J Clin Periodontol 2014; 41 (Suppl. 15): S98–S107 doi: 10.1111/jcpe.

12193

Fundamental principles in Rino Burkhardt and Niklaus P. Lang

The University of Hong Kong, Prince Philip
Dental Hospital, Hong Kong SAR and

periodontal plastic surgery and University of Zurich, Zurich, Switzerland

mucosal augmentation – a
narrative review
Burkhardt R, Lang NP. Fundamental principles in periodontal plastic surgery and
mucosal augmentation - a narrative review. J Clin Periodontol 2014; 41 (Suppl. 15):
S98–S107. doi: 10.1111/jcpe.12193.

Abstract
Aim: To provide a narrative review of the current literature elaborating on fun-
damental principles of periodontal plastic surgical procedures.
Methods: Based on a presumptive outline of the narrative review, MESH terms
have been used to search the relevant literature electronically in the PubMed and
Cochrane Collaboration databases. If possible, systematic reviews were included.
The review is divided into three phases associated with periodontal plastic sur-
gery: a) pre-operative phase, b) surgical procedures and c) post-surgical care. The
surgical procedures were discussed in the light of a) flap design and preparation,
b) flap mobilization and c) flap adaptation and stabilization.
Results: Pre-operative paradigms include the optimal plaque control and smoking
counselling. Fundamental principles in surgical procedures address basic knowl-
edge in anatomy and vascularity, leading to novel appropriate flap designs with View the pubcast on this paper at http://
www.scivee.tv/journalnode/61758
papilla preservation. Flap mobilization based on releasing incisions can be per-
formed up to 5 mm. Flap adaptation and stabilization depend on appropriate
Key words: Periodontal plastic surgery;
wound bed characteristics, undisturbed blood clot formation, revascularization wound healing; wound closure; wound
and wound stability through adequate suturing. stability; clot formation; vascularity; suturing
Conclusion: Delicate tissue handling and tension free wound closure represent
prerequisites for optimal healing outcomes. Accepted for publication 11 February 2013

Periodontal plastic surgery encom-
passes “surgical procedures per-
formed to prevent or correct
anatomical, developmental, trau-
matic or disease-induced defects of
Conflict of interest and source of
funding statement
The authors declare no conflict of
interest. The present review has been
supported by the Clinical Research
Foundation (CRF) for the Promotion
of Oral Health, Brienz, Switzerland.
S98
the gingiva, alveolar mucosa or
bone” (Wennstr€ om 1996; Proceed-
ings of the World Workshop in Peri-
odontics 1996). Irrespective of the
differences in various techniques,
indications and surgical designs, a
number of basic principles are to be
considered if optimal treatment out-
comes are to be expected and unde-
sired complications prevented.
To optimize results, not only the
surgical procedure per se but also
the pre-operative measures and post-
surgical care are to be respected as
well.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
It is the aim of the present review
to elaborate on the fundamental
principles of periodontal plastic sur-
gery in a narrative way and to out-
line possible consequences in case of
omission or ignorance.
Pre-operative phase
The oral cavity represents a contami-
nated aquaeous environment that is
subjected to biofilm formation on
hard, non-shedding surfaces, such as
teeth, implants, prosthetic appliances
and biomaterials. Without any spe-

cial precautions biofilm formation
on these structures may severely
affect the healing process and jeop-
ardize treatment outcomes following
surgical procedures.
Poor oral hygiene has been dem-
onstrated to severely affect the opti-
mal outcome of, for example,
regenerative procedures in intrabony
defects (Tonetti et al. 1996). More-
over, environmental and behavioural
aspects such cigarette smoking have
been documented to negatively influ-
ence treatment results (e.g. Tonetti
et al. 1995, Chambrone et al. 2009,
Patel et al. 2012).
Therefore, it is obvious that the
two major influencing factors, poor
oral hygiene habits and cigarette
smoking have to be controlled prior
to performing elaborate periodontal
surgical procedures. There are three
major aspects by which optimal oral
hygiene practices contribute to suc-
cessful clinical outcomes: (a) healthy
periodontal soft tissues allow a pre-
cise incision, handling and closure of
the mucosal flaps (Yeung 2008) (b)
optimal oral hygiene prevents wound
infection (Heitz et al. 2004) and (c)
absence of biofilm promotes a non-
disturbed wound healing (Bartold
et al. 1992).
The periodontal status of the
dentition may influence the surgical
outcomes, some parameters have to
be evaluated routinely before the
surgical procedures. Among these,
the assessment of the oral hygiene
habits by quantifying plaque accu-
mulation (Silness & L€ oe 1964,
O’Leary et al. 1972) and the pres-
ence of bleeding on probing (BoP)
has been shown to detect an inflam-
matory lesion in the gingiva around
teeth (Lang et al. 1986). Absence of
bleeding on probing has been
reported to represent periodontal
health with a high negative predic-
tive value (Lang et al. 1990). To
ensure acceptable presurgical hygiene
conditions, the full-mouth bleeding
scores are recommended to be below
20% (Lang et al. 1996, Tonetti et al.
1995).
While adequate compliance of the
patient in performing oral hygiene
practices may be documented by low
percentages of BoP, smoking coun-
selling may lead to successfull cessa-
tion or at least significant reduction
in daily cigarette smoking, thus
improving healing (Bain 1996).
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
In addition, to reduce the bacte-
rial load in the oral cavity prior to
periodontal surgery, it is recom-
mended to let the patient rinse with
a 0.1 or 0.2% chlorhexidine digluco-
nate solution for 1 min. (Bonesvoll
et al. 1974, Gjermo et al. 1974).
Besides the local factors which
can be influenced presurgically, prep-
aration prior to periodontal surgery
should include a thorough examina-
tion and diagnosis and complete
assessment of systemic risk factors.
There is no doubt that our patients
population is consuming more and
more drugs, additionally, the geriat-
ric dental population is increasing.
Therefore, clinicians are confronted
with an increased number of patients
suffering from a systemic disease
which may interfere with the wound
healing after the surgery. Such multi-
ple disease states include hyperten-
sion, congestive heart failure,
diabetes, arthritis and osteoporosis.
In these individuals, polypharmacy is
the norm (Hersh & Moore 2008)
and the potential for adverse drug
interactions or increased risks for
adverse surgical outcomes must be
evaluated carefully prior to the
surgery (Vassilopoulos & Palcanis
2007).
Surgical procedures
The mucoperiosteal full- and split-
thickness flaps are the most com-
monly applied procedures in peri-
odontal plastic surgery. They may be
used in combination with or without
interposed connective tissue grafts.
The fundamental principles govern-
ing flap surgery may also be applied
to free mucosal grafting.
Flap surgery will be discussed
with respect to (a) flap preparation,
(b) flap mobilization and (c) flap
adaptation and stabilization.
Flap preparation
Flap design in periodontal plastic
surgery is substantially based on the
vascularization of the oral mucosal
and periodontal tissues to be incor-
porated in the surgery. In this
respect, the anatomical structures
and their vascular supply are key
issues. Recommendations for appro-
priate incision design have been pre-
sented in a human cadaver study
(Kleinheinz et al. 2005) applying
micro- and macroscopic visualization
Principles of wound healing S99
of the course and density of the
blood vessels supplying the various
regions of the oral cavity.
Based on reliable knowledge of
the distribution pattern and architec-
ture of the arterial vascular system of
the human oral mucosa, recommen-
dations for ideal flap preparation
and releasing incisions may be given:
(a) incise the sulcular area around
teeth and avoid marginal and para-
marginal incisions, (b) place midcres-
tal incisions in edentulous areas, (c)
avoid releasing incisions, (d) never-
theless, if a releasing incision is
required, carry it out as short and as
medially as possible, (e) do not place
releasing incisions on the buccal root
prominences as the mucosal tissues
covering roots are usually thin and
delicate (M€ uller et al. 2000). This
facilitates firm flap adaptation and
provides a better vascular network
within the pedicle flap.
Flaps are classified according to
their outline (e.g. semilunar, trian-
gle), the direction of the intra-opera-
tive advancement (e.g. rotating,
apically or coronally advanced) or
the composition of the contributing
tissues (e.g. full thickness, split thick-
ness). In contrast to connective tis-
sue grafts which get their nutrition
by plasmatic diffusion (Oliver et al.
1968), flaps are characterized by a
functioning network of vessels. Thus,
the main concern focused on the
importance of maintaining the blood
supply from vessels entering a pedi-
cle at its base when planning the flap
outline. Based on this aspect, for
many years, the clinical recommen-
dations tended to two aspects which
were to be noted before starting with
the first incision. These were a) a
broad flap base allowing many nutri-
ent vessels to proliferate into the flap
and b) a flap length to width ratio
which should not exceed 2:1 (Milton
1970). These principles were a logical
consequence of the fact that with
increasing flap width at its base an
increased blood supply and hence,
support of a greater flap length was
assured.
In recent years, however, a deeper
insight into the biological processes
of wound healing (Kleinheinz et al.
2005) let these recommendations
appear too simplistic and actually
have been proven to be a fallacy as
established already decades ago
(Milton 1970).
S100 Burkhardt and Lang
It cannot be assumed that major
vessels enter the base of mucosal
flaps at regular intervals. In addi-
tion, animal experiment revealed
that the mandibular vasculature was
characterized by arterial vessels
transversing somewhat obliquely in a
general posterior to anterior direc-
tion (Jeffcoat et al.1982). Most of
the conclusions of studies focusing
on vascular impairment are based on
histological examination of speci-
mens after vascular perfusion. They
suggest that blood vessels remain
intact and patent following surgery
(Karring et al. 1975). Alternative
techniques like fluorescein angiogra-
phy (M€ormann et al. 1975,
M€ ormann & Ciancio 1977) and
laser-Doppler flowmetry (Retzepi
et al. 2007a,b) are more reliable
techniques to qualitatively and quan-
titatively assess the vascularity of an
injured mucosal area.
Following horizontal incisions
along the mucogingival junction, the
blood supply of the gingiva was dis-
played with a fluorescent dye
(M€ ormann & Ciancio 1977). One
day after injury, the gingiva coronal
to the incision showed a severe anae-
mia which was more pronounced in
the inter-dental and papillary area
than on the tooth prominences. The
differences were explained by the
influence of the collateral vessels
coming from the periodontal liga-
ment and thus, contributing to the
marginal blood supply.
These results have been con-
firmed in another angiographic dog
study (McLean et al. 1995).
Based on historical and contem-
porary wound healing studies, novel
flap designs have been propagated
and validated in clinical trials with
respect to treatment outcomes espe-
cially after regenerative surgery. Ini-
tially, the major paradigm was to
maintain inter-dental papillae
through adequate flap design with
the purpose of achieving primary
wound closure following regenerative
surgery in intrabony defects (Evian
et al. 1985, Takei et al. 1985). Later
on, these flap designs have been
refined to further improve primary
flap closure. Both, a modified papilla
preservation (Cortellini et al. 1999a)
and a simplified papilla preservation
technique (Cortellini et al. 1999b)
have been presented. The application
of these two techniques in several
regenerative studies revealed a clear
superiority of these designs regarding
clinical attachment level gains com-
pared to previously performed access
flaps (e.g. Tonetti et al. 2002). The
positive outcomes were attributed to
improved and maintained flap clo-
sure during wound healing. As a
consequence of this development,
papilla preservation has become a
basic principle of access flap surgery.
With the paradigm of obtaining
primary flap closure, hereby optimiz-
ing regenerative processes in intrab-
ony defects, a further development
encompassed the choice of minimally
invasive techniques. For this pur-
pose, visualization had to be
improved by magnification. Hence,
the use of microsurgical instruments
together with magnifying aids
became a standard way of perform-
ing periodontal plastic surgery (Cor-
tellini & Tonetti 2001).
While the introduction of micro-
surgical techniques enabled the
clinician to perform already existing
surgical interventions with more
careful handling of the tissues and
minimized trauma, novel surgical
approaches became feasible based on
improved visualization and illumina-
tion. Minimally invasive surgical
technique (MIST) resulted from this
optimization (Cortellini & Tonetti
2007). A recent modification of the
MIST (m-MIST) was validated in a
small study and resulted in excellent
clinical outcomes after regenerative
therapy of intrabony defects. More-
over, patient reported outcome mea-
sure documented decreased morbidity
for the patient (Cortellini & Tonetti
2009).
Similar attempts have been pub-
lished by other authors (Zucchelli &
De Sanctis 2005, Trombelli et al.
2009).
It appears from these studies that
the novel flap designs that include
limited elevation of flaps and subse-
quent primary flap closure in the
inter-dental region substantially
improved the outcomes of regenera-
tive surgery and decreased patient
morbidity. Consequently, they
should be recommended as routine
procedures in periodontal plastic
surgery.
Concerning the coverage of
mucosal recessions, a comparison
between conventional macrosurgical
and a minimally invasive treatment
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
approach has been performed in a
randomized controlled clinical trial
(Burkhardt & Lang 2005). The study
population consisted of 10 patients
with bilateral Class I and Class II
recessions at maxillary canines. In
split-mouth design, the defects were
randomly selected for recession cov-
erage either by a microsurgical (test)
or macrosurgical (control) approach.
Immediately after the surgical proce-
dures and after 3 and 7 days of heal-
ing, fluorescent angiograms were
performed to evaluate graft vascular-
ization. The results at test sites
revealed a vascularization of
8.9  1.9% immediately after the
procedure. After 3 days and after
7 days, the vascularization rose to
53.3  10.5% and 84.8  13.5%
respectively. The corresponding vas-
cularization at control sites were
7.95  1.8%/44.5  5.7% and
64.0  12.3% respectively. All the
differences between test and control
sites were statistically significant.
Moreover, the clinical parameters
assessed before the surgical interven-
tion, and 1, 3, 6 and 12 months
post-operatively, revealed a mean
recession coverage of 99.4  1.7%
for the test and 90.8  12.1% for
the control sites after the first month
of healing. Again, this difference was
statistically significant. The percent-
age of root coverage, both test and
control sites remained stable during
the first year at 98% and 90%
respectively.
The present clinical experiment
has clearly demonstrated that peri-
odontal plastic surgical procedures
designed for the coverage of exposed
root surfaces, performed by using a
microsurgical approach, improved
the treatment outcomes substantially
and to a clinically relevant level
when compared with the clinical per-
formance under routine and macro-
scopic conditions.
Flap mobilization
Most of the commonly applied tech-
niques in periodontal plastic surgery
require a flap lengthening in order to
restore the soft tissue architecture, to
cover the denuded root or implant
surfaces and/or to achieve a primary
wound closure after augmentation.
Such flap advancement can only be
performed up to a limited percentage
of the original flap length. In addi-
tion, it might create a functionally

and, when applied in the zone of
aesthetic priority, aesthetically
adverse effects which negatively
influences the result.
The common way of flap length-
ening consists of one or two vertical
releasing and a periosteal incisions at
the base of the buccal flap. As the
periosteum mainly consists of dense
collagen fibres, the periosteal cut
releases the flap tension so that the
elastic fibres of the lining mucosa
can be stretched easily.
The distance of flap lengthening
depends on the outline of the flap
and has been evaluated in a recent
cohort study (Park et al. 2012). By
just placing one vertical releasing
incision and pulling with a tension
of 5 g, the flap could be mobilized
by 1.1  0.6 mm corresponding to
113.4% of its original length. These
values increased to 1.9  1.0 mm
(124.2%) by a second vertical inci-
sion at the opposite end of the hori-
zontal incision. After combining the
two vertical releasing incisions with
a periosteal releasing cut, a statisti-
cally highly significant flap advance-
ment of 5.5  1.5 mm (171.3%)
became possible.
Such flap advancement also dis-
placed the buccal masticatory
mucosa coronally which may cause
an irregularity of the mucogingival
junction and impair the aesthetic
appearance in high lip line situa-
tions. In addition, when implant
supported reconstructions are to be
incorporated, the aforementioned
technique left the buccal area cov-
ered by a zone of mobile, much thin-
ner lining mucosa which is more
prone to the formation of a soft tis-
sue dehiscence (Bengazi et al. 1996,
Oates et al. 2002, Zigdon & Machtei
2008). Hence, alternative surgical
modalities have to be considered in
cases when flap advancement is
required for primary wound closure.
A recommended procedure is the
use of a free connective tissue graft
harvested from the palate (Lorenz-
ana & Allen 2000) and fixed on the
crest of the edentulous area at the
reunion of the two flap margins.
The graft bridges the gap between
the buccal and oral flap and protects
the underlying bone or augmented
area (Kan et al. 2009, Stimmelmayr
et al. 2010). Although frequently
applied, there is limited evidence
that soft tissue grafts are effective in
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
achieving the above mentioned
goals. Neither is there evidence that
increasing mucosal thicknesses will
lead to improve aesthetic outcomes
(Esposito et al. 2012).
The masticatory mucosa of the
hard palate consists of a collagen-rich
connective tissue with dense fibres in
the Lamina propria. Therefore, a pal-
atal flap cannot be mobilized just by
a U-shaped incision, but requires
more sophisticated flap designs.
Among these, the laterally positioned
flaps (Nemcovsky et al. 1999, Pe~ nar-
rocha et al. 2005), prepared in verti-
cal layers, and the techniques based
on horizontal, split-thickness flap
advancement (Tinti & Parma-Benfe-
nati 1995, Triaca et al. 2001) have to
be mentioned.
These flap designs are technique-
sensitive, but may be advantageous
in the zone of aesthetic priority as
the mucogingival line has not to be
displaced and no buccal releasing
incisions are required.
Greater extent of buccal flap
advancement requires releasing inci-
sions which, in turn, may hamper
the aesthetic outcomes by scar for-
mations and unfavourable mucosal
textures.
Compared to the healing of skin
wounds, the oral mucosa is less
prone to scar formation due to its
different inflammatory cell infiltrate
with lower levels of macrophages,
neutrophil and T-cell infiltration and
a lower level of the pro-fibrotic cyto-
kine TGF-b1 (Coleman et al. 1998,
Szpaderska et al. 2003). Neverthe-
less, other factors such as flap ten-
sion and the precision of flap margin
adaptation influence the extension
and severity of scar formation (Bur-
gess et al. 1990, Nedelec et al. 2000).
Hence, each incision in the buccal
mucosa of the anterior upper jaw
must be placed with respect to func-
tional and aesthetic outcomes.
Besides the risks mentioned for
adverse aesthetic outcomes, buccal
releasing incisions impair the blood
supply of the flap and decrease its
stability (M€ormann & Ciancio 1977).
Therefore, new flap designs based on
avoiding vertical incisions have been
developed for different periodontal
surgical indications. Based on recent
literature, these tunnel techniques
allow passive flap advancement and
are equally or even more effective
than the traditional approaches with
Principles of wound healing S101
releasing incisions (Cortellini & To-
netti 2007, 2009, Hofm€ anner et al.
2012).
Flap adaptation/stabilization
Wound healing primarily depends on
early formation and organization of
the blood clot and the establishment
of an attachment of the clot resistant
to mechanical forces acting on the
flap and opposing surfaces partici-
pating in wound closure (Wikesj€ o
et al. 1991b). The attachment of the
blood clot to a wound bed consisting
of soft tissue may dramatically differ
from that of the blood clot attach-
ment to a hard, non-shedding sur-
face, such as a root or implant
surface, the latter being more com-
plex. An impaired clot adhesion to
such hard surfaces may weaken the
tensile strength of the wound during
early healing and leave the wound
bed-mucosal flap interface more sus-
ceptible to tear compared to physio-
logically occurring tensile forces in
wound margins (Wikesj€ o & Nilveus
1990). Tensile forces vary depending
on the stability of the blood clot and
subsequently, on the biochemical
and mechanical properties of the
wound bed (Werfully et al. 2002).
Hence, healing following flap surgery
at hard, non-shedding surfaces is
conceptually a more complex process
than wound healing in most other
sites of the oral cavity.
Most of the models investigating
the tensile forces on the wound mar-
gins dealt with interfaces in recession
coverage (Wikesj€ o et al. 1991a,b,
Pini-Prato et al. 2000).
In an animal experiment (Wikesj€ o
et al. 1991a), initial blood clot adhe-
sion was chemically hampered by the
application of heparin, while contra-
lateral control defects were treated
with saline. As a result, the heparin
treated teeth exhibited a 50% con-
nective tissue repair to the root sur-
face after 4 weeks, while the controls
displayed a 95% repair. Heparin
treatment of the root surfaces jeop-
ardized blood clot adhesion, and
hence, connective tissue repair of the
periodontal defects were severely
delayed. Since fibrin clot adhesion
was disturbed chemically by the
application of heparin, it must be
assumed that mechanical displace-
ment of a flap on a wound surface
may result in similar disturbances of
fibrin clot adhesion. Hence, the sta-
S102 Burkhardt and Lang
bilization of the soft tissues covering
the wound area with appropriate
suturing appears to be a key prere-
quisite for optimal surgical outcomes
(Burkhardt & Lang 2010).
More recent research on blood
clot formation during early wound
healing (within the first hour after
clotting) has revealed that even mini-
mal tensile forces on the blood clot
may change its morphology and nat-
ure (Baker et al. 2005). As a proof
of principle, it could be established
that treating a root surface with
either saline or EDTA rendered the
root surface extremely vulnerable to
tear resulting in blood clot disrup-
tion with applying only minimal
forces. On the other hand, surface
treatment of the root with citric acid
resulted in an intact fibrinous net-
work that was not susceptible to clot
disruption upon mechanical tear
with similarly light forces. Recent
clinical studies supported the men-
tioned findings. No clinical benefits
could be documented for root condi-
tioning with EDTA after the cover-
age of buccal mucosal recessions
(Bittencourt et al. 2007), after access
flaps in periodontitis affected
patients (Parashis et al. 2006) and
for regenerative therapies of intrab-
ony defects (Sculean et al. 2006).
While the studies described were
predominantly concerned with blood
clot adhesion to the wound bed and
the clot, therefore, was considered as
a biological entity, a deeper insight
into clot biology, composition and
biochemistry has clearly revealed
that a great diversity of structural,
biological, physical and chemical
properties present as a result of
fibrin polymerization depending on
the conditions of the environment
under which the clot developed. The
structure of the fibrin clot appears to
directly affect the clot’s fibrinolytic
(Varju et al. 2011), mechanical (Wei-
sel 2007, Liu et al. 2010) and visco-
elastic properties (Weisel 2007). It is
evident that the replacement of fibrin
in the blood clot with collagen will
also depend on the fibrin network
structure. The more stretched the
fibres are, the more difficult it
becomes for capillaries to invade the
clot tissue (Varj
u et al. 2011). On the
other hand, the more relaxed the
fibrin network is constructed the eas-
ier its replacement becomes. Obvi-
ously, the fibrin network structure
yields a great variability both within
the same host as well as among dif-
ferent individuals depending on
mechanical and chemical environ-
mental factors (Brown et al. 2009).
From a clinical point of view, it
may be speculated that a blood clot
under very limited strain would have
to be preferred over a clot under
heavy tension. It is evident that
delayed dissolution of the fibrin net-
work with depositing of collagen
and insprouting of vessels will sub-
stantially delay wound maturation.
Influence of residual tension on
flaps before suturing was assessed in
a human randomized prospective
study in patients that were treated
for Miller Class I maxillary reces-
sions (Pini-Prato et al. 2000). On
one side of the jaw, the control sites,
coronally advanced flaps were
replaced and sutured under regular
residual tension. On the test sites,
the flaps were further released by
periosteal incision before suturing.
While the residual mean tension on
the control sites was 6.5 g, it was
only 0.4 g on the test sites. After
3 months of healing, the mean root
coverage was 78% with complete
root coverage in 18% of the sub-
jects. However, the mean root cover-
age on the test sites corresponded to
87% with 45% of the subjects yield-
ing complete coverage. Although the
difference in residual flap tension
was minimal (approximately 6 g),
the influence on the recession reduc-
tion was significant, again indicating
the necessity of a tension free flap
closure (Pini-Prato et al. 2000).
In one study, the role of flap ten-
sion in primary wound closure was
investigated in humans (Burkhardt
& Lang 2010). In that study, 60
patients scheduled for single implant
installation were recruited. Before
suturing, the tensile forces of the
flaps were recorded with an elec-
tronic device. After 1 week, the
wounds were inspected with regards
to complete closure. While flaps with
minimal tension of 0.01–0.1N
resulted in only a few (10%) wound
dehiscences, flaps with higher closing
forces (>0.1N) yielded significantly
increased percentages of wound
dehiscences (>40%). This study also
revealed that flaps with a thickness
of >1 mm demonstrated significantly
lower proportions of flap dehiscences
at higher closing forces (>15 g) than
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
thinner flaps (≤1 mm). The results of
this study indicated a necessity to
control closing forces in the wound
margins. In order to minimize tissue
trauma, finer suture diameters may
be helpful owing to the fact that
thinner sutures (6-0, 7-0) lead to
thread breakage rather than tissue
tear and breakage (Burkhardt et al.
2008).
Even though in the above men-
tioned study, flap thickness appeared
to be less influential on wound sta-
bility than flap tension, gingival
thickness seemed to positively affect
the outcome of flaps replaced on
hard, non-shedding surfaces (Hwang
& Wang 2006). The necessity of a
minimal, optimal tissue thickness for
complete root surface coverage
remains a matter of debate although
the systematic review presented iden-
tified a lower limit of 0.7 mm flap
thickness (Hwang & Wang 2006).
Although never substantiated, flap
thickness was always assumed to
affect the vascularity of the pedicle.
The vascularity of a flap depends
on its length, especially when the
flap is replaced on an avascular sur-
face like a root or an alloplastic
material of an implant. Several stud-
ies confirm a decrease in the flap
vascularity with increasing flap
length (M€ ormann & Ciancio 1977,
McLean et al. 1995). Interestingly,
in wound healing studies at early
healing stages, significantly greater
proportions of the flaps gained fluo-
rescence by extravascular diffusion
over that achieved by the intra-capil-
lary circulation. While it is certainly
prudent to avoid long pedicle flaps
in covering hard, non-shedding sur-
faces, other flap properties, such as
its thickness and alternate vascular
sources deserve recognition.
The same principles apply to
root/implant coverage with soft tis-
sue grafting where the majority of
the wound bed consists of a hard,
non-shedding surface. It has been
demonstrated that the revasculariza-
tion of soft tissue grafts originated
almost exclusively from capillaries of
the wound bed (Capla et al. 2006),
while the original vessels of the graft
receded and served as a pathway for
new ingrowing capillaries.
Regarding flap fixation with
sutures, it has been demonstrated
that the choice of various suturing
techniques had a limited influence on

the blood circulation in the healing
wound.
In an angiographic dog study
(McLean et al. 1995), the vascular
events following mucoperiosteal flap
elevation were studied in relation to
two different suturing techniques.
After flap adaptation primary wound
closure was achieved by either hori-
zontal mattress suturing or inter-
rupted single suturing. The flaps
reached from 2P2 to 1M1 and were
divided into three inter-proximal and
two mid-buccal sites for analysis of
the inter-capillary and vascular diffu-
sion extent. It was realized that the
sole act of flap elevation initiated
substantial and significant vascular
trauma. Significant reduction in flap
circulation in relation to the presur-
gical baseline lasted for at least
3 days in the mid-buccal sites but
persisted for 7 days at the inter-
proximal sites. No significant differ-
ences in the vascular changes could
be detected between the two suturing
techniques. However, both suturing
techniques appeared to have exer-
cised a local negative influence on
the circulation until they were
removed. This, in turn, means that
suturing may severely impinge on
the microcirculation of flaps and
hence, jeopardize optimal physiologi-
cal wound healing.
Consequently, sutures should
remain as little as absolutely needed
to assure stability of the healing
wound, depending on the individual
situation and not as a stereotype
regime of a seven to 10 days period.
As indicated before, a less trau-
matic approach in periodontal plas-
tic surgery by using magnification
aids and fine suture materials,
ensures passive wound closure in
most surgical interventions. This
speculation was substantiated by an
in vitro experiment, which evaluated
the tearing characteristics of mucosal
tissue samples for various suture
sizes and needle characteristics in
relation to the applied tension forces
(Burkhardt et al. 2008). The pig jaw
mucosal tissue samples were
attached in a test-tearing apparatus
of a Swiss textile company and the
tension tearing diagrams were traced
for 3-0, 5-0, 6-0 and 7-0 sutures with
forces up to 20 N. While the 3-0
sutures almost exclusively led to tis-
sue breakage at an average of
13.4 N, the 7-0 sutures broke before
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
tissues were torn in every instance,
namely at a mean applied force of
3.6 N. With 5-0 and 6-0 sutures,
both events occured at random at a
mean force of 10 N. This, in turn,
means that a clinician will influence
the amount of damage to the tissue
by selecting thicker or thinner suture
material. Considering this fact, it
may be speculated that wound dehi-
scences may be prevented and a pas-
sive flap adaptation improved by the
choice of thinner sutures which inev-
itably requires magnification if its
benefits are fully appreciated.
It is evident that flap design, flap
advancement and stabilization
receive a higher degree of attention
in situations when mucoperiosteal
and/or mucosal flaps are positioned
to cover large defects on hard, non-
shedding surfaces. Owing to the fact
that such sites are constituted of the
connective tissue surface of the flap
and an avascular surface such as
dentin, titanium, ceramics or another
alloplastic material, they require a
careful tissue management and stable
flap adaptation, especially in the
anterior zone of the upper jaw where
the mucosal morphology and topog-
raphy play an important role for the
aesthetic result.
Post-operative care
As periodontal plastic surgical pro-
cedures are performed in the con-
taminated oral cavity, it is evident
that wound infection may occur as a
result of the oral environment per se
or in conjunction with flap fixation
and suturing techniques. There is a
fine balance between the host resis-
tance to infection and factors initiat-
ing or promoting infection. Insight
into this relationship between the
host and the pathogens may be
gained from quantitative bacterio-
logic studies. In most soft tissue inju-
ries, the wound bacterial count
provides an accurate prediction of
subsequent infection (Edlich et al.
1977). Wounds combining >105 bac-
teria per gram of tissue are destined
to develop infection. When the bac-
terial count is below that level, the
wounds will usually heal by primary
intention without infection. This
large number of bacteria required to
elicit infection reflects the remark-
able ability of soft tissues to resist
infection in the oral cavity. This
Principles of wound healing S103
state of high resistance to infection
can be reduced by several factors
including circulatory embarrassment,
tissue injury, dead space and the
presence of foreign bodies (calculus,
sutures, etc.).
Using strict aseptic technique,
pressure syringe irrigation to remove
bacteria during wound cleansing,
removal of possible foreign bodies
and careful debridement of all teeth
are prerequisites for proper surgical
interventions. Primary wound clo-
sure may be initiated after irrigation
without the development of infection
if strict aseptic techniques have been
applied (Edlich et al. 1977).
Early contamination of the
wound may occasionally occur
through the sutures being placed for
flap fixation. Hence, it is important
to remove sutures as soon as possi-
ble whenever the fixation of the tis-
sues appear to be complete and the
flaps revascularized with the wound
bed.
As studied years ago, wound
infections do not appear to be
related to the suturing materials with
the exception of silk that has a ten-
dency to a higher rate of wound
infections owing to the collection of
biofilm by silk sutures (Mouzas &
Yeadon 1975, Blomstedt 1985).
Anti-infective therapy has been
shown to reduce biofilm formation
and inflammation along suture
tracks (Leknes et al. 2005). Braided
silk, however, elicits more severe tis-
sue reactions than ePTFE regardless
of infection control.
The fact that the total infectious
burden in the oral cavity may be the
determining factor by which wound
infections may develop, it is reason-
able to apply an effective antiseptic
agent, such as chlorhexidine digluco-
nate 2–3 weeks to deplete the supra-
gingival plaque reservoir. The
beneficial clinical effects on wound
healing of such measures have been
well documented. Following gingi-
vectomies, the rinsing twice daily
with 0.2% chlorhexidine gluconate
promoted wound healing signifi-
cantly (Langebæk & Bay 1976).
Applying infection control with daily
applications of chlorhexidine in a
histometric wound healing study in
dogs (Hamp et al. 1975) documented
significantly improved wound heal-
ing following standardized gingivec-
tomies with only minor signs of
S104 Burkhardt and Lang
inflammatory infiltrates in the biop-
sies up to 42 days.
The placement of a chlorhexidine
containing gel dressing after flap sur-
gery revealed significantly improved
bleeding tendency and lower gingival
exudate flow rates compared with a
placebo gel application in a split-
mouth design up to 35 days follow-
ing flap surgery (Asboe-J€ orgensen
et al. 1974).
In clinical trials on the efficacy of
periodontal surgical techniques in
reducing pockets and gaining clinical
attachment (Westfelt et al. 1983),
post-surgical chlorhexidine rinses
twice daily for 6 months with a
0.2% solution were equally effective
in improving clinical parameters
after periodontal surgery as provid-
ing biweekly professional tooth
cleansing. Hence, it is evident that
the use of chlorhexidine following
periodontal surgery represents a fun-
damental concept contributing to the
reduction of the infective burden in
the oral cavity and hence, the pro-
motion of oral postsurgical health.
Without optimal oral hygiene,
periodontal surgical procedures may
result in clinical substantially jeopar-
dized outcomes (Nyman et al. 1977).
Six, 12 and 24 months after comple-
tion of the respective treatments, the
patients were recalled for assessment
of their oral hygiene standard and
periodontal conditions. The results
showed that oral hygiene instruction
given once before surgery, only tem-
porarily improved the patient’s oral
hygiene habits. Renewed accumula-
tion of plaque in the operated areas
resulted in recurrence of periodontal
disease including a significant further
loss of attachment irrespective of the
treatment rendered. None of the sur-
gical approaches chosen was effec-
tive in preventing recurrence of
destructive periodontitis. On the
other hand, the same surgical treat-
ment performed in plaque-free denti-
tions (Rosling et al. 1976) resulted in
maintained high oral hygiene stan-
dards, low gingival inflammation,
substantial pocket elimination and
gain of clinical attachment.
In regenerative and plastic surgi-
cal procedures, the therapeutic out-
comes may depend even more on the
achievement of optimal oral hygiene
standards than in conventional peri-
odontal surgery (Cortellini et al.
1994).
As a consequence, a stringent
infection control programme has
been propagated and validated in an
experimental study (Heitz et al.
2004). In this protocol, tooth brush-
ing with an ultra soft surgical tooth-
brush is introduced on the third day
after surgery. The brush is used as a
carrier for chlorhexidine application.
After 1 week, the ultra soft brush is
replaced with a soft brush that is
used for the next 2 weeks. Following
this, regular tooth brushing habits
are resumed and chlorhexidine rinses
discontinued. The study yielded
superiority in healing outcomes com-
pared to conventional post-surgical
care (Heitz et al. 2004). It is under-
stood that following periodontal
plastic surgical interventions, profes-
sional tooth cleaning once a week
has to be performed for the first
postsurgical month.
Last, but not least, it has to be
realized that wound healing may be
negatively affected by psychological
stress (Kiecolt-Glaser et al.1995).
Caregivers of patients with Alzhei-
mer’s disease demonstrated a signifi-
cantly delayed wound healing after
standardized punch biopsies than
their counterpart controls. Hence,
stress-related defects in wound repair
could have important clinical impli-
cations for recovery from surgery. In
a study with student volunteers
(Marucha et al.1998), students took
an average of 3 days longer to com-
pletely heal a 3.5-mm standardized
punch biopsy wound during examin-
ations. This represents 40% longer
to heal a small, standardized wound
than during stressless vacation times.
Production of interleukin 1beta (IL-
1beta) messenger RNA (mRNA)
declined by 68% during examina-
tions, providing evidence of one pos-
sible immune mechanism. It appears
that even a factor as transient, pre-
dictable and relatively benign as
examination stress may significantly
affect the wound healing process
(Marucha et al.1998).
In periodontal plastic surgery
where tissue handling is difficult and
procedures are delicate, the influence
of psychological stress contributing
to compromised wound healing
should not be underestimated.
Such psychological stress may also
be caused by patient’s anxiety of the
surgical intervention and the expecta-
tion of associated pain. Therefore,
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
pain control by sedation, anaesthesia
and systemic prescribed drugs belong
to the basic requirements for a suc-
cessful surgical intervention. Know-
ing how well an analgesic and
technique works and its associated
adverse effects is fundamental to clin-
ical decision making. In a recent
review article, the cause of pain with
its underlying mechanisms are
explained in detail and recommenda-
tions for appropriate analgesics are
listed up (Ong & Seymour 2008).
Even if the guidelines vary among
countries and continents, conven-
tional non-steroidal anti-inflamma-
tory drugs (NSAIDs) have been
widely used to control postoperative
pain. They are proven to be effective,
tolerated by patients, easy to adminis-
ter and have an acceptable potential
for interaction with other systemic
drugs. Older clinical data suggested
that acetaminophen was as effective
as NSAIDs drugs in pain conditions
(Bradley et al. 1991, Tramer et al.
1998) but the Oxford Pain Group
League table of analgesic efficacy
(Richards 2004) and a meta-analysis
(Hyllested et al. 2002) indicate that
overall, NSAIDs are clearly more
efficacious than acetaminophen in
periodontal surgery.
Appropriate postoperative
instructions should be given to the
patient including an explanation
concerning all medications, potential
discomfort and complications as well
as diet modifications and where to
call if adverse events occur or ques-
tions arise.
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Address:
Rino Burkhardt, DMD, MAS
(Periodontology)
The University of Hong Kong
Prince Philip Dental Hospital
Hong Kong SAR and University of Zurich
Weinbergstr. 98
CH-8006 Zurich
Switzerland
E-mail: rino.burkhardt@bluewin.ch

Clinical Relevance
Scientific rationale for the study:
Irrespective of the indication, the
success of a periodontal or implant
surgical procedure depends on sev-
eral factors which have to be con-
trolled before, during and after the
intervention. We therefore per-
formed a narrative review to assess
the most important influencing
factors.
Principal findings: In the pre-opera-
tive phase, optimal plaque control
and smoking counselling are of
paramount importance. The funda-
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
mental principles in surgical proce-
dures include 1) flap preparation
based on basic knowledge in vascu-
larity of the involved tissues leading
to appropriate flap designs (papilla
preservation, avoidance of releasing
incisions, minimally-invasive techni-
ques), 2) flap mobilisation with
respect to flap thickness and passive
advancement and 3) flap stabilisa-
tion which depend on wound bed
characteristics, residual flap tension
and proper suturing to ensure undis-
turbed blood clot formation, faster
revascularisation and therefore, better
Principles of wound healing S107
wound healing outcomes. In the
post-operative period, applying an
infection control with daily rinsings
of chlorhexidine reduces the infec-
tious burden in the oral cavity and
prevents the wound from mechani-
cal disruption.
Practical implications: The results
emphasize the effectiveness and
need for oral hygiene measures in
the pre- and postoperative phase.
A delicate tissue handling and ten-
sion free wound closure in the sur-
gical phase represent prerequisites
for optimal treatment results.