmar Weng. DDS. Dr Meo Dent" periodontai surgery have been
determined by functional as-
pects oniy: osseous surgery or
The closure ot surgical wounds in a layer-by-layer fashian. a common prin- modified Widman tlap surgery
ciple of plastic surgery, is applied in this article to the field of periodantat for eiiminating or reducing
surgery with the introduction of a now nap design. The suggested tech- pockets,'-^ apically repositioned
nique is Indicated with all periodontal procedures that aim for hard and flaps tor preserving gingival tis-
soft tissue augmentation (guided bone regeneration, muoogingivai sue,^ and mucogingival surgery
surgery, or plastic periadontal surgery) where passive, tension-free wound for increasing the zone of at-
closure is fundamental for wound heating and a successful functional and tached gingiva and eliminating
esthetic outcome. By means at a series ot incisiohs. buocal and lingual
frenum pull" or halting progres-
flaps are split several times; this results in a double-partial thickness flap
sive gingival recession,^ During
and a coronatly positioned palatal sliding flap, respectively. Thus, several tis-
sue layers are obtained and the passive advancement of flaps becomes
recent years periodontal sur-
possible for the coverage of augmented areas. Wound closure with micro- gery has shifted its focus from
surgical suture materiai is accomplished in a multilayer approach, which achieving mere functional
ensures adaptation and closure of the outer tissue layers without any ten- goals toward a combination of
sion. Two case reports demonstrate the new plastic periodontal approach. both good functional and es-
Qr\iJ Periodontics Restorative Dent 1999:19:37-43.) thetic results. While accomplish-
ing the best possible functional
result (eg, exposure ot subgingi-
val restoration margins, barrier
•Private Practice, Munioh; and Ciihicai Associate Professor, membrane piacement for guid-
Department of Restorative Dentistry ond Period ontology, Dentai ed bone regeneration, or im-
School, Albert Ludwigs University of Freiburg, Germany, piant insertion in an ideai posi-
""Department of Prosthodontics, Dentai Schooi, Bayerische Juiius
Moximiiians University of Wüízburg, Germany; and Division of
tion), esthetics should not only
Periodontics, Dentai Branch, University of Texas at Houston, be maintained (and certainly
nof worsened, eg, by scarring or
Reprint requests: Dr Dietmar Weng, Bayerische Julius Moximilians loss of interdental tissue), but
University of WCirzburg, Dental Schooi, Department of
Proslfiodontics, Pleicherwall 2,97070 Wurzburg, Germany,
aiso enhanced. Sometimes the
e-maii: dietmar.weng@moil,uni-wuerzburg.de esthetic outcome is the only

Volume 19,Number I,1W9

38
important factor and function
becomes secondary (eg, treat-
ment of recessions tor esthetic
reasons or the creation of popil-
iae), Prediotabiiity becomes the
key word in this type of peri-
odontai surgery.
To produce predictable
functionai and esthetic out-
comes, the application of pias-
tic surgery principles to peri-
odontai surgery can be helpfui
because these disciplines share
common characteristics such
as emphasis on esthetics, flap
advancement, and rotation;
grafting techniques; and the
wish fo prevenf scarring,*
Incision design and suturing
technique criticaiiy infiuence
the postoperative wound heal-
ing process in terms of biood
suppiy and flap survival.'' If the
latter is not compieteiy guaran-
teed, esthetic as well as func-
tional success becomes unpre-
dicfabie. The infroduction of
microsurgical insfrumenfs info
periodontai surgery has signifi-
cantly contributed to o new
ccncept of tissue handiing.
It is the purpose of this arti-
cle to present a multilayer op-
proach to flap handiing in peri-
odontai surgery to enhanoe
functionai and esthetic out-
comes.
Surgical technique
The main objective of the foi-
iowing tlap design is to ailow the
passive advancement of bofh
The Internationol Journal of Periodontics â Restorative Dentistry
the iingual and the bucoal flap.
if employs a series of incisions to
spiit the mucosa into several lay-
ers, permifting tension-free mo-
biiization and adaptation of the
tissues (Fig 1), The proposed
suturing technique is designed
to avoid any tension in the out-
ermost tissue iayer after flap cio-
sure. Therefore, this technique is
indicated whenever the passive
ciosure of flaps is crucial for a
successful outcome, eg, when
covering barrier membranes
affer guided bone regeneration
or when gaining tissue height for
the creation at papillae. Micro-
surgicai instruments and suture
materiais in combination with
ioupes or a surgicai microscope
will greatly contribute to the
achievement of this goai.
Affer delivery ot a iocai
anesthetic agent, C-shaped
vertical releasing incisions are
piooed on the buccal aspect
at individual discretion, depend-
ing on accessibiiity of the area
for a specific procedure and on
fhe neoessity tor flop advance-
ment. The C-shaped incision
aiiows advancement of the fiap
coronoliy by reducing tension
on the nourishing blood vesseis
at fhe base of the tlap.^ A
slightly iingualiy placed para-
crestai incision is then made ta
the bone at a 90-degree angie
toward the outer surface.
Starting from this paracrestal
incision, a fuli-thickness flap is
elevated 2 to 3 mm beyond the
mucogingival junction. From this
point, the flap is continued os a
partioi-thickness preparation
into the vestibule (Fig l a ) . In
contrast to the traditionai tull-
parfial thickness fîap design,' it is
necessary fo leave as much
connective tissue as possibie en
the periostium during this prepa-
ration. Thereafter, the remaining
layer o1 connective tissue and
periostium is eievated 2 to 3 mm
from the bone surtace and then
spiit a second time into the
vestibule (Fig 1 b). It is thus possi-
ble to obtain an inner flap thot
is 1.5 to 2.0 mm fhiok (Fig 1 c). By
positioning the inner tlap coro-
naiiy, fhe outer fiap will move
coronally as well, and a tension-
free adaptation wili be possible.
On fhe paiatai aspect ct the
maxiiia, a coronaiiy positioned
paiatai siiding flap—as de-
scribed by Tinfi and Parma-
Benfenoti^"—is recommended
(Fig Id). Briefly, verticai reieasing
incisions are made on the mesiai
and distal ends of the previously
described paracrestal incision.
An "accordion" flap is then pre-
pared, ie, 2 undermining sharp
preparations are started in ditfer-
enf pianes. The first preparation
is started within the paracresfai
incision iine and runs coronoapi-
cally approximafely 1.5 mm
beiow the surface. The second
preparafion sfarts inside a sec-
ond horizontai incision line thcf
connects the apicai extensions
ot the vertical incisions. This
preparation runs apicocoronally
and is also parallel to the outer
flap contour, but it is iocated at
a deeper ievei than the lirst one.
 39

fig l o Fuii-thickness preparation is
carried out 2 to 3 mm beyond the
mucogingival¡unction (biue dot) and
then continued as a partiai-thickness
dissection into the vestibule, it is impor-
tant to leave a sufficient amount of
connective tissue an the periostium.
Fig tb Second sharp preparation is
started In an apical direction within the
remaining layer ot periostium and con-
nective tissue. (Biue dot = mucogingival
junction.)
Fig Ic Resulting doubie-partial thick-
ness Hap with an outer and an inner
flap The periostium in the apical part Is
stili attached to the bone. (Blue dot =
muc ogingival jun cf ton.)

Fig ld(\eff) Palatal top con öe

unfolded and moved toward the öuc-
cal aspect because of the tissue
preparation in 2 different pianes.

Fig Ie (rigtit) Inner layer is sutured

with horizontal mattress sutures, inner
buccal and lingual Haps are approxi-
mated over the augmented sits

Fig KQeft) CaranaiSypositioned

palatal sliding flap ('accardion " nap) is
prepared on the palatal aspect of the
maxiiia. creating 2 tissue layers. (Blue
dot = mucogingival junction.)

Fig }g (right) There is no tension in the

outer top upon suturing in multiple lay-
ers aver the augmented area; the flaps
adapt passiveiy.

Volume 19, Number 1,1999

40
Care has to be taken that the
higher dissection line does net
meet the seoohd horizontal inci-
sion, and that the deeper dis-
section line dees not meet the
original paracrestal incision. The
palatai fiap can then be un-
tolded like an accordion, and
advanoement toward the buc-
oal side is facilitated (Fig 1 e). This
flap design allows an inner flap
and an outer flap, whioh is oru-
cial for using piasfic surgery prin-
ciples such as suturing different
layers of tissues during wound
closure. The cpranaily positioned
sliding flap design cannot be
used on the lingual aspect of
the mandible. In this area, a
combined fuii-partial thickness
flap must be raised: after eievat-
ing a fuii-thickness fiap approxi-
mafeiy 2 to 3 mm beyond the
muocgingival junction, a partial-
thiokness dissection is oorried out
so that the flap can be easiiy
positioned as far coronaliy as
needed.
After preparation of these
flaps, any necessary augmenfa-
ticn procedure (barrier mem-
brane, bone gratt, connective
fissue graft, or any oombinafian
of these) is performed.
Repcsitianing and suturing
of the flaps is accomplished in
a muitilayer approach, it is thus
possible fo suture net oniy in dif-
ferent planes but also in differ-
ent layers, which is one of the
concepts cf piastio surgery. The
material of choice has a suture
size of # 7-0 or 8-0, and should
be resorbabie for the inner layer
The Internafionol Journol of Periodontics S Restorative Dentistry
and nonresorbable for the
outer layer. Whenever possible,
nonresorbabie sutures should
be used, sinoe a resorbabie su-
ture wiii always increase the
intlammatcry response during
the healing process.''^"''^ First,
the inner linguai and buooai
flaps are readapted and su-
tured with a crossed hcrizontai
mattress suture. Because of the
vertical and horizontai aug-
mentation of the site, compiete
olosure of this tissue iayer wiii
not be achievable in all oases
(Fig if^.After suturing the 2 inner
flaps, the 2 outer flaps can be
readapted without any tension
beoause the inner flaps are
conneoted at their base with
the outer flaps. This wiii allow
suturing with # 7-0 and 8-0
sutures without the potentiai
danger of tearing fhe fiaps. A
horizontal mattress suture is per-
formed at the level of the
muccgingival junction to adapf
fhe 2 outer flaps. Sinoe both the
buccal and lingual fiaps consist
of connective tissue and epi-
thelium oniy, the approximation
is additicnaliy simplified. Within
the outer fiaps, but more coro-
naliy 1 or 2 additional horizontai
mattress sutures are placed,
each suture bringing the buc-
cai and lingual tissue margins
cioser together. Finally, inter-
rupted or oontinucus sutures
are perfcrmed at the tpp of the
incision. This final suture layer will
be dene without any tension
CFiglg).
Case reports
Case J
The new plastic surgical ap-
proach was used to horizcn-
tally augment the mandibuiar
right posterior area in combi-
nation with implant piaoe-
ment. After a crestal inoision,
the double-partial thickness
design was prepared on the
buccai aspect, while on the
iingual aspeot a fuil-partiai
thickness fiap was used. En-
dossecus oral impiants were
then placed (Fig 2a), and the
area was augmented with Bio-
Oss (Osteoheaith) and cov-
ered with an expanded pciy-
tetrafluoroethyiene (e-PTFE)
membrane (Gore-Tex Aug-
mentation Material, 3i/Gore).
The inner flap of the buccal
side was sutured to the oon-
neotive tissue of fhe linguai
fiap with horizontal mattress
sutures (Fig 2b). The outer buo-
cai fiap was then fixed to fhe
linguai fiap with severai hcri-
zonfal matfress sutures and a
continuous suture (Fig 2c). Five
days later, healing cf the aug-
mented area hod occurred to
an advanced degree (Fig 2d).
Seven months after the aug-
mentation procedure, the pa-
tient presented for abutment
placement with no scar tissue
visible in the surgical area (Fig
2e).
 41

Fig 2a After plocemenf of 3 Fig 2c After the outer flaps ore

endosseous impionts. bony dehiscences sutured, the tissues ore held ih place
occurred on the buccai aspect. without tension.

Fig 2b (right) Horizontai mattress

sutures approximate the ¡nner buccai
flap to the lingual nap.

Fig 2d Occiusoi view of ir>e surgicai Fig 2e No scor tissue is visibie 7 months offer initiai sutgery at preserifation for sec-
orea after 5 days. ond-stoge surgery..

Volume 19, Number 1,1999

42
Fig 3a Four weeks after extraction of
the maxillary central incisors the
patient is ¡cheduied for augmentation
of the maxiilary anterior region.
Case 2
In this case the new flap design
was applied to augment a
maxiiiary anterior region with
autogenous bone. The patient
presented 4 weeks after extrac-
tian of his periodontaily cam-
promised maxiiiary central
incisors (Fig 3a), After preparing
the previously described flaps
on the buccal and lingual as-
pects, a piece of autogenous
bone was harvested from fhe
chin and fixed with 2 endos-
seaus impiants in the area of
the extracted central incisors.
The area was filled with autoge-
nous graft materiai and cov-
ered with a Bio-Gide barrier
(Osteoheaifh), Four months
later (Fig 3b), the patient was
scheduled for an additional soft
tissue augmentation proce-
dure, which was performed
The Internationai Journal cf Periodontics & Restorative Dentistry
Fig 3b Healing of augmented site 4
months postoperative.
according to the same tech-
nique, Fcur-month healing after
the soft tissue augmentation is
shown in Fig 3c,
Discussion
The concept of multilayer
wound ciosure has evoived
from general surgery, in which
surgicaliy or traumatically cre-
ated wounds are reunited layer
by iayer. This technique ensures
proper adaptation af the same
kind of tissue, which subse-
quently has to bridge smailer
gaps to achieve true regenera-
tion. The method of multipie
suturing also distributes the ten-
siie forces over severai sutures
and ailcvi/s the most passive
adaptation possible in the out-
ermost tissue layer. This is impor-
tant because it has been
Fig 3c Healihg result 4 months after
soft tissue augmehtatioh procedure.
proven that the tension pro-
duced by sutures should be
kept as minimai as possible.'
Everyday periodontai surgery
shows that heaiing and regen-
erative results are seriously com-
promised when the flap cannot
be kept completely closed.
There are 2 main reasons why
flaps can open; (1) suture loos-
ening with eventual loss, and (2)
sutures tearing the flap margins
or compromising blood suppiy
as a result of excessive tensiie
forces. The first problem can be
addressed by proper choice of
suture materiai and correct knot
techniques, and the second
problem can be solved by ade-
quate passive fiap advance-
ment and verticai tensiie force
distribution. Sutures should never
act as ligatures, but only adapt
flaps and hold them in the
proper position.

In general, puncturing peri-
odonta! flap tissue with a nee-
dle represents a reduction in the
avaiioble blood supply. This
holds true especially in areas in
which the blood supply is ai-
reody reduced by either an-
atomic space iimifafions (eg,
papiilary area) or by impiant
materials (eg, barrier mem-
branes). By choosing micrcsurgi-
cal suture materials (# 7-0 or 8-
0), the number ot sutures within
a given tissue area can be in-
creased without further com-
promising the blood supply.
iHandling such materials, how-
ever, usualiy requires magnifica-
fion devices fo controi their
exact manipulation.
Partial-thickness prepara-
tions ot periodontai flaps neces-
sitate a certain omount of tissue
thickness. Especiaily when these
preparations are performed
severai times within the same
flap, proper fiap thickness is
necessary to maintain sufficient
fiop nourishment and tissue
strength to withstand the forces
of the suture material.
43
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Volume 19. Number 1,1999