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Soft tissue managment

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SOFT TISSUE MANAGEMENT

Prepared byMuhammed Ahmed Omar

Introduction

Last decade, demand on endodnotic surgery has

been increased.

Point of view Endodontic macro surgery.

The evolution to microsurgery.

Gingival tissue

Collateral circulation through blood vessels communicating between the periodontal plexus and the periosteal plexus.

Soft tissue access

◦The term Flap indicates a section of soft tissue that is outlined by a surgical incision.

Certain basic principles must be considered before

deciding on the type of incision and flap design:

1. Regional anatomical structures.

2. Recognition of the position of the root within the

mandible or the maxilla.

3. Periodontal conditions play an essential role in the

decision making process.

Principles of Flap design

4. Type and quality of restorations in special reference

to the position of the restoration margin to the

gingiva need to be determined and are critical to the

esthetic outcome.

5. Evaluation of the size and position of the expected

periradicular pathology in relation…..

Flap Design

◦In order to design a mucoperiosteal flap successfully for

oral surgery there are number of points that must be

considered:

Broad base

Adequate size

Anatomical considerati

on

Margins on sound

bone

Relieving

incisions

• Broad base

Mormann and Ciancio The circulation changes observed suggested that flaps receive their major blood supply from their apical aspect

Adequate size

• the flap must be large enough to allow the surgeon to visualize the tooth in question and adjacent teeth fully. • Small flap causes difficulty for the

surgeon and tension on the flap, resulting in excessive tissue trauma. • A general rule for the size of a

flap is to start one tooth behind the tooth to be operated and continue to one tooth in front.

Anatomical considerationAnatomical structures that must be taken into consideration when designing a flap are explained according to the area of flap placement.

Mandible There are nerves which should be considered when planning surgery in mandible:

Mental nerve Lingual nerve

Mental nerve

Maxilla 

The greater palatine nerve and vessels• majority of palatal surgeries are done using an envelope flap

around necks of teeth, the neurovascular bundle are reflected with the flap without much difficulty.

• vertical relieving incision done at the anterior end of the flap, as posterior relieving incision will severe the greater palatine vessel causing risk bleeding.

Nasopalatine nerve• If the anterior part of the palate needs to be reflected, then this

neurovascular bundle can be safely cut at the level of the foramen.

• The resultant bleeding can be easily controlled with pressure and the nerve can regenerate.

Margins on sound bone

1. the incision should rest on sound bone once the surgery is complete.

2. The surgeon should anticipate the approximate amount of bone that will need to be removed so that this can be taken into account when designing the flap.

3. If the incision does not lie on a sound bone, then this will result in delayed healing and a higher chance of wound breakdown. 

Relieving incisions

Avoid incision lines over radicular eminences such as canines and maxillary first bicuspids.

Avoid incisions across major muscle attachment.

Extent of horizontal incisions should be adequate to provide access with minimal soft tissues trauma.

Extent of vertical incisions should be sufficient to allow the tissue retractor to seat on solid bone leaving the apex well exposed.

Junction between horizontal and vertical incision lines should either include or exclude the involved interdental papilla.

Flaps should include the full thickness of the mucoperiosteum.

Avoid horizontal and severly angled vertical incisions. The supraperiosteal vessels assume a vertical course parallel to long axis of teeth. Collagen fibers of the gingival mucosa (gingival ligament)are vertically oriented as well. These severely angled incisions shrink excessively during surgery as a result of contraction of cut collagen fibers and severance of gingival blood vessels. It often results in placing excessive tension during suturing , tearing out of the nutrition and subsequent scar formation as a result of healing by secondary intention.

Any Idea about differentFlap Designs

Flap designs and Incisons:

◦The wide variety of flap designs reflects the number of variables to be

considered before choosing an appropriate flap. As conditions vary with

each individual patient and specific situation, there will always be a need

to select the best flap design for every single case.

The choice of flap designs should allow

maintenance of optimal blood perfusion during

surgery.

This implies using a design where vertical

releasing incisions run vertical, parallel to the

tooth axis and to supraperiosteal blood vessels

in the mucosa and gingiva, resulting in minimal

vascular disruption.

The flap design plays an important role as to how much

recession will occur postoperatively.

• Paramedian rather than mid-axial releasing incisions are recommended to minimize recession risks (Mormann).

The incision line should begin in a 90-degree angle to the outer contour of the marginal gingiva as shown and marked with a green line. This rule applies to any type of incision, to avoid thinning out of tissues and allowing sufficient blood supply to reach the area, promoting better healing(Velvart)

The tissue margin comprises unsupported epithelial cells without the epithelial base cells, which are responsible for formation of a multilayered seal of epithelial cells.

single straight incision directed to the crestal bone. The pointed tissue ending will necrotize at its very end, creating a small, but visible defect and a recession. This type of incision is simple to perform, but will result in a poor healing result. (peters)

the incision line should begin and ends in a 90-degree angle to the outer contour of the marginal gingiva as shown and This rule applies to any type of incision, to avoid thinning out of tissues and allowing sufficient blood supply to reach the area, promoting better healing.

Classification:

I. Full mucoperiosteal flaps:a) Triangular (single vertical releasing

incision)b) Rectangular (double vertical releasing

incisions)c) Trapezoidal (broad base rectangular)d) Horizontal (no vertical releasing

incision)e) Papilla-base.

II. Limited mucoperiosteal flaps:a) Submarginal scalloped rectangular

(luebke – ochsenbein)b) Submarginal curved (semi- lunar)

I- Full mucoperiosteal flaps:

The entire soft tissue overlying the cortical bone plate is reflected.

The advantage of these flaps is keeping intact supraperiosteal vessels.

a) Triangular flap:

Two incisions; horizontal and vertical.Vertical releasing incision.Horizontal incision intrasulcular

gingival incision.

Advantage

• Rapid healing

• Ease of closure

Disadvantage

• Limited surgical access

indications

• Maxillary incisor region.

• Maxillary and mandibular posterior teeth.

• The most recommended flap for posterior mandibular region

Not recommended for:

Teeth with long roots (maxillary canines)Mandibular anterior teeth due to the lingual inclination of their roots.

b) Rectangular flap:

Two vertical and a horizontal intrasulcular incision.

Advantage

• Good surgical access.

disadvantage

• Difficult re-approximation of margins.

• Difficult post surgical stabilization.

• Great potential for post surgical

indication

• Mandibular anterior.

• Maxillary canines.

• Multiple teeth.

Not indicated

• Mandibular posterior teeth.

c) Trapezoidal flap:

Two vertical releasing incisions which join a horizontal intrasulcular incision at obtuse angles.

Advantage

• It creates a broad-based flap.

• It was assumed that this provide a better blood supply.

disadvantage

• More bleeding due to disruption of more of the vertically oriented blood vessels.

• Shrinkage, pocketing or clefting of soft tissue due to severing of more collagen fibers.

• Wound healing by secondary intention.

Not indicated

• periradicular surgery.

d)Horizontal (envelope) flap:

A horizontal, intrasulcular incision with no vertical releasing incision.

It has a very limited application due to the limited surgical access.

Advantage

• Improved wound healing.

• Excellent wound closure and postsurgical stabilization.

disadvantage

• Extremely limited access.

indication

• Repair of cervical defects; such as perforations, resorption, cervical caries.

• Hemisection.• Root

amputation.

Not indicated

• Periradicular surgery.

E) Papilla-base Flap: A horizontal incision at the papillary base extending

intrasulcular toward the crestal bone. At least one vertical incision is established.

The key point of the PBI is to avoid thinning of the split flap

Peters and velvart stated that Papilla base flaps have allowed virtually recession free healing after endodontic surgery.

II. Limited mucoperiosteal Flaps:

◦ They have a submarginal (subsulcular) horizontal, or horizontally oriented, incision, and does not include marginal or interdental tissues. Therefore in this type of flaps more vertically oriented blood vessels and collagen fibres are severed.

A) Submarginal scalloped rectangular (luebke – ochsenbein) Flap:

A modification of the rectangular flap.It provides the advantages of the rectangular

and semilunar flaps.

The horizontal incision is placed in the attached gingival.

The horizontal incision is scalloped following the contour of marginal ginigva above the free gingival groove. Vreeland and Tidwell modified the submarginal incision by placing a scalloped horizontal incision 1 to 2 mm below the gingival margin

Advantage

• Does not involve marginal or interdental gingivae.

• Crestal bone is not exposed.

• Adequate surgical access. Disadvantage

• Disruption of vertically oriented blood vessels producing more bleeding.

• Severing vertically oriented collagen fibres producing flap shrinkage.

• Difficult reapproximation.

• Delayed healing.• Scar formation.

indications

• Maxillary incisor region.

• Maxillary and mandibular posterior teeth.

• The most recommended flap for posterior mandibular region

B) Submarginal curved (Semilunar) Flap:

A curved incision in the alveolar mucosa and attached gingival.

Incision begins at the alveolar mucosa extending into attached gingival and then curves back into the alveolar mucosa, resembling a half moon.

Advantage

Does not disturb the gingival margin and interdental papillae.

disadvantage

Poor surgical access.

Poor wound healing due to disruption of blood supply to un-flapped tissues.

Difficult wound closure.

Postsurgical scarring.

Considerations in palatal surgery:Palatal approach is difficult limited visibility and accessibility.

Indicated flap designs:1. Horizontal (envelope).2. Triangular.

The horizontal intrasulcular incision extends mesially to:

Envelope flap palatal midline.Triangular flap mesial to the first premolar.Extends distally as far as needed to give accessibility.

Triangular flap:Vertical releasing incision extends from a point near midline and join the anterior extent of the horizontal incision mesially.Vertical palatal incisions are safe in premolar area, or mesial to it.Greater palatine artery branches rapidly as it courses anteriorly. 

Indications of palatal flaps:

1. Surgical procedures in palatal roots of molars and premolars such as apicectomy, amputation, or perforation repair.

2. Repair of perforations or resorption defects of palatal surfaces of anterior teeth.

Incisions Flap design and surgical exposure should be planned before initial incision is made.

SCALPEL:Handle- No. 3, No.7Differently shaped Disposable, sterile sharp

blade:

1. No.15 or 15c • most commonly used• Relatively small• Around teeth through

mucoperiosteum , blades with rounded end (BB 369, Aesculap, Tuttlingen, Germany) 2.5mm.

2. No.10- similar to No.15Large skin incisions

3.No. 11• Small stab incisions• Sharp, pointed • Incising an abscess

4.No.12• Hooked• Mucogingival procedures• Posterior aspect of teeth/

maxillary tuberosity

•Pen Grasp: Allow maximal control•Hold mobile tissue firmly

•Press down firmly

LASERS.◦ The term Laser is the acronym for “Light Amplification

by Stimulated Emission of Radiation”.

◦ CO2 laser with wavelength of 10,600nm

Photobiology Of Lasers

Photochemical Biostimulation - Stimulatory effects of laser on

biochemical and molecular processes that normally occur in tissues such as healing and repair.

Photodynamic Therapy – induce reactions in tissues for the treatment of pathologic condition.

Tissue fluorescence - used as a diagnostic method to detect light reactive substance in tissue.

Photo thermal interactions Photo ablation – removal of tissue by vaporization and super heating of tissue fluids , coagulation, and hemostasis.

Photocoagulation Laser heats the tissues to 60 deg C for a limited time leading to coagulation of the tissues with minimal alteration in the appearance of tissue structure.

Photomechanical

•Photo disruption - breaking apart of structures by laser light.

•Photoaccoustic interaction- involve removal of tissue with shock wave generation.

Flap reflection and retraction:

• Marginal gingiva is very delicate:

1.do not begin reflection in the horizontal incision.

2.Attached supracrestal tissues are clinically very important.

Damaging these tissues apical epithelial downgrowth causing:

Increased sulcular depth and loss of soft tissue attachment level.

Submarginal flaps:

1. Reflection should not begin also in the horizontal incision.

2. Reflecting forces may damage wound edges, delay healing, and causes scar formation.

What’s the Next step?

Flap Reflection:• It should begin in the vertical

incision few millimeters apical to its junction with the horizontal incision.

• Once this part is lifted from cortical plate a periosteal elevator is inserted between it and the bone with its sharp side toward bone.

• The elevator is then moved coronally so that;

The marginal and interdental gingivae as well as the wound edge are separated without direct application of dissectional forces.

• By doing so all direct reflective forces are applied to periosteum and bone only.

• The horizontal sulcular incision may be made with a scalpel.

Elevation starts at the middle portion of the vertical incision.

Flap Retraction:

Retractor should rest on sound cortical bone.

If retractor rests on the base of reflected tissues damage of microcirculation and delayed healing occur.

Groove technique.

Time of retraction: General rule: the longer the flap

is retracted the greater the post surgical complications

Because of: Reduced vascular flow. Tissue hypoxia.Frequent flap irrigation with sterile saline to prevent dehydration.

Limited mucoperiosteal flaps more susceptible to dehydration.

Therefore, they require more frequent irrigation.

After reflecting a mucogingival flap, scaling of root-attached tissues and tissue tags on cortical bone should be avoided to allow rapid reattachment and protection against bone resorption.

 SURGICAL SITE CLOSURE

  After irrigation with saline solution to remove debris, the

wound edges are reapproximated carefully to allow primary intention healing.

Compression of the repositioned flap with a saline-moistened piece of gauze is necessary to create a thin fibrin layer between flapped tissue and cortical bone Replacement of a thin blood clot with parallel fibrin fibers by new fibrous tissue results in collagen adhesion.

Suturing

DEFINITION OF SUTURE

The Term suture describes any type of material utilized to approximate tissues or skin, in another meaning it means to sew.

The primary objective of suturing in dental field is to position and secure flaps in order to promote healing.

Goals of suturing

1. Provide an adequate tension of wound closure without dead space.

2. Maintain hemostasis.

3. Permit primary intention healing

4. Reduce postoperative pain .

5. Prevent bone exposure resulting in delayed healing and unnecessary resorption.

6. Permit proper flap position.

Needles

• The conventional cutting point has two opposing cutting edges and third edge on the inside curvature of the needle.

• The reverse cutting point has two opposing cutting edges and third cutting edge on the outer curvature of the needle.

• The tapered point is used primarily on soft, easily penetrated tissues . it leaves small hole and can be used in soft tissue surgery.

The blunt point has a rounded end which does not cut through the tissue .

IDEAL SUTURE Material

Tensile st: adequate material strength will prevent suture breakdown & use of proper knots for the material used will prevent untying or knot slippage.

Tissue biocompatibility: sutures made from organic material will evoke a higher tissue response than synthetic sutures.

tissue reaction α amount & size of suture material.

•Low capillarity: multifilament type soak up tissue fluid by capillary action providing a rich medium for microbes increasing chances of inflammation & infection.

•Good handling & knotting properties: ease of tying & a thread type that permits minimal knot slippage also influence thread selection.

•Sterilization without deterioration of properties: most sutures available in packages are sterilized by dry heat & ethylene oxide gas.

• Non allergic, non electrolytic and non carcinogènic

• Its use should be possible in any operation.

• Low cost

Classification of Suturing material

•Organic•Synthetic•Natural

According to their origin

According to their behavior in tissue:

Absorbable

Cat Gut

Chromic Cat Gut

Collagen

POLYGLACTIN910(VICRYL)

VICRYLplus ANTIBACTERI

AL

Non absorbable

Natural:

Silk

Cotton

Synthetic

Nylon

Polypropylene

According to their structure

•Monofilament

•multifilament

According to the size

◦ It varies from 4-0 to 8-0.

Types of absorbable suture material

Gut / cat gut Oldest known absorbable suture.Galen referred to gut suture as early as 175

A.D.Derived from sheep intestinal sub mucosa or

bovine intestinal serosa.When placed intra orally sutures are digested in 3-5days.

CHROMIC CATGUTCoated with thin layer of chromium salt

solution to minimize tissue reaction, increase TS, slow the absorption rate, better knot security, and ease of handling.

It is monofilament and is available in the plain form as well as “tanned” in chromic acid. The tanning process delays the digestion by white blood cell lysozymes.

Absorbed in 10-15 days

COLLAGEN SUTURE

◦Natural, absorbable, monofilament

◦Obtained by homogenous dispersion of pure collagen fibrils from the flexor tendons of cattle.

◦TS - < 10% after 10 days.

◦Disadvantage of premature absorption.

SYNTHETIC ABSORBABLE

POLYGLACTIN 910 (VICRYL)

Synthetic suture

Monofilament/multifilament

Lactide has hydrophobic qualities→delaying

loss of TS

TS - 14 – 21 days, strongest material.

Absorption –60-90days.

Minimal tissue reactivity and can

be used in infected tissues

Coated with polyglactin 370 and

calcium stearate which allows easy

passage through tissues as well as

easier knot placement.

VICRYL plus ANTIBACTERIAL SUTURE

◦Handles and performs same as normal vicryl.◦In vitro studies shown that triclosan on VICRYL plus

creates a zone of inhibition around the suture.

Non absorbable sutures

SilkBraided or twisted

Advantage:Ease of handling – more for braidedGood knot securitymade non capillary in order to withstand action of body fluids & moisture.(wax

or silicon coated)Cost effective

Disadvantage:nonabsorbable silk sutures are easy to tie and handle but are no longer

recommended as they accumulate plaque, allow rapid bacterial colonization and are uncomfortable to remove because of ingrowth of tissue

COTTON

◦Natural, multifilament, non absorbable◦From stable Egyptian cotton fibers◦good knot security◦Not good in presence of contaminated wounds or

infection◦Rarely used nowadays as it is weak.

Nylon

◦Used for skin closure.

◦ Causes tissue irritation when used intra-orally.

◦ Very hard material.

Polypropylene

They are non-absorbable, sterile surgical suture composed of an isotactic crystalline steroisomer of polypropylene, a synthetic linear polyolefin. The suture is pigment blue to enhance visibility.

High tensile strength. Monofilament. It has good plasticity and it expands with

tissue swelling to accommodate the wound. Disadvantage: High memory, poor knot security and lack of

elasticity.

Is a unique, microporous, nonabsorbable monofilament made of expanded polytetrafluoroethylene (ePTFE), the same proven material used in other Gore Medical Products. This unique material offers the benefits of both monofilament and multifilament sutures with the excellent material properties of PTFE including:

• Soft and supple for excellent handling and minimizing the irritation caused by knots

• No out of package memory• White color is highly visible in the surgical field• Minimal biological tissue response with cellular ingrowth.• Monofilamnet.

GORE-TEX®

Lilly GE, Armstrong , When comparing

histological tissue response of different

suture materials, monofilament sutures (e.g.

nylon, gut, steel, PTFE, PROLENE and

chromic gut) produced smaller

inflammatory reaction than multifilament

materials (e.g. silk, siliconized silk,

polyester, teflonized polyester, cotton, or

linen)

• To avoid necrosis of papillae by inserting too much suture material, # 6 – 0 to # 8 – 0 suture sizes are recommended in micro- surgical techniques(Blatz MB, Lindemann)

SUTURING TECHNIQUES

Efforts are made to minimize scar formation and

recessions after surgical procedures.. Microsurgery

alone will not accelerate epithelial healing rates, but

through perfect tissue adaptation of wound edges, it

can create smaller distances for epithelial migration

during the healing process.

A) interrupted suture, (B) anchor suture, (C) sling suture, and (D) vertical mattress suture

Healing Process

Bleeding.

Clot formation.

Inflammation.

Proliferation.

• P.N.Ls, Macrophages migrates..

Tissue Repair.

• Fibroblast domination with collagen and GAGs

Remodeling.

• Rapid soft tissue healing is a result of reduced tissue trauma and enhanced wound closure during microsurgical procedures. To achieve these goals several measures are necessary:

Accurate Treatment planning

• Patient related factors

• Flap design

• Operator skills

Minimal tissue trauma

• Incision• Micro-

instruments and materials.

Suture Removal

• Epithelial streaming as a sheet or as

fingers is observed after 2 days,

eventually resulting in a multilayered

seal(Wirthlin MR, Hancock EB ).

Because of early epithelial bridging,

suture removal is therefore advocated

after 2 to 3 days . Initial resistance to

rupture forces is attributed to

regeneration of epithelial attachment

to tooth surfaces(Wirthlin) .

• Other authors do not recommend suture

removal before 4-5 days, as stainable

collagen content in granulation tissue, which

determines tensile wound strength, is only

present after 4 days(Torabinejad).

• More and more variables of wound

healing, including patient nutritional

status, bacterial infection, wound care

and available tissue oxygen, are being

researched. Consequently, novel

therapies are evolving, such as growth

factor therapy.

Papilla Preservation/Protection

◦Complete and predictable restoration of lost interdental papillae is one of the biggest challenges .

◦Therefore, it is imperative to maintain the integ- rity of the papilla during surgical procedures.