The replacement of single or multiple

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1 CASE REPORT The Washing Line Suture Technique for Securing the Subepithelial Connective Tissue Graft Shane J. J. McCrea, MMedSci, MSc, BDS Following tooth extraction, resorption of the buccal wall of the socket will occur; this will be true for both the maxilla and the mandible. Where the extraction site is surrounded by natural dentition, the loss of the buccal alveolar plate can degrade the visual aesthetics of an implant-supported prosthetic rehabilitation. To aid the harmonization of the hard and soft tissue morphology, both hard and soft tissue augmentation can be carried out either consecutively with an extraction/immediate implant placement or prior to an implant placement in the delayed scenario. The contemporary method of increasing soft tissue volume is to use the Subepithelial Connective Tissue (auto) Graft (the SCTG). The graft requires fixation, otherwise it can be extruded from the recipient site. This article presents a novel suturing technique which can confidently secure the SCTG, thus resisting its dislodgement. Key Words: implantology, extraction, sutures, subepithelial connective tissue graft INTRODUCTION The replacement of single or multiple teeth in an aesthetically sensitive zone is a major challenge. Tooth extraction results in both buccal soft and hard tissue remodeling that manifests itself as a reduction in volume morphology, that is, resorption. Bone resorption at a new extraction socket is continuous, with the greatest amount occurring within the first month. Pietrokovski et al 1 studied 123 human edentulous dry bone specimens, concluding that in the maxilla, bone resorption was centripetal and apical, that is, bone resorption was overwhelmingly from the buccal surface of every socket with significantly reduced resorption from the palatal aspect of the socket. In the mandible, resorption was centrifugal and apical, forming an edentulous crest central to the former tooth sockets. This difference in resorption produced a reverse horizontal overlap of the residual crests, with the edentulous maxilla at the same level The Dental Implant and Gingival-Plastic Surgery Centre, Bournemouth, Dorset, UK. Corresponding author, shanemccrea@aol.com DOI: /AAID-JOI-D or internal to the facing edentulous mandible. 2 Over time, the degree of resorption is directly related to a decrease in the aesthetic value achieved with dental implant replacement surgery. Both bone and soft tissue grafting techniques have been developed to address the loss in tissue volume. The subepithelial connective tissue graft (SCTG) is frequently used at periodontal recession sites to increase the volume of soft tissue at a deficient site and also convert thin periodontal phenotype A 3,4 into a stable thick gingival phenotype B. Bashutski and Wang 5 having reiterated the importance of tissue thickness and transferred the concepts to implant treatment planning. Current understanding is geared toward establishing a thick tissue biotype around implants because of its contribution to the aesthetic result of an implantsupported restoration. A thick biotype resists recession, 6,7,8 is able to better conceal titanium, 9 and helps maintain gingival morphology. 16 Thus, thick biotype is preferred to thin biotype around dental implants. Evans and Chen 17 performed a study on immediate implants, defining biotype by probe transparency. The study found that periimplant marginal stability was dependant on the baseline tissue thickness: Increasing soft tissue thickness minimizes the potential for peri-implant Journal of Oral Implantology 381

2 The Washing Line Suture Technique mucosal recession. Soft-tissue thickness can be increased by the Abrams roll technique and by placement of a SCTG. Further, inherent thick tissue biotype is important because thick tissues have an increased blood supply that will enhance neo-vascularization of bone grafts, leading to increased rate of healing and graft incorporation. Another advantage of thick tissue is its ability to attain and maintain primary wound closure. Adequacy of soft tissue coverage is one of the main factors in ensuring periodontal regeneration. Flap exposure results in a reduction of the bone regenerated in grafting techniques, primarily as a result of bacterial contamination. 10 An intact band of attached keratinized gingival tissue (KGT) is considered critical to the protective function of the mucogingival complex, although there is no agreement as to the minimum requirements. 11,12 The rationale for gingival augmentation around both natural teeth and dental implants includes improved plaque control and improving patient comfort with restorative, prosthetic, or orthodontic procedures and the prevention of gingival recession. 13 The stability of soft and hard tissues at implant sites have been investigated by Bouri et al. 14 They found that the Mean Gingival Index score, Plaque Index score, and radiographic bone loss were significantly higher for those implants with a narrow zone (,2 mm) of KGT. Further, implants with a narrow zone of KGT were more likely to bleed upon probing. Additionally, they found a significant independent association between the width of keratinized mucosa and radiographic bone loss. They concluded that an increased width of KGT around implants is associated with lower mean alveolar bone loss and improved indices of soft tissue health. This position was most recently reiterated by Kim et al. 15 From the aspect of long-term maintenance and management, as well as aesthetics, the presence of an appropriate amount of keratinized gingiva is required. Both immediate and delayed implant placement results in a reduction of the inherent width of keratinized gingival tissue (wkgt). The coronally advanced flap (CAF) is one of the options used for primary wound closure at both extraction sites and extraction-immediate dental implant placement sites. However, the CAF moves the mucogingival junction (MGJ) in a coronal direction, resulting in both aesthetic and functional impairment. The placement of the SCTG will both maintain and regenerate the wkgt. Nonetheless, the placement of harvested connective tissue (CT) at a recipient site can prove difficult. The CT needs to be firmly secured; otherwise, it will be in danger of being fully extruded from the site during the edematous phase of natural healing. Further, if it is mobile, it can be partially extruded from the wound site and suffer sloughing. For these reasons, the author has developed a technique for firm fixation of the CT graft under a mucoperiosteal flap while at the same time allowing optimization of its mesiodistal and coronal placement, thus resulting in not only the preservation or reattainment of soft tissue volume but also the retention or improvement of the width of keratinized gingival tissue. The following case reports detail the surgical procedure of the washing line suture technique. METHODS AND MATERIALS All illustrations are from patients presenting at a private practice dedicated to periodontics, dental implants, and advanced restorative techniques. Where teeth were determined to be beyond further conservative therapy, the patients were offered options of further treatment that included extraction and dental implant replacement therapy. All patients signed informed consent before treatment. Extraction and implant placement Pre-extraction: One hour prior to surgery, all patients received the same systemic coverage: 2 g amoxicillin (or 600 mg clindamycin when allergic), 400 mg ibuprofen, and 2 mg dexamethasone, as well as a mouthrinse of chlorhexidine gluconate 2% at 20 min prior to surgery. All surgery was carried out under intravenous sedation (midazolam) and local anesthesia (articaine 4%, Septodont, Saint Maur Des Fosses, France). Mucoperiosteal flaps were either raised after the extractions (Figures 1 through 4) or prior to extraction (Figures 5 and 6). All extractions were facilitated with periotomes to reduce trauma to the socket walls. The sockets were debrided of all inflammatory and granulation tissue, excluding that 382 Vol. XL/Special Issue/2014

3 McCrea FIGURE 1. Case 1. (a) Initial presentation of a 76 year old white male with hyperdontia. (b) Following removal of impacted supernumeraries, an implant has been inserted. (c) The alveolar void and buccal defect have been filled with Bio-Oss granules. (d) Bio-Gide membrane in place. (e) Harvested connective tissue securely fixed at recipient site using the washing line suture. (f) Wound coverage with the coronally advanced buccal flap. (g) 18 months postsurgery, or 12 months postloading of the implant, there is now a creation of a normal-appearing muco-gingival junction and width and volume of keratinized gingival tissue. Additionally, a central papilla has formed. (h) Schematic of suture technique in Case 1. For the mesio-distal fixation, 5.0 Prolene is introduced at point A through the fixed buccal mucosa. The suture then penetrates the donor connective tissue (CT) through the four points as shown, to re-emerge freely at the other side and penetrate the underside of the fixed buccal mucosa at point B. The suture then re-enters the fixed mucosa at point C to further penetrate the connective tissue in another 4 penetrations before penetrating the fixed mucosa again through point D where it is tied off. Crestally, the suture passes through the palatal mucosa and into the coronal portion of the connective tissue where it is returned back through the CT, and under the palatal mucosa to penetrate it and re-emerge on the palatal surface where it is tied off this is repeated as shown. at the marginal soft tissue: No remaining sulcular epithelium was removed from the soft tissue margin. Other than the presented Figure 3 ( old edentulous sites of 3 years), all buccal bony walls were thin and often suffered fracture during the implant placement (Figures 2, 4, 5, and 6). Of the latter, the implants were placed immediately (MIS, SEVEN, Tel Aviv, Israel) with displacement of their axis to the palatal wall of the vacant sockets. The primary stability of all inserted implants was high, all implants having an initial seating torque value of 50 Ncm as calibrated on the seating apparatus (Implantmed, W&H Dentalwerk, Buermoos, Germany). Final seating of the implants (torque value in excess of 50 Ncm) was carried out using a handwrench. The vacated sockets were then packed with the xenograft Bio-Oss (Geistlich Pharma, Wohlhusen, Switzerland); particle size mm. Journal of Oral Implantology 383

4 The Washing Line Suture Technique FIGURE 2. Case 2. (a) Initial presentation. The tooth had been removed 4 weeks prior to this surgical session. Soft tissue infill is apparent. (b) The buccal flap is elevated taking care to preserve all the new soft tissue infill at the socket. (c) The socket is debrided of all granulations. (d) The implant has been placed at the palatal wall. (e) Bio-Oss granules have been placed into the alveolar void. (f) Bio-Gide covering the wound site. (g) The connective tissue has been secured in a variation of the washing line technique. See Figure 4. (h) The flap is coronally advanced to cover the site completely. (i) Operative site at 5 months, prior to second-stage surgery. (j) The crown has been in occlusal function for 12 months. The soft tissue morphology is in harmony with the adjacent natural teeth and gingiva. (k) Schematic of the variation in suture technique. Following the re-entering of the suture at point C and then back into the connective tissue, there is a change in direction - the suture is now directed coronally and penetrates the underside of the palatal mucosa to emerge on the palatal surface. The suture is then directed back into the palatal mucosa and into the connective tissue. To eventually emerge at point D. 384 Vol. XL/Special Issue/2014

5 McCrea FIGURE 3. Case 3. (a) Initial presentation. Teeth 11 and 22 were extracted 3 years previously. The buccal concavity as a result of natural bone resorption is very apparent. The patient wears a removable acrylic prosthesis. (b) Diagnostic periapical radiographs of the prospective implant sites. (c) A mucoperiosteal flap was raised, preserving the interdental papillae. The flap design was widened in anticipation of the large wound and increase in volume that would result from the graft materials and the need for increased sulcus vascularity for wound repair. (d) The osteotomies have been prepared with their axis centralized such that there was avoidance of buccal bone dehiscence. (e) Cover screws have been fitted and Bio-Oss granules have been placed into the buccal bone concavities. (f) Bio-Gide covering the wound sites. (g) Connective tissue has been harvested from the palate and divided and placed at each implant site. Both connective tissue (CT) grafts are secured in place with a single washing line suture of 6.0 Ethilon that is secured through the still attached buccal mucosa at either side of the wound. Once again, the suture design allows the surgeon to move the individual CT grafts along the wound front and optimize their mesio-distal positions at each site. The CT grafts are then secured medially with 5.0 Prolene through the palatal tissue. (h) The flap is coronally advanced and secured with 5.0 Prolene crestally and 6.0 Prolene sutured in an apico-coronal direction at the relieving incisions. The papillary suturing is through the papillae, not over them, thus avoiding their compression. (i,j) 5 months postsurgery, there is harmonization of the MJG with the tissues adjacent to the surgical sites. The anatomical morphology of the surgical sites display a distinct visual re-attainment of tissue volume. (k) The implants have been functionally loaded for 6 months this being 13 months postimplant placement. Tissue volume has been reattained and maintained. Journal of Oral Implantology 385

6 The Washing Line Suture Technique FIGURE 4. Case 4. (a) Initial presentation. The lower incisors exhibit grade 3 mobility and will be extracted together with the lower right canine which has a failed root-treatment. (b) The teeth have been extracted, followed by the raising of a mucoperiosteal flap. The sockets have been debrided. (c) The osteotomies have been prepared in the vacated sockets of teeth 43 and 32 with their axis centralized to account for the certainty of both buccal and lingual bony resorption. The implant depth is such that the collars of the implants are submerged 2 mm below the bony level of the adjacent teeth 44 and 33. (d) Bio-Oss granules have been placed into the alveolar void. (e) Bio-Gide covering the wound site. (f) The connective tissue is secured in place with the washing line suture of 5.0 Prolene. (g) The flap is coronally advanced and secured with 5.0 Prolene crestally and 6.0 Prolene sutured in an apico-coronal direction at the relieving incisions. (h) At 5 months the implants have been exposed with simple crestal incisions. (i) Gingival margins at 6 months prior to impressions for a fixed prosthesis. The morphology and volume of the edentulous ridge have been maintained. (j) Fixed prosthesis after 12 months in occlusal function. (k) Periapical radiographs taken of the implants after 12 months in occlusal function. Buccal surface preparation After immediate implant placement and alveolar socket in-fill, or where substantial buccal resorption had occurred, all buccal dehiscences and depressions were further augmented with Bio-Oss (See Figures 1c, 2e, 3e, 4d, 5e, and 6g). The Bio-Oss granules were then covered with its dedicated resorbable membrane Bio-Gide (See Figures 1d, 2f, 3f, 4e, 5f, and 6h) Graft harvesting and placement The palate is the most common site for the harvesting of autogenous connective tissue. The technique involves an initial vertical incision 90 degrees to the palatal bone in the zone mesial to 386 Vol. XL/Special Issue/2014

7 McCrea FIGURE 5. Case 5. (a) Initial presentation, where tooth 11 is decoronated with a fractured root-treated root. (b) A flap was raised prior to extraction of the right central incisor, preserving the interdental papillae. The buccal flap was widened in anticipation of the large wound and the need for increased sulcus vascularity in wound repair. (c) The root has been luxated and the socket debrided. The thinness of the buccal bony plate is very apparent. (d) The osteotomy has been prepared with its axis displaced to the palatal wall, and the implant has been inserted such that its collar is approximately 2 mm below the bone crest of the adjacent teeth. (e) A cover screw has been fitted and Bio-Oss granules have been placed into the alveolar void. (f) Bio-Gide covering the wound site. Connective tissue (CT) is harvested from the left palatal vault. (h) The CT is secured in place with the washing line suture of 5.0 Prolene that is secured through the still attached buccal mucosa at either side of the wound. The suture design allows the surgeon to move the CT along the wound front and optimize its mesio-distal position. The CT is then secured medially with 5.0 Prolene through the palatal tissue. (i) The flap is coronally advanced and secured with 5.0 Prolene crestally and 6.0 Prolene sutured in an apico-coronal direction at the relieving incisions. The papillary suturing is through the papillae, not over them, thus avoiding their compression. (j) Site at 5 months prior to uncovering the implant showing the tissue harmony with the adjacent teeth and no displacement of the mucogingival junction. (k) Day of fitting the crown-6 months since the surgery. To note is the position of the mucogingival junction which is unchanged. (l) Periapical radiograph taken at 12 months of occlusal function. Implant used was a MIS SEVEN 4.2 æ 13 mm. Journal of Oral Implantology 387

8 The Washing Line Suture Technique FIGURE 6. Case 6. (a) Initial presentation. A poorly constructed crown has been fitted to tooth 11. The inadequate margins of the crown have been disguised with composite. There is recession of the marginal soft tissue. (b) The periapical radiograph shows tooth 11 has had an inadequate root-filling and subsequent apicectomy followed by the fitting of a post-crown whose preparation has perforated its root laterally. There is a large medial bony radiolucency present in association with the root perforation. (c,d) A mucoperiosteal flap was raised, preserving the interdental papillae. The extent of the medial bone destruction is visible. (e) The root has been luxated and the socket debrided. The thinness of the buccal bony plate is very apparent. The palatal marginal tissues have been judiciously preserved. (f) Osteotomy has been prepared with its axis displaced to the palatal wall, and the implant has been inserted such that its collar is approximately 2mm below the bone crest of the adjacent teeth. A cover screw has been fitted. (g) Bio-Oss granules have been placed into the alveolar void and been used to augment the buccal dehiscence. (h) Bio-Gide covering the wound site. (i) The connective tissue is secured in place with the washing line suture of 5.0 Prolene. (j) The flap is coronally advanced and secured with 5.0 Prolene crestally and 6.0 Prolene sutured in an apico-coronal direction at the relieving incisions. (k) The implant was exposed at 5 months. This photo shows the situation at 6 months just prior to the impression for the crown construction. (l) Marginal tissues at 6 months post-functional loading of the implant. The marginal tissues of the central incisors are harmonious and the level of their MJG has been maintained. 388 Vol. XL/Special Issue/2014

9 McCrea the second molar tooth, parallel to the arch of the teeth at the donor site just shy of the bone. The blade is removed and reinserted, angled 135 to 180 degrees to undermine the palatal tissues at a depth of 1 mm toward the midline. A micro-periosteal elevator is used to tease a full-thickness flap away from the bone, thus allowing easier manipulation of the palatal tissue. The desired width of connective tissue is then cut away. 16 In general, the subepithelial connective tissue was harvested from either the right or left hard palatal vault, mesial to the first premolar and anterior to the second molar region (Figure 5g). At the recipient site, the suture material (5.0 Prolene, Johnson & Johnson, New Jersey, USA) was initially placed through the still fixed mucosa and then passed through the donor connective tissue and along its length to penetrate its farthest extremity (Figures 1e, 3g, 4f, 5h, and 6i). The suture needle was then passed under the second fixed mucosal site through to the outer surface. The suture was then reentered into the mucosa and passed through the SCTG once again and through to the start position, where it again penetrated the SCTG. The needle was then finally placed through the fixed mucosa to emerge adjacent to the original penetration, where it was tied off. The fixation of the harvested connective tissue to the recipient site must allow the maintenance of actual volume of the donor tissues; the washing line is placed under the donor tissue, thus maintaining its volume and hindering unwanted compression. The SCTG is now moved along the suture washing line with ease, optimizing its position. To complete the centralizing of the SCTG, the coronal side of the graft was securely sutured under the sulcular margin of the palatal mucosa with interrupted sutures (5.0 Prolene). A variation of this standard suture technique can be used, as shown in Figure 2g and 2k, whereby the suturing is continuous into the coronal portion of the SCTG and the palatal mucosa. The buccal flaps were all replaced coronally with minimal tension, being secured interdentally and crestally with 5.0 Prolene (Figures 1f, 2h, 3h, 4g, 5i, and 6j). Relieving incisions were secured with 6.0 Prolene interrupted sutures placed apico-coronally (Figures 1f, 2h, 3h, 4gG, 5i, and 6j). To facilitate wound healing, the donor sites were covered with Eugenol-free Coe-Pack for 3 days (GC-Fuji, Leuven, Belgium). RESULTS Wound healing was always uneventful. Sutures on the palatal donor site were removed at 14 days. The sutures at the relieving incisions and that of the washing line were removed at 28 days. Five months were allowed for the implants to integrate before they were uncovered (Figures 2i, 3i, 3j, 4h, and 5j) with a modified Abrams roll technique to help thicken the labial soft tissue. 17 The implants were all restored at 6 months following surgery (Figures 4i, 5k, and 6k). Results of the presented cases show that not only is the tissue volume enhanced (or sustained) but that there is a visible maintenance in the position of the mucogingival junction (Figures 2j, 3k, 4j, 5k, and 6l). Figure 1 is an extreme presentation of hyperdontia in a male Caucasian of 76 years of age: Figure 1a shows the initial presentation and the lack of normal marginal tissues associated with a mesiodens and the impacted, malformed right central incisor. Figure 1g shows the creation of an acceptable volume and width of keratinized gingival tissue at the crown on the implant and a simulated central papilla. DISCUSSION The vascularization of a connective tissue graft originates from the periodontal plexus, the supraperiosteal plexus and the overlying flap. 18 Graft survival being heavily dependent on the maintenance of blood supply and early revascularization. Preparation of the recipient site is to maximize blood supply for blood clot formation and organization to prevent graft necrosis while minimizing mobility to prevent tearing of the delicate blood vessels that will invade the graft and cause neovascularization. 19 The inability to achieve neovascularization is the causative factor for graft sloughing and the failure or diminishment in attainment of optimal results. Therefore, immobilization of the CT graft and primary closure of the wound are prerequisites for optimization of the results. Though discussed, there is a paucity in descriptive information as to the fixation methods for the CT graft in the dental literature, especially in relation to dental implant surgery and large open surgical sites. The purpose of this paper is to rectify that lack of descriptive documentation. The author performs the washing line suture technique as routine for the firm fixation of the Journal of Oral Implantology 389

10 The Washing Line Suture Technique subepithelial connective tissue graft. All grafts heal uneventfully and integrate completely by primary wound healing. The advantage of the method is the certainty that the graft will remain in its secured position with no wandering and danger of exfoliation from the wound site. The tension-free coronally advanced flap 20,21 provides a primary seal for the wounds resulting from immediate implant placement and bone augmentation and the increased volume associated with the placement of the SCTG and the bone augmentation. This is the reason for uneventful bone and soft tissue graft healing, which will then result in nondisplacement of the mucogingival junction. Unfortunately, the volume increase in tissues below the CAF may well result in their physical displacement: The washing line has addressed this problem. The results of all the presented cases display a visual optimization of volume maintenance facilitating aesthetic implant-supported restorations in some trying circumstances. CONCLUSIONS Where aesthetics are of prime concern to the patient and the surgeon, the role of periodontal plastic surgery techniques has now been amplified. The subepithelial connective tissue graft is still considered the gold standard for maintaining the position of the mucogingival junction and thickening the buccal soft tissue, resulting in the local conversion of thin marginal gingiva into thick marginal tissue. However, the loss or dislodgement of the SCTG must remain a consideration. The author has addressed the problems associated with the securing of the SCTG by providing a predictable suture technique that is within the capabilities of the experienced periodontist/implantologist: the washing line suture technique. ABBREVIATIONS CAF: coronally advanced flap CT: connective tissue KGT: keratinized gingival tissue SCTG: subepithelial connective tissue graft wkgt: width of keratinized gingival tissue REFERENCES 1. Pietrokovski J, Starinsky R, Arensburg B, Kaffe I. Morphologic characteristics of bony edentulous jaws. J Prosthodontics. 2007;16: Smukler H, Landi L, Setayesh R. Histomorphometric evaluation of extraction sockets and deficient alveolar ridges treated with allograft and barrier membranes: a pilot study. Int J Oral Maxillofac Implants. 1999;14: Müller HP, Eger T. Gingival phenotypes in young male adults. J Clin Pertiodontol. 1997;24: Müller HP, Eger T. Masticatory mucosa and periodontal phenotype: A review. Int J Periodontics Restorative Dent. 2002;22: Bashutski JD, Wang HL. Common implant aesthetic complications. Implant Dent. 2007;16: Kois JC, Kan JY. Predictable peri-implant gingival aesthetics: surgical and prosthodontic rationales. 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J Prosthet Dent. 1980;44: McCrea SJJ. Micro-surgical repair of labial gingival tissues following excision of an epulis: a case report with 18-month followup. Oral Surg. 2010;3: Prato G, Pagliaro U, Baldi C, et al. Coronally advanced flap procedure for root coverage. Flap with tension versus flap without tension: a randomized controlled clinical study. J Periodontol. 2000; 71: Pini Prato G, Baldi C, Nieri M, et al. Coronally advanced flap: the post-surgical position of the gingival margin is an important factor for achieving complete root coverage. J Periodontol. 2005;76: Vol. XL/Special Issue/2014