Principles of Flap Design in Dental Implantology

Volume 23, Number 6 June 2012

Principles of Flap Design
in Dental Implantology

EDITOR By Mohammed JA, BDS, MSc, SHAIFULIZAN ABR, DDS, MD,
Arun K. Garg, DMD; Editor in Chief Hasan FD, BDS, MSc

EDITORIAL ADVISORS There is no single flap design that serves as the optimal approach for every
implant surgery,1 and as the need for cosmetic procedures with minimally
Editor Emeritus: Morton L. Perel, DDS, MScD invasive techniques increases, so, too, does the variability in flap design. In other
words, there is no single technique that is suited to every surgical situation, and
Renzo Casselini, MDT, the skilled surgeon must be thoughtful and creative in selecting every incision
Professor of Restorative Dentistry, since the manner in which that incision is designed, executed, and sutured will
Loma Linda University, Loma Linda, CA have an enormous impact on implant success rates and overall aesthetic outcome.
The site of implant placement, whether it is in the aesthetic zone or hidden pos-
Leon Chen, DMD, MS, teriorly, also has an impact on the flap design. Another factor to consider is the
Private Practice in Periodontology, width of the ridge in which the implant is placed. Some ridges are wide enough
Las Vegas, NV to place an implant with minimal tissue reflection, while other ridges are narrow
and require wide flap reflection for better visualization and ridge width determi-
Scott D. Ganz, DMD, nation. Further, narrow ridges sometimes need bone augmentation and guided
Private Practice of Prosthodontics, Maxillofacial Pros- bone regeneration membranes, which necessitate planning for wide flap design
thetics and Implant Dentistry, Fort Lee, NJ to cover the bone graft and the membrane. This article discusses the principles
of flap design in dental implantology in an effort to summarize techniques to aid
Zhimon Jacobson, DMD, MSD, practitioners with optimal procedure selection.
Clinical Professor,
Department of Restorative Sciences/Biomaterials, Boston Principles
University
Principle 1: New scalpel blades and sharp peri-osteal elevators are essential
Jim Kim, DDS, MPH, MS,
Private Practice of Periodontics, for making incisions and elevating flaps to protect the viability of the mucosa.
Diamond Bar, CA
The incision should be made clearly in order to avoid retracting, and elevation
Robert E. Marx, DDS,
Professor of Surgery, requires flawless use of a dedicated peri-osteal elevator.2
Chief, Oral & Maxillofacial Surgery
Principle 2: Full visibility of the operative site is essential. It has been sug-
Peter Moy, DMD,
Private Practice, gested that the incision be made longer
West Coast Oral and Maxillofacial Surgery Center and
Center for Osseointegration, Los Angeles, CA than the amount required to expose the Inside This Issue
operative site. This offers greater visibil-
Myron Nevins, DDS,
Associate Professor of Periodontology, ity of the bone. It should be pointed out
School of Dental Medicine, Harvard University, that long incisions heal as rapidly as short Wounds and Suturing . . . . 44
Boston, MA
ones.2 (See Figures 1,2.)
H. Thomas Temple, MD,
Professor of Orthopedic Surgery and Director of Univer-
sity of Miami Tissue Bank, University of Miami School of
Medicine Miami, FL

• The images contained within this issue are from Dr. Jasim
Al-Juboori’s practice.

The official publication of the
American Dental Implant Association

NOW AVAILABLE ON-LINE!
Go to www.ahcmedia.com/online.html for access.

Figure 1: The incision is made longer than 42 surface of the bone,5 is essential and
the amount required in osirtdee.r to adequate- will facilitate implant placement.
ly expose the operative Figure 2: Long incisions heal as
rapidly as short ones. Principle 10: It is also essential
Principle 3: The periosteum serves to ensure that all wounds have clean
as the major vascular supply to the Principle 7: Flexibility in position- edges, which will facilitate closure and
bone; therefore, at most, only a mini- ing the surgical guide4 must be provided. optimize healing by primary intention.3
mal amount, if any, of the periosteum (See Figure 4)
should be removed.3 Principle 8: Allow for proper iden-
tification of important anatomical Principle 11: Permitting the raising
Principle 4: If papillae are involved, landmarks: The location and path of of a full mucoperiosteal flap ensures
they should not be bisected but elevated the blood vessels and nerves should that it has a good vascular supply. In-
in total.2 be evaluated, protected, and preserved sufficient blood supply compromises
during the duration of the surgical pro- the survival of the unreflected tissue,
Principle 5: If the implant proce- cedure. Beyond general knowledge of which can lead to necrosis as well as
dure is to involve the alveolar ridge, these structures, acknowledging their the potential for a deleterious aesthetic
the incision should be made at the crest precise locations is crucial in specific result. The choice of flap design should
within the linea alba.2 (See Figure 3.) areas (for example, the mental foram- allow for maintenance of optimal and
ina and incisal canal4). This is an essen- sufficient blood supply to all parts of
Principle 6: If tension-relieving in- tional part of preoperative planning. the mobilized tissues as well as the soft
cisions are required to avoid stretching tissues in the surrounding area.3
or tearing the tissues, these incisions Principle 9: Identification of the
should be made obliquely to ensure contours of the adjacent teeth, as well Principle 12: Flap blood perfusion
broad-based flaps.2 as the concavities or protrusions on the must be maintained up to the point at
which the ratio of length to the width
of the parallel pedicle flap equals 2:1.
The length/width ratio requirement
usually favors a slight trapezoidal
shape of the flap.3

Principle 13: The tissue flap must
be kept moist at all times to help avoid
shrinkage and dehydration of the tissue.
With prolonged duration of the surgical
procedure, the involved tissues are at risk
of drying out, especially when a high de-
gree of hemostasis has been achieved.3

Principle 14: The goal is always to
minimize scarring and avoid vestibular
flattening.6

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Dental Implantology Update™ June 2012

43

Figure 3: The incision should be Figure 4: Clean edges are essential to fa- Principle 15: It is imperative to
made at the crest within the linea alba. cilitate primary closure and optimize heal- provide for closure away from the sub-
ing by primary intention. merged fixture installation or augmen-
tation site.6
Figure 5: Appropriate and careful reflection and manipulation
of the tissue flap is imperative. Principle 16: As with any operative
technique, the minimization of postsur-
Figure 6: Use proper suture material, with an atraumatic needle. gical bacterial contamination improves
There should be minimal tension during reapproximation. outcome and decreases morbidity.4
June 2012
Principle 17: Minimal tension dur-
ing reapproximation and after suturing
is important to avoid impairment of
the circulation at the wound margins.
Shrinkage of the reflected tissue with
wound dehiscence will ultimately lead
to increased scar formation.4

Principle 18: Tissue trauma, such as
stretching, tearing, or distortion, should
be avoided through appropriate and
careful reflection and manipulation of
tissue flap. Excessive trauma from re-
traction may cause increased swelling
and delay healing.6 (See Figure 5.)

Principle 19: The integrity of the
periosteum should be maintained
throughout. The periosteum will serve
as a barrier against the connective tissue
cells so that these cells cannot invade
the bone cavity during the healing pro-
cess and prevent a complete bone fill.3

Principle 20: Providers should
avoid oblique relieving incisions over
prominent root surfaces because reces-
sion may result if there is an underlying
bony dehiscence.

Principle 21: In cases of reduced
quantity of keratinized tissue, it is
beneficial to position the crestal inci-
sion toward the palatal aspect, the area
where more keratinized tissue as it ex-
tends onto the palatal mucosa.

Principle 22: When graft materials
or membranes are used, it is sensible to
place relieving incisions at least at one
tooth, proximal to the area of augmen-
tation.

Principle 23: If doubt exists as to
the need to expose anatomical struc-
tures, such as the incisive nerve, or if
augmentation techniques may be in-
dicated, then the wider flap design in-
cluding papillae is mandatory .

Principle 24: For larger implant
sites that are 8 mm and larger, choose a

Dental Implantology Update™

mesiodistal crestal incision of 5-6 mm 44 be the “father of modern dentistry,” a
to allow for nonreflection of papillary French physician who practiced den-
tissue. For sites that are less than or Oral and Maxillofacial Surgeons. tistry similar to what we know today
equal to 7 mm mesiodistally, there is a 2007;65:20-32. from the late 17th to mid 18th centuries,
need to reflect the papillae. 5. Kleinheinz J, Buchter A, Kruse- the man also touted as the individual
Losler B, et al. Incision design in who first created dental prostheses, can
Principle 25: Atraumatic wound implant dentistry based on vascu- be credited with early methods of den-
handling avoids tension and pressure larization of the mucosa. Clin Oral tal surgical technique. This review ar-
to the flap that may lead to impaired Implants Res. 2005;16:518-523. ticle covers types of wounds and wound
blood flow and interrupted lymph 6. Hunt WB, Sandifer JB, Assad DA, healing, the healing process itself, and
drainage.1 Gher ME. Effect of flap design on basic surgical knotting techniques.
healing and osseointegration of den-
Principle 26: Controlling intraoper- tal implants. International Journal Surgical Wounds
ative bleeding (adequate hemostasis) is of Periodontics & Restorative Den- and Wound Healing
necessary to avoid the possibility of he- tistry 1996;16:583-593.
matoma formation, another causative 7. Al-Juboori MJ, bin Abdulrahaman Suturing and surgical knotting is an
factor in delayed wound healing.1 S, Subramaniam R, Tawfiq OF. Less important component of the surgeon’s
morbidity with flapless implant. Dent skill set. Dental implant practitioners
Principle 27: Practitioners should Implantol Update. 2012;23:25-30. require specific, high-quality technique
strive to eliminate the formation of any 8. Heydenrijk K, Raghoebar GM, in this area, given the importance of
dead space in which fluids might col- Batenburg RH, Stegenga BA. Com- the aesthetic outcome in the evolution
lect after wound closure1. parison of labial and crestal inci- of more advanced implant procedures.
sions for the 1-stage placement of In addition to the aesthetic outcome,
Principle 28: The use of proper IMZ implants: A pilot study. J Oral proper wound healing is essential to re-
suture materials with an atraumatic Maxillofac Surg. 2000;58:1119-23; duce the risk of postoperative infection,
needle must be practiced.1 Further, discussion 1123-1124. or worse, treatment failure.
practitioners must have exceptional
surgical knotting and suture selection Wounds and Types of Wounds
techniques. (See Figure 6.) Suturing in Dental and Wound Healing
Implant Surgery
Principle 29: Avoid any local or ex- There are four types of surgical
ternal pressure on the wound during the By Arun Garg, DMD wounds based on risk of infection dur-
healing period.1 Educate patients about ing and after surgery: clean, clean-con-
the importance of postoperative care. In 2006, french and italian scientists taminated, contaminated, and dirty and
reported in Nature that Stone Age infected.2,3 Any surgical process in the
Principle 30: In cases of non-sub- humans used dental drills made of flint mouth almost ensures at least a clean-
merged implants, the flap edge should some 9,000 years ago.1 The Neolithic contaminated or contaminated wound
be repositioned upward to prevent dentists drilled teeth to cure toothaches. secondary to the capacity of infection
overgrowth of the gingiva above the Modern analysis suggests that the drill- of oral flora. Some oral wounds are con-
healing cap or cover screw postopera- ing was “surprisingly effective” in re- sidered dirty and infected at the outset
tively; the provider can achieve this by moving rotting tooth material.1 What’s and require a high degree of attention,
making the connective tissue (perios- more, and somewhat surprising in light such as an oral abscess, for example.
teum) face the healing cap rather than of the advancements made in modern Wound healing in oral mucoperiosteal
the epithelium.7,8 n medicine and dentistry, including but tissues after surgical wound healing is
not limited to surgical sterility, antibiot- unique relative to other types of surgi-
REFERNCES ic therapy, and novel imagining modali- cal wounds. Flap design plays a large
1. Askary ASE. Reconstructive Aes- ties like X-ray and computed tomogra- role in this process. Further, dental im-
phy (CT) scanning, early dental patients plant surgery also conveys the prospect
thetic Implant Surgery: Blackwell survived the drilling and went on to use of approximating a vascular soft-tissue
Munksgaard 2003:66-90. their teeth after the procedures; this was surface with an avascular root surface.
2. Cranin AN. Implant surgery: The assessed by looking at the surfaces of As mentioned in the previous article
management of soft tissues. J Oral the teeth that had been drilled. Perhaps featured in this issue of Dental Im-
Implantol. 2002;28:230-237. Pierre Fauchard, the man considered to plantology Update, flap design should
3. Velvert P, Peters IC, Peters AO. Soft be trapezoidal in shape, with a wider
tissue management: Flap design, portion at the base of the flap to pro-
incision, tissue elevation, and tis- vide adequate blood supply to healing
sue retraction. Endodontic Topics.
2005;11:78-97.
4. Sclar AG. Guidlines for flapless
surgery. American Association of

Dental Implantology Update™ June 2012

Figure 1: The Square Knot 45 used for tissue regeneration), where
appropriate. Healing by second inten-
Figure 2: The Granny Knot and healing by third intention, also tion involves a more complicated or
known as delayed primary closure. prolonged healing in which infection,
tissues, as well as flexibility to help trauma, lost tissue, or poor approxi-
ensure non-tension primary wound Healing by first intention is a mation of wound edges has occurred.
closure.4 Passive positioning of soft four-stage process involving normal An example of a procedure wherein
tissue reduces tears on flap edges dur- wound-healing processes with mini- healing by secondary intention occurs
ing the suturing process, which limits mal edema, the absence of local infec- is gingevectomy. Healing by third in-
retraction; this can be best achieved tion, no serious discharge or separation tention involves bringing two surfaces
with properly placed vertical releas- of wound edges, and minimal scar- of granulation tissue together because
ing incisions and appropriate flap re- ring. The four stages of wound healing of contaminated, traumatic wounds
flection.5 are described below. This should abso- with high risk of infection3,6 (extrac-
lutely be the goal in many dental im- tion sockets without flap or advanced
Types of wound healing are de- plant surgical procedures (specifically, soft-tissue graft). Generally, there
scribed by rates and pattern of heal- first-stage dental implants, root cov- is significant scarring in this type of
ing, and are generally divided into erage, bone grafting, and membranes wound healing.
three categories: healing by first in-
tention, healing by second intention, Wound healing follows a step-by-
step process that includes hemostasis,
inflammation, and repair — known
formally as hemostasis, inflamma-
tion, proliferation or granulation,
and remodeling or maturation. When
skin is punctured, the body’s immune
system reacts. Polymorphonucleo-
cytes (PMNs), platelets, and plasma
proteins enter the wound, causing lo-
cal vasoconstriction. Platelets at the
wound help to form a stable clot to
seal punctured vessels, and local acti-
vating factors lead to aggregation and
clumping. Adenosine diphosphate
from surrounding tissues causes ad-
hesion with local collagen, and plate-
let production of thrombin leads to
the production of fibrin from fibrino-
gen. Platelet-derived growth factor
and transforming growth factor beta
(TGF-beta) attract PMNs, which lead
to the inflammation stage.

Inflammation, classically appear-
ing as swelling and warmth, is a fac-
tor associated with this second stage
of healing. Macrophages replace
PMNs after approximately 48 hours
to continue the inflammation process,
removing wound debris and releasing
more growth factors.

Approximately 72 hours after tis-
sue puncture, the proliferation stage
begins, wherein fibroblasts are drawn
to the site by inflammatory cell growth
factors, which synthesize collagen.

June 2012 Dental Implantology Update™

46

The most essential aspect to insure
proper wound healing is practicing a
sterile and aseptic surgical technique.
Attention to the length and direction of
the incision, as well as dissection tech-
niques, tissue handling, hemostasis,
tissue irrigation, debridement, closure
material selection, elimination of dead
space, closure tension, and postsurgi-
cal wound stressors are also impera-
tive, and some of these were described
in this issue’s previous article on flap
design.

Figure 3: The Surgeon’s Knot Suture Materials
A primary goal of dental surgery is
Clinical signs of granulation include can regenerate periodontium with new
granular red tissue at the base of the cementum.7 to establish nontension closure of pri-
wound, dermal and subdermal tissue mary wounds for soft-tissue flaps so
replacement, and wound contraction. In Factors Affecting that wounds heal properly. Nontension
this stage, fibroblasts release collagen, Wound Healing primary closure is essential to implant
which forms a framework for increased success (for the implant and for any site
dermal growth. New collagen is sup- Wound healing, described above, is a requiring a bone graft), but several flap
ported by angiogenesis as new capillar- physiologic process and, as such, is af- designs can facilitate surgical wound
ies appear. Further, keratinocytes start fected by a variety of physiologic vari- healing with minimal complications. In
epithelialization of the wound, causing ables and determinants. Age, weight, order to obtain optimal positioning and
further contraction and the formation nutritional status, fluid status, the pres- securing of surgical flaps to provide
of a layered wound covering. ence or absence of other chronic under- ideal conditions for wound healing,
lying diseases, the status of a patient’s practitioners must understand three ar-
The final stage of wound healing, immune status, and history of chemo- eas of suturing: types of sutures, sutur-
known as remodeling, involves the therapy and radiation exposure all affect ing techniques, and surgical knotting
continued work of collagen as it re- a body’s ability to heal. Certainly, loss techniques.8,9
structures itself over weeks to repair of tissue elasticity, slower metabolisms,
the skin. Wound tensile strength in- and poor circulation seen in elderly in- A large study of the effect of suture
creases as dermal cells are remodeled dividuals provide unique challenges to materials on wound healing revealed
by fibroblasts over the course of many the implant surgeon, as do vitamin and no significant difference between su-
months to years. protein deficiencies or tobacco expo- ture materials and suture techniques.10
sure history, diabetes, and hypertension There are two basic categories of su-
Periodontal healing patterns can (which are also more prevalent in older tures — nonresorbable and resorb-
involve the downgrowth of epithelial populations). In this setting, and in light able, and each has advantages and
cells into the wound, resulting in a long of the fact that aging populations are disadvantages. Nonresorbable suture
junctional epithelium. Proliferation of more likely to seek implant procedures, materials are naturally elastic, which
connective tissue can cause connec- dental implant surgeons must know helps secure knotting. Conversely, re-
tive tissue adhesion and root resorp- about tissue mechanics, factors that in- sorbable sutures tend to reduce postop-
tion. Bone cell predominance can also fluence wound healing, and strategies to erative inflammation. Suture size refers
cause root resorption, ankylosis, or employ when wound healing is thwart- to the diameter of the suture material,
both. Ingress of the periodontal liga- ed or prolonged. measured from 1-0 to 10-0, and grow-
ment and perivascular cells from bone ing increasingly smaller in diameter
and lower in tensile strength. As size
decreases, cost of suturing materials
tends to increase.2 Dental surgeons tend
to use the 3-0 and 4-0 diameter suture
materials most commonly; the 5-0 and
6-0 are reserved for delicate muco-
gingival surgery. The principle rule of

Dental Implantology Update™ June 2012

thumb in suture selection is to choose 47 Periosteal suturing: These su-
the smallest diameter suture that will tures are used to penetrate the peri-
hold the wound tissue together during a practitioner’s direct grasp), and ten- odontal/peri-implant tissues and
healing. Smaller diameter fibers allow sion should be limited to secure the periosteum to the bone, and then ro-
the provider to complete more sutures flap without reducing blood flow to tate the needle back to the original
without decreasing blood supply to the tissue being closed. Blanching direction through the periosteum and
the tissue. must be avoided. The clinician should keratinized tissues
grasp the needle in the center, avoiding
Nonresorbable sutures are made of the needle and suture juncture; needle Simple loop modification to the
silk or polyester (monofilament and entry should be made at right angles interrupted sutures: These sutures
polytetrafluoroethylene). While knot to the tissues. Periosteum-to-perios- are used to approximate and coapt
tying is facilitated with the use of non- teum and tissue-to-tissue techniques surgical flaps. There is no placement
resorbable materials, there does tend should be employed when multiple of suture material between the tissue
to be a localizing process that draws levels are being sutured.11 Swelling, flaps.
fluids and bacteria to the wound site. as described above, occurs within the
Braided strands of polyester fibers can first 48 hours postoperatively, and, Single interrupted sling sutures:
be coated with a lubricant to facilitate as such, sutures should not be placed These sutures are used for a flap el-
passage through tissue, although this closer than 2-3 mm from the edge of evated on one side of the arch or for
certainly diminishes the capacity of the flap to prevent tearing. The most positioning facial and lingual flaps at
the knot to stay tied. common suturing techniques are in- different levels. It involves only two
terrupted, sling, mattress, continuous papillae to adapt the flap around the
Resorbable sutures have become inter-locking, and anchor sutures. tooth or implant, started on the mesial
more popular because they tend to side of the site, with the needle encir-
reduce postoperative inflammation, Continuous sutures: These su- cling the tooth before being passed
and patients prefer them because they tures are used for securing flaps more under the distal point.
do not require a return visit for su- than several centimeters long and for
ture removal. Natural resorbable su- repositioning surgical flaps apically or Sling suture about single tooth:
tures include plain gut (lost 24 hours coronally; they can be used for joining This suture is used principally for a
after insertion into the oral cavity) two or more inter-dental papillae of flap raised on one side of the tooth,
and chromic gut (treated with chro- the same flap. The advantages of this and involves only one or two adjacent
mium salt to resist oral enzymes for suture are that it minimizes multiple papillae — most often in flaps posi-
7-10 days). These materials are con- knots, employs teeth-to-anchor flaps, tioned coronally and laterally, requir-
traindicated in patients with severe and enables independent placement ing one of the interrupted sutures,
gastroesophageal reflux disease and and tension of buccal, lingual, and anchored about the adjacent tooth or
bulimia with purging, as breakdown palatal flaps. Disadvantages include slung around the tooth, for holding
will occur much faster. Synthetic re- loose flaps or untied sutures. In Fig- both papillae. The buccal or lingual
sorbables do exist and are made from ure 8, modification of this technique, is reflected, and the clinician passes a
a naturally occurring polymer of the specifically for highly restricted ar- 3/8 circle reverse cutting needle under
body: polyglycolic acid; these tend to eas and for coapting tissue and re- the distal contact point of the most
resorb naturally within 21-28 days. sembling the simple loop interrupted distal interdental papilla, then the in-
Poliglecaprone 25 sutures have a 90- suture technique with second needle ner side of the elevated surgical flap 3
day resorption rate, with high tensile penetration through the outer surface mm from the papilla tip. The clinician
strength, but many patients consider of the lingual flap. The knot is tied at then passes the needle under the next
them to be stiff and abrasive.11 the buccal aspect of the flap after the contact point in a mesial direction be-
needle passes back under the contact fore piercing the inner surface of the
Suturing Techniques point. elevated surgical flap 3 mm from the
Maximizing healing requires the tip of the interdental papilla.
Mattress suture: These sutures
proper choice of surgical technique, are used for increased security and There are other suture techniques
and different clinical scenarios war- control of the flap to enable a more available to clinicians, including
rant different technique application. precise placement of the flap. This modifications of standard techniques
Sutures are typically placed distal to technique is often used with perios- described above.
the last tooth, in interproximal spaces, teal stabilization. It is used to resist
and should be inserted first through muscle pull, to adapt flaps to bone, Knot tying is used in a multitude
the most mobile tissue flap with a as a regenerative barrier, implant or of disciplines outside of healthcare,
circular needle. Suture needles must tooth, and to avert surgical flap edges. and the principles are the same even
be grasped by needle drivers (never It also facilitates papillary stabiliza- if the scales of purpose are vastly dif-
tion and placement. ferent. Surgical knotting techniques

June 2012 Dental Implantology Update™

are also a relevant skill for the implant 48 tion of plastic surgery principles.
surgeon to master. There are more than International Journal of Periodon-
1,400 available knots, but only a few 3. Dunn DL, editor. Ethicon Wound tics and Restorative Dentistry.
of these are used in implant dentistry. Closure Manual. Sommerville, NJ. 1999;19(1):36-43.
Knots should have the following: firm- 2005. Johnson&Johnson. Accessed 9. Silverstein LH, Kurtzman GM.
ness, simplicity, smallness, avoidance online on 5/1/2012 at http://www. A review of dental suturing for
of instrument damage to the suture or surgery.uthscsa.edu/pediatric/train- optimal soft-tissue management.
surrounding tissues, adequate but not ing/woundclosuremanual.pdf. Compendium of Continuing Educa-
too much tension, approximation of tis- tion in Dentistry. 2005;26(3):163-
sues, traction, flatness, and avoidance 4. Heller JW, Heller RL, Cook G, 166, 169-170.
of extra throws (wherein bacteria can D’Orazio R, Rutkowski J. Soft tissue 10. Gabrielli F, Potenza C, Puddu P, et
settle). The most important knots for management techniques for implant al. Suture materials and other fac-
the dental implant practitioner include dentistry: A clinical guide. Journal tors associated with tissue reactiv-
the square knot (Figure 1), the slipknot, of Oral Implantology. 2000;26(2): ity, infection, and wound dehiscence
and the surgeon’s knot (Figure 3). 91-103. among plastic surgery outpatients.
Plastic and Reconstructive Surgery.
The square knot involves two over- 5. Moore RL, Hill M. Suturing tech- 2001;107(1):38-45.
hand knots completed in opposite di- niques for periodontal plastic 11. Silverstein LH. Principles of Dental
rections. First, the clinician makes a surgery. Periodontology 2000. suturing: The complete guide to sur-
loop over the jaws of the needle holder, 1996;11:103-111. gical closure. Majwah, New Jersey.
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makes a second overhand knot, plac- healing and repair. EMedicine.
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7. Rose LF, Mealey BL. Periodontics:
The slipknot is similar to the square Medicine, suergery and implants. St.
knot, except two single overhand knots Louis. Mosby, 2004.
are made in the same direction. Further
tightening of the knot is possible before 8. Hurzeler MB, Weng D. Functional
it is locked by an overhand knot made and esthetic outcome enhancement
in the opposite direction. of periodontal surgery by applica-

The surgeon’s knot is the most com- To reproduce any part of this newsletter for promotional purposes,
monly used in implant surgery, and it
is generally used with braided sutur- please contact:
ing material and a standard mattress
technique. It consists of a modified Stephen Vance
square knot made up of two overhand
knots completed in opposite direc- Phone: (800) 688-2421, ext. 5511
tions. The first is a double overhand
knot; the second is a single. Doubling Fax: (800) 284-3291
the first overhand knot can prevent
knot loosening. n Email: [email protected]

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References To reproduce any part of AHC newsletters for educational purposes,
1. Coppa A, Bondioli L, Cucina A,
please contact:
et al. Palaeontology: Early Neo-
lithic tradition of dentistry. Nature. The Copyright Clearance Center for permission
2006;440:755-756.
2. O’Neal RB, Alleyn CD. Suture Email: [email protected]
materials and techniques. Current
Opinoins in Periodontology. 1997;4: Website: www.copyright.com
89-95.
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Dental Implantology Update™ June 2012