Basic Surgical Techniques and Armamentarium










602
26
Basic Surgical Techniques
and Armamentarium
CHRISTOPHER R. RESNIK AND RANDOLPH R. RESNIK
B
asic dental surgical methods were practiced in the early
Roman times when diseased gingival tissues were excised
with instruments and no local anesthetic. Today, many of
the principles of modern-day surgical procedures are based on the
teachings of William Stewart Halsted, MD, the “Father of Mod-
ern-Day Surgery.” Halsted, an American surgeon and cofounder
of Johns Hopkins Hospital, developed surgical principles in the
late 19th century that are still universally used today. He empha-
sized a strict aseptic technique and tissue-handling principles to
obtain predictable soft tissue surgical success rates. He determined
that the gentle handling of lacerated tissues would aid healing by
causing less damage to the blood and nerve supply in the operative
eld. With his work, the “Tenets of Halsted” resulted that have
helped to guide the principles of surgery in all medical disciplines
1
(Box 26.1).
Dental implant surgery encompasses a broad range of proce-
dures involving the hard and soft tissues of the oral cavity. e
procedures vary from simple exodontia to technically challeng-
ing full-mouth, bone augmentation and implant procedures. e
implant clinician must have a strong foundation for basic surgical
principles so that potential complications are avoided. For most
implant procedures, specic instruments and armamentarium, as
well as protocols, have been developed to facilitate the procedures.
With these basic principles in mind, surgical protocols and bio-
logic principles have been developed in the eld of oral implantol-
ogy. Over the years the surgical management of the dental implant
patient has led to a more evidence-based practice and the intro-
duction of improved techniques and instrumentation. erefore
this chapter will emphasize basic surgical principles that should
ideally be used during implant-related procedures. In addition,
a comprehensive review of the surgical armamentarium will be
discussed.
Flap Design
Surgical aps are made to gain access to a surgical area or to relocate
tissue from one area to another. Over the years the mucogingival
ap design used in oral implantology has changed dramatically. e
use of technology has allowed for more accurate and ideal place-
ment of implants and bone grafts, along with better techniques for
handling tissue and preserving blood supply. In the early years of
oral implantology, most surgeries were completed with an aggressive
full reection of the surgical area including full releasing incisions
that traumatized the tissue and compromised the blood supply.
Following the original Brånemark protocol, implants were buried
below the tissue and left to integrate for 4 to 6 months before a
second surgery to uncover and place a healing abutment (stage 2
technique). In the 1990s a more conservative, one-stage surgery
technique became popular that involved placement of a healing
abutment at the time of implant placement. is procedure showed
remarkable results, with decreased morbidity. en in the 2000s
immediate implant placement became popular, and advancements
in guided surgery allowed the advent of “apless” surgery, which
resulted in much less trauma. With advanced technology, clinicians
are now able to 3D print surgical guides in their oce that are based
on cone beam computed tomographic imaging for ideal implant
placement and accurate anatomy, which has led to more accuracy
with apless techniques. However, apless surgery is not indicated
in all cases and certainly may lead to higher morbidity. erefore it
is imperative that the implant surgeon understand the basic prin-
ciples of ap design.
e type of ap used in surgery varies dramatically, with much
of the design criteria based on the purpose and anatomic area of
the surgical site. Flap designs may be classied by the type of tissue
(full versus partial thickness) and the number and type of inci-
sions used to create them (envelope, papilla sparing, triangular,
trapezoidal, vestibular, etc.).
When developing the ideal ap design, a few basic principles
pertain to all aps used in implant dentistry.
Maintain Blood Supply
e primary goal of any ap design is to retain and maxi-
mize the native blood supply to continuously nourish the
1. The gentle handling of tissues
2. An aseptic technique
3. Sharp anatomic dissection of tissues
4. Careful hemostasis, using fine, nonirritating suture material in minimal
amounts
5. The obliteration of dead space in the wound
6. The avoidance of tension
7. The importance of trauma to the surgical site postoperatively
BOX
26.1
Tenets of Halsted

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CHAPTER 26 Basic Surgical Techniques and Armamentarium
surrounding tissue and bone.
2
If the blood supply is disrupted
to the wound margin, in theory the health of the tissue may be
compromised, which may lead to poor wound healing. It has
been shown that three essential factors are required to main-
tain and regenerate soft tissue quality with implant-related pro-
cedures: (1) preservation of the blood supply to the adjacent
papilla, (2) preservation of the bone on the adjacent teeth, and
(3) minimal scar tissue formation during surgery.
3
When soft
tissue becomes rigid and nonexible as a result of traumatic
surgical manipulation or previous surgical interventions, it may
not allow for ideal adaptation or exibility around the dental
implant or prosthesis.
4
Most importantly in the esthetic zone, it is imperative to
maintain the papilla. e vascularity of the papilla tissue is sup-
plied by various vascular anastomoses that cross the alveolar
ridge. If repeated incisions and trauma to the vascular supply
occur, scar tissue formation will result as broblasts become pre-
maturely activated to form excess brotic tissue. is type of
tissue is usually dicult to manipulate and may lead to recession
and esthetic complications. An exaggerated level of erythema,
edema, and discomfort may be indicative of compromised blood
supply.
5
e base of the ap is important in maintaining the blood sup-
ply. Ideally the ap should always be broader than the free mar-
gin (i.e., ridge area) to preserve the blood supply. All areas of the
ap must have a source of uninterrupted vasculature to prevent
ischemic necrosis of the ap.
6
Ideally aps should have sides that
converge, moving from the base to the apex (ridge). e length of
the ap should generally not exceed twice the width of the base.
e base of the ap should not have signicant pressure or be
excessively stretched or twisted, which may compromise the blood
supply (Fig. 26.1).
Flap Design to Provide Access
e ap design must provide sucient access to provide necessary
visualization of the entire surgical area. Adequate access must also
exist for the insertion of instruments required to perform the sur-
gery and to reect the tissue to maintain access. e ap must be
held out of the operative eld by a retractor that ideally would rest
on intact bone without tension. Excess tension most likely will
result in tissue trauma and an increase in swelling.
7
If increased
edema is present, the patient may experience greater discomfort,
and there is a greater possibility of incision line opening or com-
promised wound healing (Fig. 26.2).
Full-Thickness Reflection
e ap should be a full-thickness mucoperiosteal ap that will include
the surface mucosa, submucosa, and periosteum. Because implant
surgery usually requires access to the underlying alveolar bone, all
tissue must be suciently reected. In addition, full-thickness aps
are ideal because the periosteum is the primary tissue responsible for
the bone healing process, and replacement of the periosteum in its
original position hastens that healing process. In addition, torn, split,
and macerated tissue heals much slower than a cleanly reected full-
thickness ap, thereby delaying the healing process.
8
A sharp scalpel should be used to score the bone to obtain a
full-thickness reection, thus ensuring complete penetration
through the tissue layers. When reecting the tissue, the underly-
ing bone should be “scraped,” thus minimizing the possibility of a
partial-thickness ap. Care must be taken when reecting the tis-
sue to separate the tissue away from the bone. When using a peri-
osteal elevator (e.g., 2–4 Molt), the tip edge should always rest on
the bone to prevent tearing through of the tissue ap (Fig. 26.3).
Minimize Trauma to Tissue
Meticulous handling is required to minimize trauma to the soft tissue.
Proper use of appropriate tissue forceps, avoidance of excessive suction-
ing by the assistant, and “tieback” sutures all contribute to improved
ap management. Nonlocking tissue pickups (e.g., Adson forceps) are
commonly used to hold soft tissues in place when retracting tissue
or during the suturing process. Various designs of tissue forceps exist,
most commonly having smooth tips, cross-hatched tips, or serrated
teeth (often called mouses teeth). Serrated teeth forceps used on tissues
will result in more tissue damage because they may tear the tissue,
whereas smooth surface forceps tend to be much gentler to the tissue.
Fig. 26.1 Ideal ap design with broad base incision that preserves the blood
supply. Note how the width of the incision base is much greater than the ridge.
Fig. 26.2 Flap design provides sufcient access to visualize the entire
surgical eld. Too small of a ap will lead to stretching of the tissue and an
increase in inammation.
Fig. 26.3 Full-thickness reection with 2–4 Molt instrument.

604
PART VI Implant Surgery
Tissue retractors should be selected and placed in a position
to prevent undue pressure on the ap. Maintaining the retractors
on bone and not on the tissue will minimize trauma to the tissue.
Excessive pressure and tension on the tissue ap will impair blood
circulation, alter the physiologic healing of the surgical wound,
and predispose the wound to bacterial colonization, which may
lead to incision line opening (Fig. 26.4).
9
Vertical Release Incisions
Vertical release incisions may be used to maintain the blood sup-
ply and decrease the tension to the ap. Usually the primary blood
supply is to the facial ap, which is from the unkeratinized mobile
mucosa. Vertical release incisions are often made to the height
of the mucogingival junction, and ared 45 degrees to allow for
spreading of the tissue and maintenance of the blood supply.
10
Vertical release incisions should not be made over bony promi-
nences (e.g., canine eminence) because this will increase tension
on the incision line and may increase the possibility of incision
line opening. In addition, it is often dicult to suture over these
areas because the tissue tends to be very thin (Fig. 26.5).
Maintain Flap Margins Over Bone
e soft tissue ap design should also have the margins of the
wound over host bone whenever possible. is is especially impor-
tant when approximating tissue over bone grafts or barrier mem-
branes. e host bone provides growth factors to the margins and
allows the periosteum to regenerate faster to the site.
11
e mar-
gins distal to the elevated ap should exhibit minimal reection.
e palatal ap and the facial tissues distal to the reected ap
usually are not elevated from the palatal bone (i.e., unless augmen-
tation is required) because the blood supply to the incision line
will be compromised. In some cases the soft tissue reection distal
to the surgery site may be split thickness to maintain periosteum
on the bone around the incision line. is will improve the early
vascularization to the incision line and adhesion of the margins to
reduce retraction during initial healing.
Prevent Desiccation of Tissue
e tissues should be maintained in a moist environment with-
out prolonged periods of desiccation.
12
If excessive drying of the
tissues occurs, there is less likelihood that complete wound clo-
sure will occur. If the tissue margins become desiccated, periodic
irrigations with sterile saline (0.9% sodium chloride) or saline-
moistened gauze may be used.
Flap Mobility
e passivity of the ap is paramount for the successful wound
healing of the soft tissues. When sutures are positioned too tight
to overcome the residual tension of the ap, they may alter the
blood supply, thereby reducing the vessel patency and impair-
ing vascularization.
13
Excessive ap tension is the most frequent
causative factor leading to incision line opening.
14
is is best
prevented by appropriate incision and ap design, the use of
periosteal releasing incisions (PRIs), and blunt dissection (“tis-
sue stretching”).
Past techniques to expand tissue primarily used a more api-
cal tissue reection and horizontal scoring of the periosteum
parallel to the primary incision. Historically the vestibular
approach by Brånemark allowed for optimal visualization of
anatomic landmarks, suturing remote from the surgical area,
complete tissue coverage, as well as predictable primary clo-
sure and healing.
15
e postoperative disadvantages of this
approach include distortion of the vestibule and other ana-
tomic landmarks, edema, dicult suture removal, and cumula-
tive patient discomfort.
16
Langer and Langer
17
documented the use of overlapping par-
tial-thickness aps. is approach results in extension of the coro-
nal aspect of the buccal or palatal ap, allowing primary intention
closure around the site in an overlapping manner. is is usually
eective for primary closure when less than 5-mm advancement
of the ap is necessary (Fig. 26.6).
A submucosal space technique developed by Misch
18
in
the early 1980s is an eective method to expand tissue over
Fig. 26.4 Tissue retractors should ideally be positioned on bone to pro-
vide ideal access to the surgical eld and minimize trauma to the tissue
and vital structures.
Releasing
incision
Blood supply Blood supply
Fig. 26.5 Vertical release incisions are required to provide access to
the surgical eld and prevent excess pressure on tissue aps. The cor-
rect release incision is on the left which maintains the blood supply. The
incorrect ap design is illustrated on the right as the blood supply is cut off
because of the location of the release incision.
Fig. 26.6 Flap with excess tension increases possibility of incision line
opening.

605
CHAPTER 26 Basic Surgical Techniques and Armamentarium
larger grafts (greater than 15 Å 10 mm in height and width)
(Box 26.2).
e utility of periosteal incision for gaining ap release was
studied by Park.
19
He found aps could be advanced up to 171.3%
(more than 1½ longer than its original length) by two vertical
incisions and a PRI under a minimal tension of 5 g, whereas one
or two vertical incisions without PRI could advance the ap only
113.4% and 124.2%, respectively. ese results suggested that
PRI can be predictably used to attain tension-free primary closure
under a minimal pulling tension of aps (Fig. 26.7). A sharp scal-
pel blade at a 45 degree angle or Metzenbamm scissors are used
to score the periosteum to create greater ap extension. is will
allow tension-free primary closure.
Types of Flaps
Flapless
Flapless implant surgery has become popular because of the
associated decreased pain and morbidity. In the apless tech-
nique a tissue punch is used to remove the gingival tissue over
the osteotomy site. Mainly this technique has been advocated
because of the preservation of the blood ow to the papilla and
decreased postoperative pain. Oliver
20
has shown that apless
surgery is advantageous for preserving the crestal bone and is
reduced when the gingival tissue is thick (>3 mm).
21
However,
when performing apless surgery, adequate bone quantity must
be present, along with sucient keratinized tissue. e associ-
ated disadvantage of this technique is the inability to visual-
ize the underlying bone. Cone beam computed tomographic
imaging and guided surgery have made apless surgery more
predictable; however, inherent errors still exist. In most apless
surgery cases a tissue punch is used to expose the bone. e
gingival tissue will be removed in the area of the osteotomy.
Care should be exercised in using a tissue punch when an inad-
equate amount of keratinized tissue is present. Flapless surgery
has been shown to result in overheating the bone because it is
often dicult to irrigate the osteotomy adequately when a ap
is not raised (Fig. 26.8 and Box 26.3).
22
Papilla Sparing
e interproximal soft tissue in sites next to adjacent natural
teeth may be classied into three categories: (1) papillae have an
acceptable height in the edentulous site, (2) papillae have less
than acceptable height, or (3) one papilla is acceptable and the
other papilla is depressed and requires elevation.
23
When the
interproximal papilla has an acceptable height, “papilla-saving”
incisions are made adjacent to each neighboring tooth. e ver-
tical incisions are made on the facial aspect of the edentulous
site and begin 1 mm below the mucogingival junction, within
the keratinized tissue. Extending the vertical incisions beyond
the mucogingival junction increases the risk for scar formation
at the incision site. e full-thickness incision then approaches
the crest of the edentulous site, leaving 1.0 to 1.5 mm of the
interproximal papilla adjacent to each tooth. is maintains the
blood supply to the papillae and will help to preserve the papil-
lae after healing. e goal is for the facial ap to be advanced
over the implant or in approximation to a permucosal exten-
sion at the conclusion of the procedure, with no voids at the
Procedure
1. A full-thickness facial flap first is elevated off the facial bone
approximately 5 mm above the height of the vestibule.
2. One incision with a scalpel, 1 to 2 mm deep, is made through the
periosteum, parallel to the crestal incision and 3 to 5 mm above the
vestibular height of the mucoperiosteum. This shallow incision is made
the full length of the facial flap and may even extend above and beyond
the vertical release incisions. Care is taken to make this incision above
the mucogingival junction; otherwise the flap may be perforated and
delay soft tissue healing.
3. Soft tissue scissors (e.g., Metzenbaum) are used in a blunt
dissection technique to create a tunnel apical to the vestibule and
above the unreflected periosteum. The scissors are closed and
pushed through the initial scalpel incision approximately 10 mm
deep, then opened slowly.
4. This submucosal space is parallel to the surface mucosa (not deep
toward the overlying bone) and above the unreflected periosteum. The
thickness of the facial flap should be 3 to 5 mm because the scissors are
parallel to the surface. This tunnel is expanded with the tissue scissors
several millimeters above and distal to the vertical relief incisions.
5. The submucosal space is developed and the flap is advanced the
distance of the “tunnel” and draped over the graft to approximate the
tissue for primary closure without tension. Ideally the facial flap should
be able to advance over the graft and past the lingual flap margin by
more than 5 mm. The facial flap may then be returned to the lingual
flap margin and sutured. This soft tissue procedure is performed before
preparing the host region for any type of bone grafting or augmentation
around an implant.
BOX
26.2
Submucosal Space Technique
AB
Fig. 26.7 Tissue tension reduction: (A, B) Severing periosteal bers with a 15 blade parallel; to the ap.

606
PART VI Implant Surgery
incision line and primary closure (Fig. 26.9). Bilateral buccal
vertical releasing incisions should extend obliquely at an angle
and connect to the horizontal incision. is ap is indicated in
the esthetic zone, areas where you need to increase the amount
of keratinized gingiva on the buccal, or in patients with a thin
gingival biotype (Box 26.4).
Envelope
An envelope ap is designed with a midcrestal incision over the
implant site, followed by sulcular incisions on the buccal and
palatal that extend at least one tooth to the mesial and distal. A
full-thickness ap is reected using blunt dissection. One of the
benets of this ap is that scarring from vertical incisions will
be avoided. On reection, if more access is required for osseous
defects or implant placement complications, a vertical releasing
incision may be added to create a triangular or trapezoidal ap.
e envelope ap is contraindicated in cases where extensive bone
grafting is required because of the limited access and the increased
risk for tension on closure (Fig. 26.10 and Box 26.5).
Triangular and Trapezoidal
e triangular and trapezoidal incisions are more aggressive
incisions that are initiated over the implant site and sulcular
incisions that continue horizontally to at least one adjacent
tooth. Both the triangular and trapezoidal incisions involve
A B
Fig. 26.8 Flapless Incision. (A) Tissue punch bur which corresponds to diameter of the intended
implant size, (B) Slow-speed latch type handpiece used to remove tissue.
Advantages
• Lessinvasive
• Maintainstissuevasculature
• Noverticalincisions
• Lesspatientdiscomfort
Disadvantages
• Limitedvisibility
• Overheatingbone
• Limitedaccesstoevaluatebone
• Malpositioningismorecommon(unlessguided)
BOX
26.3
Flapless Surgery
A
B
Fig. 26.9 Papilla-Sparing Incision. (A) Incision maintaining 1 mm of
papilla tissue. (B) Reected ap maintaining papilla tissue intact.
Advantages
• Nodisruptionofthepapillae
• Lessmorbidity
• Minimaldisruptionofvasculature
Disadvantages
• Noaccesstoadditionalsites
• Needadditionalskillset
• Minimalreectedspaceforimplantplacement
• Difcultyinbonegrafting
• Possiblescarringinnonkeratinizedtissue
BOX
26.4
Papilla-Sparing Surgery

607
CHAPTER 26 Basic Surgical Techniques and Armamentarium
a sulcular incision and vertical releasing incisions (i.e., tri-
angular: one vertical release; trapezoidal: two vertical release
incisions). A vertical releasing incision is then extended api-
cally above the mucogingival junction. By placing the vertical
releasing incision as distal as possible, scarring may be spared
that may occur during healing.
24
PRIs are placed to aid in ap
advancement to gain tension-free primary closure. e main
advantage of these aps is direct visibility of the bone, which
allows access to bone recontouring, as well as bone grafting.
ese aps are contraindicated in patients with a thin gingival
biotype because of the tension placed on the ap
25
(Fig. 26.11
and Box 26.6).
Vestibular
e vestibular ap incision is a minimally invasive technique that
allows preservation of the interproximal tissue and allows access
for buccal ridge recontouring and soft tissue grafting.
26
is tech-
nique involves one or more full-thickness vertical incisions in the
vestibule away from the gingival margin and sulcus. After tissue
elevation a subperiosteal pouch is created to allow space for a bone
graft. e main limitation of this ap is the lack of visualization
and access to the alveolar ridge (Box 26.7).
Proper Incision Technique
e design of the surgical incision is based on many factors such
as anatomic location, tissue quality, type of procedure, and desired
Fig. 26.10 Envelope Flap. Minimal ap that maintains blood supply.
Advantages
• Noverticalincisions
• Easytosuture
• Easytomodify
Disadvantages
• Limitedaccess
• Moderatedisruptionofvasculature
• Increasedriskfortensionuponclosure
• Guidedboneregenerationnotpossible
BOX
26.5
Envelope Flap Surgery
A
B
Fig. 26.11 Examples are larger, more aggressive ap designs: (A) trian-
gular and (B) trapezoidal.
Advantages
• Bettervisibility
• Increasedpossibilityoftension-freeclosure
• Accesstoadditionalsites
Disadvantages
• Increasedbonelossandrecession
• Increaseddisruptionofbloodsupply
• Reection/Suturingofadjacentpapilla
• Increasedpatientmorbidity
BOX
26.6
Triangular/Trapezoidal Flap Surgery
Advantages
• Lessinvasive
• Nodisruptionofpapillae
• Mayusewithbone-graftingprocedures
Disadvantages
• Limitedaccess
• Lowvisibility
• Notindicatedforimplantplacement
BOX
26.7
Vestibular Flap Surgery

608
PART VI Implant Surgery
healing outcome.
27
Flap designs may be further classied as to the
type of tissue (full versus partial thickness), the number of inci-
sions used to create them (envelope, papilla sparing, triangular,
trapezoidal), or secondary incisions that dictate the aps direction
(rotating versus coronally versus apically advancing).
25
Over the years the mucogingival ap design used in oral implan-
tology has changed dramatically. Technology has allowed for the
more accurate and ideal placement of implants and bone grafts.
Better techniques and methods with tissue handling and preserv-
ing the blood supply have become reality. In the early years of oral
implantology, most surgeries were completed with an aggressive
full reection of the surgical area with multiple release incisions.
Most implants were placed with a submerged (stage 2) technique.
In the 1990s a more conservative one-stage surgery technique
became popular that involved placement of a healing abutment at
the time of implant placement. is procedure showed remarkable
results with a decreased morbidity. In the early 2000s advancements
in guided surgery allowed the advent of “apless” surgery, which
resulted in much less trauma and patient complications.
With most dental implant procedures, surgical incisions are
required. With a properly placed incision, the implant clinician
may obtain adequate access to the surgical site for implant place-
ment, identify necessary landmarks, and prevent unnecessary
complications. e design of the surgical incision is based on
numerous factors such as anatomic location, tissue quality, amount
of keratinized tissue, procedure, amount of access required, and
the desired healing outcome. ere exist numerous principles that
must be adhered to for the majority of incisions.
Proper Incision Positioning
e primary incision should ideally be located in keratinized tissue
whenever possible. is will allow for an increased wound surface
area and a resultant increase in vascularity to the incision line.
28
Not
only does this reduce signicant initial intraoral bleeding, it also
will result in severing less blood vessels. A reduction in postopera-
tive edema will result, which decreases tension to the incision line
and possible incision line opening. If there exists 3 mm or more of
attached gingiva on the crest of the edentulous ridge, the incision
should ideally bisect the soft tissue. is places half of the attached
gingiva width on each side of the incision (i.e., 1.5 mm), thereby
strengthening the incision line. If there is less than 3 mm of attached
keratinized tissue on the ridge crest, the incision should be made
more lingually so that at least 1.5 mm of attached tissue is placed to
the facial aspect of the implant. is concept is especially important
in the posterior mandible because attached tissue is required to pre-
vent tension and pulling from the buccinator muscle (Fig. 26.12).
Incisions made through attached gingiva and over healthy bone
are more desirable than those through unattached gingiva and
over unhealthy or missing bone contours. When osseous defects
are present, properly placed incisions allow the wound margins to
be sutured over intact, healthy bone that are a minimum of a few
millimeters away from the bone defect. is will result in sup-
porting the healing wound. In esthetic zones a papilla-sparing ap
may be used to preserve the papilla and minimize possible tissue
recession (Fig. 26.13).
In summary, the incision location may vary depending on
multiple factors. e goal of any incision is to allow for adequate
exposure of the operative eld and to minimize possible damage
or tearing of the tissue margins. is will lead to a better chance of
obtaining primary closure, which results in better healing and less
chance of postoperative complications.
29
Use of a Sharp Scalpel Blade
A sharp scalpel blade allows incisions to be made cleanly with-
out unnecessary damage from repeated strokes, especially if not
in the same plane. Many factors dictate how fast the scalpel blade
will dull, such as contacting teeth, titanium (e.g., implants, abut-
ments, healing cover screws), and dense bone, which tend to lead
to accelerated dulling. e resistance and thickness of the tissues
may dull the blade at dierent rates; therefore the surgeon should
change the scalpel blade whenever a dierence is noted in the
blade sharpness. Sharp dissections tend to minimize trauma to the
incision line, which will result in less tissue trauma and postopera-
tive swelling (Fig. 26.14).
Scalpel Technique
Clean, precise incisions allow for optimal wound closure. An
ideal incision includes a single stroke through the tissue in one
direction with rm, even pressure on the scalpel. Tentative
strokes, especially in dierent planes, will increase the amount of
damaged tissue and increase the amount of bleeding and inam-
mation. Long, continuous strokes are preferable to shorter,
Fig. 26.12 Incision design based on amount of attached tissue. If less
than 3 mm of attached tissue is present, then the incision is positioned
more lingually.
Fig. 26.13 Incision made more lingual to increase attached tissue to the
buccal. Note the broad based papilla sparing incision.

609
CHAPTER 26 Basic Surgical Techniques and Armamentarium
inconsistent, interrupted strokes. Ideally the incision should
always be over bone.
In most cases the blade should be held perpendicular to the
epithelial surface. is will result in an angle that produces square
wound margins, which are easier to reapproximate during sutur-
ing and less likely for surgical wound necrosis and incision line
opening to occur
30
(Fig. 26.15).
Avoid Vital Structures
e incision and ap should be designed to avoid possible injuries
to vital structures. e two most important structures in the man-
dible include the mental nerve and lingual nerve. When making
incisions in the mandibular premolar area, care should be exer-
cised with the anatomy of the mental nerve. Usually three to four
branches of the mental nerve will ascend from the mental fora-
men and are supercially located in the soft tissue. In mandibu-
lar edentulous cases the scalpel blade should always remain on
the bone. is will prevent “slipping” o the ridge and damaging
deeper vital structures. In mandibular severe atrophy cases the
mandibular canal may be dehisced, which can lead to direct tran-
section of the nerve bers. In instances where the nerve lies on top
of the ridge, the incision is carried lingual to the ridge to avoid
severing the nerve. In the posterior mandible the lingual nerve
may be closely adhered to the lingual aspect of the mandible.
erefore in the retromolar pad area, incisions should always be
positioned lateral to the pad.
In the maxilla, rarely will an incision damage a vital structure.
On the buccal, there exist no vessels that would be problem-
atic, except for the infraorbital nerve, which exits the infraor-
bital foramen. However, direct trauma is usually rare in this area.
On the palatal aspect the nasopalatine vessels exit the incisive
foramen and supply the anterior palatal gingiva. If this area
is incised, minimal bleeding will result, and the neural tissue
regenerates rather quickly.
31
Posterior palatal release incisions
should be avoided because the greater palatine nerve and artery
may be traumatized, which may lead to increased bleeding epi-
sodes (Fig. 26.16).
Proper Scalpel Grip
Pencil Grip
e scalpel is grasped close to the blade between the tips of the
thumb and the index nger, with the remaining handle resting on
the web of the thumb, much like grasping a pencil. With this grip
the motion is predominately from the thumb and index nger,
allowing for precise cutting of tissue. A nger rest may be used
to increase the accuracy of the ne cutting. is grip may also
be “backhanded” by reversing the direction of the blade without
changing the upper arm position. e pencil grip is best used for
short, ne movements for precise incisions, because the muscles
of the hand are used signicantly more than the muscles of the
forearm. e blade edge is usually held at 30 to 40 degrees to the
tissue. One of the limitations of this technique is the greater angle,
which results in less cutting-edge contact, and limits the depth of
the incision (Fig. 26.17).
Fingertip Grip
With this technique the scalpel is held between the thumb and the
middle nger, while the index nger is placed on the body of the
Fig. 26.14 Incision should be made to “score” the bone; this allows for
full-thickness reection of the tissue.
Fig. 26.15 Proper method of making incision using no. 15 scalpel blade.
Note the scalpel motion is made by moving the hand at the wrist and not
by moving the entire forearm. (From Hupp JR, Ellis E, Tucker MR. Con-
temporary Oral and Maxillofacial Surgery. 7th ed. Philadelphia: Elsevier;
2020.)
Fig. 26.16 Incisions should be made to avoid any vital structures, for
example, the mental foramen and lingual nerve in the mandible.

610
PART VI Implant Surgery
scalpel blade to apply downward pressure, much like grasping a butter
knife. is grip technique uses more arm motion and is primarily used
for making long skin incisions. e main advantage is the increased
blade-to-tissue contact, which provides good depth and direction con-
trol. e greater the length of tissue contact with the scalpel, the more
the walls of the incision resist minute or sudden changes in direction,
allowing for smoother, straighter incisions. e main disadvantage of
the ngertip grip is that it does not allow for precise blade cuts.
Palm Grip
e palm grip is used when strong pressure in indicated to incise
the tissue. e scalpel is held in the palm of the dominant hand
with the index nger on top of the handle. e cutting pressure
is derived from the palm and ngers as well as the entire arm.
However, this grip is rarely used in implant dentistry (Fig. 26.17).
Surgical Armamentarium
A full array of instruments may be used in oral implantology, and
usually the clinician will over time develop personal preferences
with respect to various procedures. e following is a summary of
some of the most popular instruments used today.
Instrument to Incise Tissue
Scalpel/Surgical Blades
e scalpel is the ideal instrument for making incisions and sepa-
rating tissue. Scalpels are basically manufactured in two forms:
disposable and metal reusable handle. e most used scalpel in
oral implantology is the #3 scalpel, which commonly has a metric
ruler on one side, which allows for intraoperative measurements.
As stated earlier, the scalpel must be held in a way that permits full
control of the instrument and at the same time freedom of move-
ment. e handle of the scalpel is grasped between the thumb and
the third and fourth ngers, and the index nger is placed over the
back of the blade to provide rm control.
e most common scalpel blade used in oral implantology is
the #15 blade or #15c blade. e #15 blade has a short, rounded
cutting edge, combined with an angled point. In addition, the
#12 or #12b blade is commonly used, mainly around teeth or in
dicult access areas. ese blades are small, pointed, and crescent
shaped, which are end cutting on the inside edge of the curve.
Blades can be either carbon steel or stainless steel. Carbon-steel
surgical blades are sharper than stainless-steel blades but may dull
quicker (Fig. 26.18).
A
B
Fig. 26.17 Scalpel Grip. (A) Pencil grip: ideal scalpel grip because maxi-
mum control is obtained. (B) Palm grip: nonideal scalpel grip with minimal
control which is rarely used in implant dentistry.
#11 #12 #12B #15 #15C
B
A
Fig. 26.18 (A) Scalpel handle: most common is the Bard-Barker. (B) Different scalpel blades: #11 is used
for incision of abscesses or infections; #12 and #12b are used around teeth to connect incisions in difcult
access areas; #15 is the most common blade used in oral implantology; and #15c has a smaller neck that
allows for easier access around teeth.

611
CHAPTER 26 Basic Surgical Techniques and Armamentarium
Instruments to Reflect Tissue
Once the incision is made, the mucosa and periosteum must be
reected to expose the bone. e Molt periosteal elevator (#9)
is one of the more common instruments to complete this task.
e periosteal elevator usually has a sharp, pointed end and a
broad, at end. Normally the pointed end is used to initiate
the reection, followed by the broad end, which allows for a
larger volume of tissue to be reected. In the authors opinion
an easier and more ecient instrument to use to reect tissue
is the 2/4 Molt. is double-ended instrument has two small,
rounded, sharp areas, 2/4 (4 mm/6 mm), and is positioned in
a dished-out fashion to allow for tissue to be reected easier
(Fig. 26.19).
In general, tissue can be reected three dierent ways: (1)
prying motion—pointed end used in a prying motion to ele-
vate the soft tissue; (2) push stroke—used after full thickness
incision to slide underneath the ap; and (3) pull or scrape
stroke—used to remove tissue tags from the bone in a scraping
motion (Fig. 26.20).
Instruments to Grasp Tissue
Tissue forceps are used to stabilize soft tissue aps for sutur-
ing and reection of aps. e most common tissue forceps
used in implant dentistry include the Adson and Allison
forceps.
Adson forceps (pickups): to grasp and stabilize soft tissue aps
during suturing or implant and bone graft procedures.
ese delicate forceps have small teeth or serrations to gen-
tly hold tissue for stability. Care should be exercised to not
crush the tissue because the tissue can be irreversibly dam-
aged (Fig. 26.21).
Allison forceps: these forceps have larger and more aggressive teeth
used to hold heavy or high-tension tissue. In implant dentistry
these types of forceps are rarely used.
Instruments to Remove Bone/Tissue
Rongeur forceps
A rongeur is a heavy-duty surgical instrument with a sharp-
edged, scoop-shaped tip, used for gouging or snipping away the
bone. e word rongeur is a French word meaning “gnawer.” In
oral implantology the rongeur is used to cut or contour tissue, or
to remove pieces of bone. Rongeur forceps have a spring between
the handles, which increases the magnitude of the removal force.
A common type used is termed double-action rongeur, which
signicantly generates more force than a single-action rongeur.
Because the blades are concave toward the inside, harvested bone
is easily retained to be used in grafting areas.
1. Side Cutting to cut and contour bone, remove sharp edges; will
retain bone for grafting purposes
2. End Cutting to cut and contour bone; one beak may engage
bone to shave bone from the ridge (Fig. 26.22)
Surgical burs
Surgical burs can also be used to remove bone. It is important to
always use irrigation when using the surgical burs. e tissue must
be adequately reected to prevent trauma to the tissue with the burs.
Cross-cut ssure burs may be used to make pilot holes in the host
bone that will allow the bone to be removed with a chisel. Additional
burs used to remove bone (i.e., alveoplasty) include special ridge
reduction burs, straight handpiece (HP) acrylic barrel shaped burs, or
HP round burs (Fig. 26.23).
Fig. 26.19 Reection technique for full-thickness reection with the 2/4
molt instrument.
Fig. 26.20 Recommended periosteal reection instrument: 2 to 4 Molt.
AB
Fig. 26.21 Adson Forceps. (A) Teeth: may perforate and tear thin tis-
sue; however, it allows for better grasping of the tissue. (B) Serrated: less
chance of perforating tissue.

612
PART VI Implant Surgery
Bone file
A bone le is a double ended serrated instrument used to remove
sharp, spiny ridges within the bone (Fig. 26.24).
Instruments to Remove Tissue From
Extraction Sockets or Bony Defects
e surgical curette is an instrument used to ensure removal of
debris and diseased tissue. ese instruments are usually spoon
shaped and have sharp edges that allow scraping of the bony walls.
Not only will the scraping remove soft tissue, the curettes will also
initiate the regional acceleratory phenomenon (RAP). e most
commonly used and recommended surgical curette has serrated
edges (e.g., Lucas 86 Currette) (Figs. 26.25 and 26.26).
Bone-Grafting Instruments
Bone scrapers
Bone scrapers are mainly used by clinicians to harvest autogenous
bone from the oral cavity and allow the collected bone particles
to be delivered to the surgical site. ese instruments consist of
a harvesting blade and collection chamber, with a narrow-tipped
syringe for access-restricted areas (Fig. 26.27).
Grafting spoon and condenser
ese instruments hold bone to be placed at a specic area with a
spoon-type of instrument. Usually a condenser is present on the
other side of the instrument, which allows for the condensing of
the bone graft material into the defect (Fig. 26.28).
Surgical Scissors
ere exists a full array of scissors used in oral implantology:
straight, curved, serrated, and nonserrated. Surgical scissors are
used to cut tissue, spread tissue, and cut sutures. Usually the
thumb and ring nger are placed in the scissor rings, with the
index nger to steady the scissor. Curved scissors are usually pre-
ferred by most surgeons because they provide a better eld of view
and access to restricted areas.
Dean: the most commonly used scissors in oral implantology,
which have slightly curved handles and oset serrated blades
that allow for easy access to cut sutures and to remove diseased
tissue. Dean scissors feature angled blades that are approxi-
mately 3 cm in length from midscrew. ey have one serrated
blade, with a slightly curved handle.
Iris: very small, extremely sharp scissors with a ne tip. Some iris
scissors have curved blades for certain types of precision tasks,
whereas others may have straight blades.
Kelly: commonly used to trim tissue or cut sutures because they
have one serrated cutting side to the scissors.
Metzenbaum: surgical scissors that are designed for delicate tissue
and blunt dissection. e scissors are available in variable lengths
and have a relatively long shank-to-blade ratio. ey are con-
structed of stainless steel and may have tungsten carbide cutting
surface inserts. Blades can be curved or straight (Fig. 26.29).
Hemostats
e hemostat is an instrument that has serrated tips that allow
for the “clamping” of tissue or small materials. Directly above the
Fig. 26.23 Bone removal using carbide HP bur in a straight 1:1 handpiece.
B
A
Fig. 26.22 Rongeur. (A) Double-action rongeur allows for greater force
for bone removal. (B) Bone removal using a “rocking” motion.

613
CHAPTER 26 Basic Surgical Techniques and Armamentarium
A B
Fig. 26.24 Bone le (A) used to smooth out sharp ridges, (B) which may lead to postoperative tissue
irritation especially after osteoplasty procedures have been performed.
A
B
Fig. 26.25 (A) Lucas 86 Surgical Curette (Salvin), which is a serrated
spoon excavator. (B) Removing tissue within an extraction site and initiat-
ing the regional acceleratory phenomenon.
Fig. 26.26 Technique for curetting the extraction socket before grafting
or addition of bone graft material.
ABC
Fig. 26.27 (A) Bone Scraper, (B) Bone scraper being used to harvest bone from tuberosity area, (C) Harvested bone in bone scraper.

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60226Basic Surgical Techniques and ArmamentariumCHRISTOPHER R. RESNIK AND RANDOLPH R. RESNIKBasic dental surgical methods were practiced in the early Roman times when diseased gingival tissues were excised with instruments and no local anesthetic. Today, many of the principles of modern-day surgical procedures are based on the teachings of William Stewart Halsted, MD, the “Father of Mod-ern-Day Surgery.” Halsted, an American surgeon and cofounder of Johns Hopkins Hospital, developed surgical principles in the late 19th century that are still universally used today. He empha-sized a strict aseptic technique and tissue-handling principles to obtain predictable soft tissue surgical success rates. He determined that the gentle handling of lacerated tissues would aid healing by causing less damage to the blood and nerve supply in the operative eld. With his work, the “Tenets of Halsted” resulted that have helped to guide the principles of surgery in all medical disciplines1 (Box 26.1).Dental implant surgery encompasses a broad range of proce-dures involving the hard and soft tissues of the oral cavity. e procedures vary from simple exodontia to technically challeng-ing full-mouth, bone augmentation and implant procedures. e implant clinician must have a strong foundation for basic surgical principles so that potential complications are avoided. For most implant procedures, specic instruments and armamentarium, as well as protocols, have been developed to facilitate the procedures. With these basic principles in mind, surgical protocols and bio-logic principles have been developed in the eld of oral implantol-ogy. Over the years the surgical management of the dental implant patient has led to a more evidence-based practice and the intro-duction of improved techniques and instrumentation. erefore this chapter will emphasize basic surgical principles that should ideally be used during implant-related procedures. In addition, a comprehensive review of the surgical armamentarium will be discussed.Flap DesignSurgical aps are made to gain access to a surgical area or to relocate tissue from one area to another. Over the years the mucogingival ap design used in oral implantology has changed dramatically. e use of technology has allowed for more accurate and ideal place-ment of implants and bone grafts, along with better techniques for handling tissue and preserving blood supply. In the early years of oral implantology, most surgeries were completed with an aggressive full reection of the surgical area including full releasing incisions that traumatized the tissue and compromised the blood supply. Following the original Brånemark protocol, implants were buried below the tissue and left to integrate for 4 to 6 months before a second surgery to uncover and place a healing abutment (stage 2 technique). In the 1990s a more conservative, one-stage surgery technique became popular that involved placement of a healing abutment at the time of implant placement. is procedure showed remarkable results, with decreased morbidity. en in the 2000s immediate implant placement became popular, and advancements in guided surgery allowed the advent of “apless” surgery, which resulted in much less trauma. With advanced technology, clinicians are now able to 3D print surgical guides in their oce that are based on cone beam computed tomographic imaging for ideal implant placement and accurate anatomy, which has led to more accuracy with apless techniques. However, apless surgery is not indicated in all cases and certainly may lead to higher morbidity. erefore it is imperative that the implant surgeon understand the basic prin-ciples of ap design.e type of ap used in surgery varies dramatically, with much of the design criteria based on the purpose and anatomic area of the surgical site. Flap designs may be classied by the type of tissue (full versus partial thickness) and the number and type of inci-sions used to create them (envelope, papilla sparing, triangular, trapezoidal, vestibular, etc.).When developing the ideal ap design, a few basic principles pertain to all aps used in implant dentistry.Maintain Blood Supplye primary goal of any ap design is to retain and maxi-mize the native blood supply to continuously nourish the 1. The gentle handling of tissues 2. An aseptic technique 3. Sharp anatomic dissection of tissues 4. Careful hemostasis, using fine, nonirritating suture material in minimal amounts 5. The obliteration of dead space in the wound 6. The avoidance of tension 7. The importance of trauma to the surgical site postoperatively • BOX 26.1 Tenets of Halsted 603CHAPTER 26 Basic Surgical Techniques and Armamentariumsurrounding tissue and bone.2 If the blood supply is disrupted to the wound margin, in theory the health of the tissue may be compromised, which may lead to poor wound healing. It has been shown that three essential factors are required to main-tain and regenerate soft tissue quality with implant-related pro-cedures: (1) preservation of the blood supply to the adjacent papilla, (2) preservation of the bone on the adjacent teeth, and (3) minimal scar tissue formation during surgery.3 When soft tissue becomes rigid and nonexible as a result of traumatic surgical manipulation or previous surgical interventions, it may not allow for ideal adaptation or exibility around the dental implant or prosthesis.4Most importantly in the esthetic zone, it is imperative to maintain the papilla. e vascularity of the papilla tissue is sup-plied by various vascular anastomoses that cross the alveolar ridge. If repeated incisions and trauma to the vascular supply occur, scar tissue formation will result as broblasts become pre-maturely activated to form excess brotic tissue. is type of tissue is usually dicult to manipulate and may lead to recession and esthetic complications. An exaggerated level of erythema, edema, and discomfort may be indicative of compromised blood supply.5e base of the ap is important in maintaining the blood sup-ply. Ideally the ap should always be broader than the free mar-gin (i.e., ridge area) to preserve the blood supply. All areas of the ap must have a source of uninterrupted vasculature to prevent ischemic necrosis of the ap.6 Ideally aps should have sides that converge, moving from the base to the apex (ridge). e length of the ap should generally not exceed twice the width of the base. e base of the ap should not have signicant pressure or be excessively stretched or twisted, which may compromise the blood supply (Fig. 26.1). Flap Design to Provide Accesse ap design must provide sucient access to provide necessary visualization of the entire surgical area. Adequate access must also exist for the insertion of instruments required to perform the sur-gery and to reect the tissue to maintain access. e ap must be held out of the operative eld by a retractor that ideally would rest on intact bone without tension. Excess tension most likely will result in tissue trauma and an increase in swelling.7 If increased edema is present, the patient may experience greater discomfort, and there is a greater possibility of incision line opening or com-promised wound healing (Fig. 26.2). Full-Thickness Reflectione ap should be a full-thickness mucoperiosteal ap that will include the surface mucosa, submucosa, and periosteum. Because implant surgery usually requires access to the underlying alveolar bone, all tissue must be suciently reected. In addition, full-thickness aps are ideal because the periosteum is the primary tissue responsible for the bone healing process, and replacement of the periosteum in its original position hastens that healing process. In addition, torn, split, and macerated tissue heals much slower than a cleanly reected full-thickness ap, thereby delaying the healing process.8A sharp scalpel should be used to score the bone to obtain a full-thickness reection, thus ensuring complete penetration through the tissue layers. When reecting the tissue, the underly-ing bone should be “scraped,” thus minimizing the possibility of a partial-thickness ap. Care must be taken when reecting the tis-sue to separate the tissue away from the bone. When using a peri-osteal elevator (e.g., 2–4 Molt), the tip edge should always rest on the bone to prevent tearing through of the tissue ap (Fig. 26.3). Minimize Trauma to TissueMeticulous handling is required to minimize trauma to the soft tissue. Proper use of appropriate tissue forceps, avoidance of excessive suction-ing by the assistant, and “tieback” sutures all contribute to improved ap management. Nonlocking tissue pickups (e.g., Adson forceps) are commonly used to hold soft tissues in place when retracting tissue or during the suturing process. Various designs of tissue forceps exist, most commonly having smooth tips, cross-hatched tips, or serrated teeth (often called mouse’s teeth). Serrated teeth forceps used on tissues will result in more tissue damage because they may tear the tissue, whereas smooth surface forceps tend to be much gentler to the tissue.• Fig. 26.1 Ideal ap design with broad base incision that preserves the blood supply. Note how the width of the incision base is much greater than the ridge.• Fig. 26.2 Flap design provides sufcient access to visualize the entire surgical eld. Too small of a ap will lead to stretching of the tissue and an increase in inammation.• Fig. 26.3 Full-thickness reection with 2–4 Molt instrument. 604PART VI Implant SurgeryTissue retractors should be selected and placed in a position to prevent undue pressure on the ap. Maintaining the retractors on bone and not on the tissue will minimize trauma to the tissue. Excessive pressure and tension on the tissue ap will impair blood circulation, alter the physiologic healing of the surgical wound, and predispose the wound to bacterial colonization, which may lead to incision line opening (Fig. 26.4).9 Vertical Release IncisionsVertical release incisions may be used to maintain the blood sup-ply and decrease the tension to the ap. Usually the primary blood supply is to the facial ap, which is from the unkeratinized mobile mucosa. Vertical release incisions are often made to the height of the mucogingival junction, and ared 45 degrees to allow for spreading of the tissue and maintenance of the blood supply.10 Vertical release incisions should not be made over bony promi-nences (e.g., canine eminence) because this will increase tension on the incision line and may increase the possibility of incision line opening. In addition, it is often dicult to suture over these areas because the tissue tends to be very thin (Fig. 26.5). Maintain Flap Margins Over Bonee soft tissue ap design should also have the margins of the wound over host bone whenever possible. is is especially impor-tant when approximating tissue over bone grafts or barrier mem-branes. e host bone provides growth factors to the margins and allows the periosteum to regenerate faster to the site.11 e mar-gins distal to the elevated ap should exhibit minimal reection. e palatal ap and the facial tissues distal to the reected ap usually are not elevated from the palatal bone (i.e., unless augmen-tation is required) because the blood supply to the incision line will be compromised. In some cases the soft tissue reection distal to the surgery site may be split thickness to maintain periosteum on the bone around the incision line. is will improve the early vascularization to the incision line and adhesion of the margins to reduce retraction during initial healing. Prevent Desiccation of Tissuee tissues should be maintained in a moist environment with-out prolonged periods of desiccation.12 If excessive drying of the tissues occurs, there is less likelihood that complete wound clo-sure will occur. If the tissue margins become desiccated, periodic irrigations with sterile saline (0.9% sodium chloride) or saline-moistened gauze may be used. Flap Mobilitye passivity of the ap is paramount for the successful wound healing of the soft tissues. When sutures are positioned too tight to overcome the residual tension of the ap, they may alter the blood supply, thereby reducing the vessel patency and impair-ing vascularization.13 Excessive ap tension is the most frequent causative factor leading to incision line opening.14 is is best prevented by appropriate incision and ap design, the use of periosteal releasing incisions (PRIs), and blunt dissection (“tis-sue stretching”).Past techniques to expand tissue primarily used a more api-cal tissue reection and horizontal scoring of the periosteum parallel to the primary incision. Historically the vestibular approach by Brånemark allowed for optimal visualization of anatomic landmarks, suturing remote from the surgical area, complete tissue coverage, as well as predictable primary clo-sure and healing.15 e postoperative disadvantages of this approach include distortion of the vestibule and other ana-tomic landmarks, edema, dicult suture removal, and cumula-tive patient discomfort.16Langer and Langer17 documented the use of overlapping par-tial-thickness aps. is approach results in extension of the coro-nal aspect of the buccal or palatal ap, allowing primary intention closure around the site in an overlapping manner. is is usually eective for primary closure when less than 5-mm advancement of the ap is necessary (Fig. 26.6).A submucosal space technique developed by Misch18 in the early 1980s is an eective method to expand tissue over • Fig. 26.4 Tissue retractors should ideally be positioned on bone to pro-vide ideal access to the surgical eld and minimize trauma to the tissue and vital structures.ReleasingincisionBlood supply Blood supply• Fig. 26.5 Vertical release incisions are required to provide access to the surgical eld and prevent excess pressure on tissue aps. The cor-rect release incision is on the left which maintains the blood supply. The incorrect ap design is illustrated on the right as the blood supply is cut off because of the location of the release incision.• Fig. 26.6 Flap with excess tension increases possibility of incision line opening. 605CHAPTER 26 Basic Surgical Techniques and Armamentariumlarger grafts (greater than 15 Å ∼10 mm in height and width) (Box 26.2).e utility of periosteal incision for gaining ap release was studied by Park.19 He found aps could be advanced up to 171.3% (more than 1½ longer than its original length) by two vertical incisions and a PRI under a minimal tension of 5 g, whereas one or two vertical incisions without PRI could advance the ap only 113.4% and 124.2%, respectively. ese results suggested that PRI can be predictably used to attain tension-free primary closure under a minimal pulling tension of aps (Fig. 26.7). A sharp scal-pel blade at a 45 degree angle or Metzenbamm scissors are used to score the periosteum to create greater ap extension. is will allow tension-free primary closure. Types of FlapsFlaplessFlapless implant surgery has become popular because of the associated decreased pain and morbidity. In the apless tech-nique a tissue punch is used to remove the gingival tissue over the osteotomy site. Mainly this technique has been advocated because of the preservation of the blood ow to the papilla and decreased postoperative pain. Oliver20 has shown that apless surgery is advantageous for preserving the crestal bone and is reduced when the gingival tissue is thick (>3 mm).21 However, when performing apless surgery, adequate bone quantity must be present, along with sucient keratinized tissue. e associ-ated disadvantage of this technique is the inability to visual-ize the underlying bone. Cone beam computed tomographic imaging and guided surgery have made apless surgery more predictable; however, inherent errors still exist. In most apless surgery cases a tissue punch is used to expose the bone. e gingival tissue will be removed in the area of the osteotomy. Care should be exercised in using a tissue punch when an inad-equate amount of keratinized tissue is present. Flapless surgery has been shown to result in overheating the bone because it is often dicult to irrigate the osteotomy adequately when a ap is not raised (Fig. 26.8 and Box 26.3).22 Papilla Sparinge interproximal soft tissue in sites next to adjacent natural teeth may be classied into three categories: (1) papillae have an acceptable height in the edentulous site, (2) papillae have less than acceptable height, or (3) one papilla is acceptable and the other papilla is depressed and requires elevation.23 When the interproximal papilla has an acceptable height, “papilla-saving” incisions are made adjacent to each neighboring tooth. e ver-tical incisions are made on the facial aspect of the edentulous site and begin 1 mm below the mucogingival junction, within the keratinized tissue. Extending the vertical incisions beyond the mucogingival junction increases the risk for scar formation at the incision site. e full-thickness incision then approaches the crest of the edentulous site, leaving 1.0 to 1.5 mm of the interproximal papilla adjacent to each tooth. is maintains the blood supply to the papillae and will help to preserve the papil-lae after healing. e goal is for the facial ap to be advanced over the implant or in approximation to a permucosal exten-sion at the conclusion of the procedure, with no voids at the Procedure 1. A full-thickness facial flap first is elevated off the facial bone approximately 5 mm above the height of the vestibule. 2. One incision with a scalpel, 1 to 2 mm deep, is made through the periosteum, parallel to the crestal incision and 3 to 5 mm above the vestibular height of the mucoperiosteum. This shallow incision is made the full length of the facial flap and may even extend above and beyond the vertical release incisions. Care is taken to make this incision above the mucogingival junction; otherwise the flap may be perforated and delay soft tissue healing. 3. Soft tissue scissors (e.g., Metzenbaum) are used in a blunt dissection technique to create a tunnel apical to the vestibule and above the unreflected periosteum. The scissors are closed and pushed through the initial scalpel incision approximately 10 mm deep, then opened slowly. 4. This submucosal space is parallel to the surface mucosa (not deep toward the overlying bone) and above the unreflected periosteum. The thickness of the facial flap should be 3 to 5 mm because the scissors are parallel to the surface. This tunnel is expanded with the tissue scissors several millimeters above and distal to the vertical relief incisions. 5. The submucosal space is developed and the flap is advanced the distance of the “tunnel” and draped over the graft to approximate the tissue for primary closure without tension. Ideally the facial flap should be able to advance over the graft and past the lingual flap margin by more than 5 mm. The facial flap may then be returned to the lingual flap margin and sutured. This soft tissue procedure is performed before preparing the host region for any type of bone grafting or augmentation around an implant. • BOX 26.2 Submucosal Space TechniqueAB• Fig. 26.7 Tissue tension reduction: (A, B) Severing periosteal bers with a 15 blade parallel; to the ap. 606PART VI Implant Surgeryincision line and primary closure (Fig. 26.9). Bilateral buccal vertical releasing incisions should extend obliquely at an angle and connect to the horizontal incision. is ap is indicated in the esthetic zone, areas where you need to increase the amount of keratinized gingiva on the buccal, or in patients with a thin gingival biotype (Box 26.4). EnvelopeAn envelope ap is designed with a midcrestal incision over the implant site, followed by sulcular incisions on the buccal and palatal that extend at least one tooth to the mesial and distal. A full-thickness ap is reected using blunt dissection. One of the benets of this ap is that scarring from vertical incisions will be avoided. On reection, if more access is required for osseous defects or implant placement complications, a vertical releasing incision may be added to create a triangular or trapezoidal ap. e envelope ap is contraindicated in cases where extensive bone grafting is required because of the limited access and the increased risk for tension on closure (Fig. 26.10 and Box 26.5). Triangular and Trapezoidale triangular and trapezoidal incisions are more aggressive incisions that are initiated over the implant site and sulcular incisions that continue horizontally to at least one adjacent tooth. Both the triangular and trapezoidal incisions involve A B• Fig. 26.8 Flapless Incision. (A) Tissue punch bur which corresponds to diameter of the intended implant size, (B) Slow-speed latch type handpiece used to remove tissue.Advantages• Lessinvasive• Maintainstissuevasculature• Noverticalincisions• Lesspatientdiscomfort Disadvantages• Limitedvisibility• Overheatingbone• Limitedaccesstoevaluatebone• Malpositioningismorecommon(unlessguided) • BOX 26.3 Flapless SurgeryAB• Fig. 26.9 Papilla-Sparing Incision. (A) Incision maintaining 1 mm of papilla tissue. (B) Reected ap maintaining papilla tissue intact.Advantages• Nodisruptionofthepapillae• Lessmorbidity• Minimaldisruptionofvasculature Disadvantages• Noaccesstoadditionalsites• Needadditionalskillset• Minimalreectedspaceforimplantplacement• Difcultyinbonegrafting• Possiblescarringinnonkeratinizedtissue • BOX 26.4 Papilla-Sparing Surgery 607CHAPTER 26 Basic Surgical Techniques and Armamentariuma sulcular incision and vertical releasing incisions (i.e., tri-angular: one vertical release; trapezoidal: two vertical release incisions). A vertical releasing incision is then extended api-cally above the mucogingival junction. By placing the vertical releasing incision as distal as possible, scarring may be spared that may occur during healing.24 PRIs are placed to aid in ap advancement to gain tension-free primary closure. e main advantage of these aps is direct visibility of the bone, which allows access to bone recontouring, as well as bone grafting. ese aps are contraindicated in patients with a thin gingival biotype because of the tension placed on the ap25 (Fig. 26.11 and Box 26.6). Vestibulare vestibular ap incision is a minimally invasive technique that allows preservation of the interproximal tissue and allows access for buccal ridge recontouring and soft tissue grafting.26 is tech-nique involves one or more full-thickness vertical incisions in the vestibule away from the gingival margin and sulcus. After tissue elevation a subperiosteal pouch is created to allow space for a bone graft. e main limitation of this ap is the lack of visualization and access to the alveolar ridge (Box 26.7). Proper Incision Techniquee design of the surgical incision is based on many factors such as anatomic location, tissue quality, type of procedure, and desired • Fig. 26.10 Envelope Flap. Minimal ap that maintains blood supply.Advantages• Noverticalincisions• Easytosuture• Easytomodify Disadvantages• Limitedaccess• Moderatedisruptionofvasculature• Increasedriskfortensionuponclosure• Guidedboneregenerationnotpossible • BOX 26.5 Envelope Flap SurgeryAB• Fig. 26.11 Examples are larger, more aggressive ap designs: (A) trian-gular and (B) trapezoidal.Advantages• Bettervisibility• Increasedpossibilityoftension-freeclosure• Accesstoadditionalsites Disadvantages• Increasedbonelossandrecession• Increaseddisruptionofbloodsupply• Reection/Suturingofadjacentpapilla• Increasedpatientmorbidity • BOX 26.6 Triangular/Trapezoidal Flap SurgeryAdvantages• Lessinvasive• Nodisruptionofpapillae• Mayusewithbone-graftingprocedures Disadvantages• Limitedaccess• Lowvisibility• Notindicatedforimplantplacement • BOX 26.7 Vestibular Flap Surgery 608PART VI Implant Surgeryhealing outcome.27 Flap designs may be further classied as to the type of tissue (full versus partial thickness), the number of inci-sions used to create them (envelope, papilla sparing, triangular, trapezoidal), or secondary incisions that dictate the ap’s direction (rotating versus coronally versus apically advancing).25Over the years the mucogingival ap design used in oral implan-tology has changed dramatically. Technology has allowed for the more accurate and ideal placement of implants and bone grafts. Better techniques and methods with tissue handling and preserv-ing the blood supply have become reality. In the early years of oral implantology, most surgeries were completed with an aggressive full reection of the surgical area with multiple release incisions. Most implants were placed with a submerged (stage 2) technique. In the 1990s a more conservative one-stage surgery technique became popular that involved placement of a healing abutment at the time of implant placement. is procedure showed remarkable results with a decreased morbidity. In the early 2000s advancements in guided surgery allowed the advent of “apless” surgery, which resulted in much less trauma and patient complications.With most dental implant procedures, surgical incisions are required. With a properly placed incision, the implant clinician may obtain adequate access to the surgical site for implant place-ment, identify necessary landmarks, and prevent unnecessary complications. e design of the surgical incision is based on numerous factors such as anatomic location, tissue quality, amount of keratinized tissue, procedure, amount of access required, and the desired healing outcome. ere exist numerous principles that must be adhered to for the majority of incisions.Proper Incision Positioninge primary incision should ideally be located in keratinized tissue whenever possible. is will allow for an increased wound surface area and a resultant increase in vascularity to the incision line.28 Not only does this reduce signicant initial intraoral bleeding, it also will result in severing less blood vessels. A reduction in postopera-tive edema will result, which decreases tension to the incision line and possible incision line opening. If there exists 3 mm or more of attached gingiva on the crest of the edentulous ridge, the incision should ideally bisect the soft tissue. is places half of the attached gingiva width on each side of the incision (i.e., 1.5 mm), thereby strengthening the incision line. If there is less than 3 mm of attached keratinized tissue on the ridge crest, the incision should be made more lingually so that at least 1.5 mm of attached tissue is placed to the facial aspect of the implant. is concept is especially important in the posterior mandible because attached tissue is required to pre-vent tension and pulling from the buccinator muscle (Fig. 26.12).Incisions made through attached gingiva and over healthy bone are more desirable than those through unattached gingiva and over unhealthy or missing bone contours. When osseous defects are present, properly placed incisions allow the wound margins to be sutured over intact, healthy bone that are a minimum of a few millimeters away from the bone defect. is will result in sup-porting the healing wound. In esthetic zones a papilla-sparing ap may be used to preserve the papilla and minimize possible tissue recession (Fig. 26.13).In summary, the incision location may vary depending on multiple factors. e goal of any incision is to allow for adequate exposure of the operative eld and to minimize possible damage or tearing of the tissue margins. is will lead to a better chance of obtaining primary closure, which results in better healing and less chance of postoperative complications.29 Use of a Sharp Scalpel BladeA sharp scalpel blade allows incisions to be made cleanly with-out unnecessary damage from repeated strokes, especially if not in the same plane. Many factors dictate how fast the scalpel blade will dull, such as contacting teeth, titanium (e.g., implants, abut-ments, healing cover screws), and dense bone, which tend to lead to accelerated dulling. e resistance and thickness of the tissues may dull the blade at dierent rates; therefore the surgeon should change the scalpel blade whenever a dierence is noted in the blade sharpness. Sharp dissections tend to minimize trauma to the incision line, which will result in less tissue trauma and postopera-tive swelling (Fig. 26.14). Scalpel TechniqueClean, precise incisions allow for optimal wound closure. An ideal incision includes a single stroke through the tissue in one direction with rm, even pressure on the scalpel. Tentative strokes, especially in dierent planes, will increase the amount of damaged tissue and increase the amount of bleeding and inam-mation. Long, continuous strokes are preferable to shorter, • Fig. 26.12 Incision design based on amount of attached tissue. If less than 3 mm of attached tissue is present, then the incision is positioned more lingually.• Fig. 26.13 Incision made more lingual to increase attached tissue to the buccal. Note the broad based papilla sparing incision. 609CHAPTER 26 Basic Surgical Techniques and Armamentariuminconsistent, interrupted strokes. Ideally the incision should always be over bone.In most cases the blade should be held perpendicular to the epithelial surface. is will result in an angle that produces square wound margins, which are easier to reapproximate during sutur-ing and less likely for surgical wound necrosis and incision line opening to occur30 (Fig. 26.15). Avoid Vital Structurese incision and ap should be designed to avoid possible injuries to vital structures. e two most important structures in the man-dible include the mental nerve and lingual nerve. When making incisions in the mandibular premolar area, care should be exer-cised with the anatomy of the mental nerve. Usually three to four branches of the mental nerve will ascend from the mental fora-men and are supercially located in the soft tissue. In mandibu-lar edentulous cases the scalpel blade should always remain on the bone. is will prevent “slipping” o the ridge and damaging deeper vital structures. In mandibular severe atrophy cases the mandibular canal may be dehisced, which can lead to direct tran-section of the nerve bers. In instances where the nerve lies on top of the ridge, the incision is carried lingual to the ridge to avoid severing the nerve. In the posterior mandible the lingual nerve may be closely adhered to the lingual aspect of the mandible. erefore in the retromolar pad area, incisions should always be positioned lateral to the pad.In the maxilla, rarely will an incision damage a vital structure. On the buccal, there exist no vessels that would be problem-atic, except for the infraorbital nerve, which exits the infraor-bital foramen. However, direct trauma is usually rare in this area. On the palatal aspect the nasopalatine vessels exit the incisive foramen and supply the anterior palatal gingiva. If this area is incised, minimal bleeding will result, and the neural tissue regenerates rather quickly.31 Posterior palatal release incisions should be avoided because the greater palatine nerve and artery may be traumatized, which may lead to increased bleeding epi-sodes (Fig. 26.16). Proper Scalpel GripPencil Gripe scalpel is grasped close to the blade between the tips of the thumb and the index nger, with the remaining handle resting on the web of the thumb, much like grasping a pencil. With this grip the motion is predominately from the thumb and index nger, allowing for precise cutting of tissue. A nger rest may be used to increase the accuracy of the ne cutting. is grip may also be “backhanded” by reversing the direction of the blade without changing the upper arm position. e pencil grip is best used for short, ne movements for precise incisions, because the muscles of the hand are used signicantly more than the muscles of the forearm. e blade edge is usually held at 30 to 40 degrees to the tissue. One of the limitations of this technique is the greater angle, which results in less cutting-edge contact, and limits the depth of the incision (Fig. 26.17). Fingertip GripWith this technique the scalpel is held between the thumb and the middle nger, while the index nger is placed on the body of the • Fig. 26.14 Incision should be made to “score” the bone; this allows for full-thickness reection of the tissue.• Fig. 26.15 Proper method of making incision using no. 15 scalpel blade. Note the scalpel motion is made by moving the hand at the wrist and not by moving the entire forearm. (From Hupp JR, Ellis E, Tucker MR. Con-temporary Oral and Maxillofacial Surgery. 7th ed. Philadelphia: Elsevier; 2020.)• Fig. 26.16 Incisions should be made to avoid any vital structures, for example, the mental foramen and lingual nerve in the mandible. 610PART VI Implant Surgeryscalpel blade to apply downward pressure, much like grasping a butter knife. is grip technique uses more arm motion and is primarily used for making long skin incisions. e main advantage is the increased blade-to-tissue contact, which provides good depth and direction con-trol. e greater the length of tissue contact with the scalpel, the more the walls of the incision resist minute or sudden changes in direction, allowing for smoother, straighter incisions. e main disadvantage of the ngertip grip is that it does not allow for precise blade cuts.Palm Gripe palm grip is used when strong pressure in indicated to incise the tissue. e scalpel is held in the palm of the dominant hand with the index nger on top of the handle. e cutting pressure is derived from the palm and ngers as well as the entire arm. However, this grip is rarely used in implant dentistry (Fig. 26.17). Surgical ArmamentariumA full array of instruments may be used in oral implantology, and usually the clinician will over time develop personal preferences with respect to various procedures. e following is a summary of some of the most popular instruments used today.Instrument to Incise TissueScalpel/Surgical Bladese scalpel is the ideal instrument for making incisions and sepa-rating tissue. Scalpels are basically manufactured in two forms: disposable and metal reusable handle. e most used scalpel in oral implantology is the #3 scalpel, which commonly has a metric ruler on one side, which allows for intraoperative measurements. As stated earlier, the scalpel must be held in a way that permits full control of the instrument and at the same time freedom of move-ment. e handle of the scalpel is grasped between the thumb and the third and fourth ngers, and the index nger is placed over the back of the blade to provide rm control.e most common scalpel blade used in oral implantology is the #15 blade or #15c blade. e #15 blade has a short, rounded cutting edge, combined with an angled point. In addition, the #12 or #12b blade is commonly used, mainly around teeth or in dicult access areas. ese blades are small, pointed, and crescent shaped, which are end cutting on the inside edge of the curve. Blades can be either carbon steel or stainless steel. Carbon-steel surgical blades are sharper than stainless-steel blades but may dull quicker (Fig. 26.18). AB• Fig. 26.17 Scalpel Grip. (A) Pencil grip: ideal scalpel grip because maxi-mum control is obtained. (B) Palm grip: nonideal scalpel grip with minimal control which is rarely used in implant dentistry.#11 #12 #12B #15 #15CBA• Fig. 26.18 (A) Scalpel handle: most common is the Bard-Barker. (B) Different scalpel blades: #11 is used for incision of abscesses or infections; #12 and #12b are used around teeth to connect incisions in difcult access areas; #15 is the most common blade used in oral implantology; and #15c has a smaller neck that allows for easier access around teeth. 611CHAPTER 26 Basic Surgical Techniques and ArmamentariumInstruments to Reflect TissueOnce the incision is made, the mucosa and periosteum must be reected to expose the bone. e Molt periosteal elevator (#9) is one of the more common instruments to complete this task. e periosteal elevator usually has a sharp, pointed end and a broad, at end. Normally the pointed end is used to initiate the reection, followed by the broad end, which allows for a larger volume of tissue to be reected. In the authors opinion an easier and more ecient instrument to use to reect tissue is the 2/4 Molt. is double-ended instrument has two small, rounded, sharp areas, 2/4 (4 mm/6 mm), and is positioned in a dished-out fashion to allow for tissue to be reected easier (Fig. 26.19).In general, tissue can be reected three dierent ways: (1) prying motion—pointed end used in a prying motion to ele-vate the soft tissue; (2) push stroke—used after full thickness incision to slide underneath the ap; and (3) pull or scrape stroke—used to remove tissue tags from the bone in a scraping motion (Fig. 26.20). Instruments to Grasp TissueTissue forceps are used to stabilize soft tissue aps for sutur-ing and reection of aps. e most common tissue forceps used in implant dentistry include the Adson and Allison forceps. Adson forceps (pickups): to grasp and stabilize soft tissue aps during suturing or implant and bone graft procedures. ese delicate forceps have small teeth or serrations to gen-tly hold tissue for stability. Care should be exercised to not crush the tissue because the tissue can be irreversibly dam-aged (Fig. 26.21).Allison forceps: these forceps have larger and more aggressive teeth used to hold heavy or high-tension tissue. In implant dentistry these types of forceps are rarely used. Instruments to Remove Bone/TissueRongeur forceps A rongeur is a heavy-duty surgical instrument with a sharp-edged, scoop-shaped tip, used for gouging or snipping away the bone. e word rongeur is a French word meaning “gnawer.” In oral implantology the rongeur is used to cut or contour tissue, or to remove pieces of bone. Rongeur forceps have a spring between the handles, which increases the magnitude of the removal force. A common type used is termed double-action rongeur, which signicantly generates more force than a single-action rongeur. Because the blades are concave toward the inside, harvested bone is easily retained to be used in grafting areas. 1. Side Cutting to cut and contour bone, remove sharp edges; will retain bone for grafting purposes 2. End Cutting to cut and contour bone; one beak may engage bone to shave bone from the ridge (Fig. 26.22) Surgical bursSurgical burs can also be used to remove bone. It is important to always use irrigation when using the surgical burs. e tissue must be adequately reected to prevent trauma to the tissue with the burs. Cross-cut ssure burs may be used to make pilot holes in the host bone that will allow the bone to be removed with a chisel. Additional burs used to remove bone (i.e., alveoplasty) include special ridge reduction burs, straight handpiece (HP) acrylic barrel shaped burs, or HP round burs (Fig. 26.23). • Fig. 26.19 Reection technique for full-thickness reection with the 2/4 molt instrument.• Fig. 26.20 Recommended periosteal reection instrument: 2 to 4 Molt.AB• Fig. 26.21 Adson Forceps. (A) Teeth: may perforate and tear thin tis-sue; however, it allows for better grasping of the tissue. (B) Serrated: less chance of perforating tissue. 612PART VI Implant SurgeryBone file A bone le is a double ended serrated instrument used to remove sharp, spiny ridges within the bone (Fig. 26.24). Instruments to Remove Tissue From Extraction Sockets or Bony Defectse surgical curette is an instrument used to ensure removal of debris and diseased tissue. ese instruments are usually spoon shaped and have sharp edges that allow scraping of the bony walls. Not only will the scraping remove soft tissue, the curettes will also initiate the regional acceleratory phenomenon (RAP). e most commonly used and recommended surgical curette has serrated edges (e.g., Lucas 86 Currette) (Figs. 26.25 and 26.26).Bone-Grafting InstrumentsBone scrapersBone scrapers are mainly used by clinicians to harvest autogenous bone from the oral cavity and allow the collected bone particles to be delivered to the surgical site. ese instruments consist of a harvesting blade and collection chamber, with a narrow-tipped syringe for access-restricted areas (Fig. 26.27). Grafting spoon and condenserese instruments hold bone to be placed at a specic area with a spoon-type of instrument. Usually a condenser is present on the other side of the instrument, which allows for the condensing of the bone graft material into the defect (Fig. 26.28). Surgical Scissorsere exists a full array of scissors used in oral implantology: straight, curved, serrated, and nonserrated. Surgical scissors are used to cut tissue, spread tissue, and cut sutures. Usually the thumb and ring nger are placed in the scissor rings, with the index nger to steady the scissor. Curved scissors are usually pre-ferred by most surgeons because they provide a better eld of view and access to restricted areas. Dean: the most commonly used scissors in oral implantology, which have slightly curved handles and oset serrated blades that allow for easy access to cut sutures and to remove diseased tissue. Dean scissors feature angled blades that are approxi-mately 3 cm in length from midscrew. ey have one serrated blade, with a slightly curved handle.Iris: very small, extremely sharp scissors with a ne tip. Some iris scissors have curved blades for certain types of precision tasks, whereas others may have straight blades.Kelly: commonly used to trim tissue or cut sutures because they have one serrated cutting side to the scissors.Metzenbaum: surgical scissors that are designed for delicate tissue and blunt dissection. e scissors are available in variable lengths and have a relatively long shank-to-blade ratio. ey are con-structed of stainless steel and may have tungsten carbide cutting surface inserts. Blades can be curved or straight (Fig. 26.29). Hemostatse hemostat is an instrument that has serrated tips that allow for the “clamping” of tissue or small materials. Directly above the • Fig. 26.23 Bone removal using carbide HP bur in a straight 1:1 handpiece.BA• Fig. 26.22 Rongeur. (A) Double-action rongeur allows for greater force for bone removal. (B) Bone removal using a “rocking” motion. 613CHAPTER 26 Basic Surgical Techniques and ArmamentariumA B• Fig. 26.24 Bone le (A) used to smooth out sharp ridges, (B) which may lead to postoperative tissue irritation especially after osteoplasty procedures have been performed.AB• Fig. 26.25 (A) Lucas 86 Surgical Curette (Salvin), which is a serrated spoon excavator. (B) Removing tissue within an extraction site and initiat-ing the regional acceleratory phenomenon.• Fig. 26.26 Technique for curetting the extraction socket before grafting or addition of bone graft material.ABC• Fig. 26.27 (A) Bone Scraper, (B) Bone scraper being used to harvest bone from tuberosity area, (C) Harvested bone in bone scraper. 614PART VI Implant SurgeryAB C• Fig. 26.28 Grafting Instruments. (A) Grafting Spoon and Packer Instrument, (B) Spoon to transport graft material to surgical site, (C) Packer to augment the surgical site.ACDB• Fig. 26.29 Surgical Scissors. (A, B) Blunt dissection tissue spreading for tension free closure. (C) Suture scissors. (D) Castroviejo scissors. 615CHAPTER 26 Basic Surgical Techniques and Armamentariumnger rings is a ratchet to control the degree of force or restric-tion. In oral implantology, hemostats are used to constrict blood vessels (i.e., bleeding), retrieve loose objects in the oral cavity, and securely hold small items (Fig. 26.30). Instruments to Retract TissueRetractors are used to hold back the cheek, tongue, or ap, which permit visibility to the surgical site. Examples include: Mirror—conventional mouth mirror to retract tongueWeider tongue retractor—broad, heart-shaped retractor with grooves and perforations that hold tongue and cheek away from surgical siteSeldin retractor—double ended with round blunted ends, used to retract a tissue ap from bone after an incisionMinnesota retractor—to retract tongue or cheek away from surgical site and has the advantage of reecting both at the same timeMisch “Spoon” cheek and tongue retractor—to hold tongue or cheek away from surgical site, ergonomically designed to reduce hand fatigueSinus graft cheek retractor—broad-based ap retractor that reduces force to the infraorbital foramen area, thus reducing the pos-sibility of a neuropraxia (Fig. 26.31) Instruments to Hold Mouth OpenBite block—sterilizable rubber block in multiple sizes to keep mouth open during proceduresMolt mouth prop—ratchet-designed instrument with rubber tips that allows variation on openingOrringer retractor—spring-loaded mouth prop that self-maintain-ing spring-loaded mouth prop which maintains upper and lower soft tissue retraction (Fig. 26.32)Suctions/Aspirators—suctioning is crucial to keeping the surgical eld clear from debris to allow the surgeon to have clear visibilityABCD• Fig. 26.30 Hemostats. (A) Straight. (B) Curved. (C) Hemostats used to remove direct impression coping screws. (D) Curved hemostats used to hold abutment to prevent countertorque. ABCDEF• Fig. 26.31 Tissue Retraction. (A) Tissue pickups and molt retracting the tissue, (B) Seldin retractors, or holding tissue (C) Misch Ridge Elevator. (D) Clinical image of Misch Ridge Elevator reecting tissue. (E) Minnesota. Retractor (F) Misch Spoon. HJGIK• Fig. 26.31, cont’d (G) Clinical image of Misch Spoon. (H) Vestibular retractor. (I) Orringer Sinus retractor. (J and K) Sutures used to tie back lingual tissue.AB• Fig. 26.32 Instruments to Hold Mouth Open. (A) Molt mouth prop. (B) Rubber mouth prop. 618PART VI Implant SurgeryGeneral surgical suction—used to clear the airway or surgical site; may be made of metal, which is autoclavable, or plastic, which is disposableFraser suction—suction that contains a hole in the handle that can be covered; vacuum relief hole controls suction by covering or uncovering the hole with ngertip; when uncovered, very little suction will result, which is important when working with bone or membranes (Fig. 26.33)Yankauer tonsil aspirator—angled, long suction that has a perforat-ed ball-type end for suctioning the posterior throat; a Yankauer is used to suction oropharyngeal secretions very eectively to prevent aspiration (Fig. 26.34) Instruments to Hold DrapesTowel clamp—a nonperforating clamp used to secure instruments and surgical materials, such as suction tubing to the surgical drapes (Fig. 26.35) Handpieces/Motors 1. Surgical motor console: Composed of a console, foot pedal, and motor cord, which allows for the use of a contraangle or straight handpiece. • 1:1 handpieces: usually straight handpieces that run at higher revolutions per minute (i.e., 40,000–50,000 revolu-tions/min); used for bone-grafting procedures • 16:1 or 20:1 handpieces: contraangle reduction implant handpieces to drill osteotomies and/or place implants (Fig. 26.36) 2. Piezosurgery units: Piezoelectric bone surgery is an inno-vative technology that selectively cuts mineralized tissue without damaging soft tissue. is technology uses a high-frequency vibration (i.e., 25–35 kHz) that is transmitted to specialized surgical tips. e major advantages of this tech-nology are the high precision accuracy, minimal thermal damage, increased healing, and less soft tissue trauma. ere exist many uses of Piezosurgery in oral implantology, which dier in various and versatile tips that are interchangeably used on the handpiece. is type of surgical unit may be used for atraumatic extractions, removal of implants, bone-grafting procedures, and sinus augmentation procedures (Fig. 26.37). • Fig. 26.33 Flexible Suction Tubing.AB• Fig. 26.34 Yankauer Suction. (A) Extended suction for in posterior oro-pharynx. (B) Yankauer suction is used to suction debris from the posterior palate area.• Fig. 26.35 Towel Clamp for Surgical Drapes. ACBD• Fig. 26.36 (A) Aseptico surgical motor (Aseptico, Woodinville, Wash.). (B) 20:1 reduction handpiece for drilling osteotomy and placing implants (Aseptico). (C) 1:1 handpiece that is used for bone removal or harvesting autogenous bone grafts (Nouvag, Goldach, Switzerland). (D) Irrigation solution should be 0.9% sodium chloride or sterile saline. (Baxter, Deereld, Ill.).AB• Fig. 26.37 (A) Piezosurgery motor console (Salvin, Charlotte, N.C.). (B) Vibrating handpiece that uses ultrasound frequency technology, resulting in precision and safe cutting of hard tissue. 620PART VI Implant SurgeryACDB• Fig. 26.38 Osteotomes. (A) Sinus osteotomes with adjustable stops. (B) Offset osteotomes to increase osteotomy diameter. (C) Straight osteotome for bone spreading. (D) Clinical image of crestal bone graft using an osteotome.OsteotomesAn osteotome is a surgical instrument which is used to cut, expand, or divide bone. ere exists multiple types which are pro-cedure specic.Pointed: designed for progressive circumferential (circular) expan-sion (i.e., bone spreading) of the alveolar ridges which are com-promised in width (i.e., Division B).Progressive osteotomes: to incrementally widen or expand bone be-fore implant placement 1. Concave: Concave osteotomes are used to infracture the oor of the maxillary sinus through the implant osteotomy. e concave tip retains bone graft material. 2. Convex: Convex osteotomes are used to raise the oor of the maxillary sinus after fracturing (SA-2 technique) (Fig. 26.38). Sinus CurettesMembrane curettes: Used to aid in the elevation of the sinus mem-brane, these curettes feature a rounder smooth tip for lifting the sinus with minimal puncture risk (Fig. 26.39). Aseptic TechniqueIdeally any surgical procedure where there may be an increased bacterial insult should use a sterile technique. ere is much misunderstanding, though, when it comes to the terms clean, aseptic, and sterile.•  Clean technique: e clean technique includes routine hand washing, hand drying, and use of nonsterile gloves.•  Aseptic technique: e aseptic technique is used for short inva-sive procedures. It includes antiseptic hand wash, sterile gloves, antiseptic rinse, and use of a clean, dedicated area.•  Sterile technique: e sterile technique includes measures to prevent the spread of bacteria from the environment to the patient by eliminating all microorganisms in that environment.is is mainly used for any procedure in which the bacterial count needs to be lowered and an increase in infection rate will lead to signicant morbidity. is includes surgical hand scrub, hands dried with sterile towels, complete sterile eld, sterile gown, mask, and gloves (Table 26.1; Boxes 26.8 and 26.9).Achieving surgical asepsis requires multiple steps, including surgical gloving and gowning, along with maintaining a sterile eld. Each member of the team involved in a sterile procedure is responsible for maintaining the aseptic environment.Sterile FieldSterile drapes are most often used within the sterile eld to cover any surgical area used during the surgery (Fig. 26.40). Drapes come in various sizes and are most easily purchased in a kit. e inner surface of the sterile eld, except for a 1-inch border, is considered the sterile eld that may be used to add sterile items. is 1-inch 621CHAPTER 26 Basic Surgical Techniques and ArmamentariumBA• Fig. 26.39 (A) Basic sinus surgery kit. (B) Sinus curette reecting sinus membrane. Clean Versus Aseptic Versus SterileClean Aseptic SterileProcedurespaceDentaloperatorySurgical suite Surgical suiteGloves Nonsterile Sterile Sterile surgicalHand hygiene before the proceduresRoutine Aseptic (e.g., alcohol)Surgical scrub iodophors, chlorhexidineSkin antisep-sisNo Alcohol ChlorhexidineSterile field No No YesSterile gown, mask, head coveringNo No YesFrom Suzuki JB, Resnik RR. Wound dehiscence: incision line opening. In: Resnik RR, Misch CE, eds. Misch’s Avoiding Complications in Oral Implantology. St. Louis, MO: Mosby; 2018. TABLE 26.1• Onlysterilematerialsandinstrumentsareplacedwithinthesterileeld.• Checkforchemicalindicatorstoverifysterilityofitemsplacedontothe sterile field, along with package integrity and package expiration (if appropriate).• Aboveandbelowthesterileeldtableisconsidered“nonsterile.”• Materialsthatdisplayamanufacturer’sexpirationdateshouldbeconsideredunsafeforuseafterthatdate.(Rationale:Expirationdatesdonot guarantee either sterility or lack of sterility.)• Ifanysterileitem(material,instrument,gown,glove)hasbeencompromised, the package contents, gown, or the sterile field is consideredcontaminated.Thismayhappenwhen: • nonsterileitemscontactsterileitems;or • liquidsormoisturesoakthroughadrape,gown,orpackage(strikethrough).• Single-usematerialsshouldonlybeusedonanindividualpatientforasingle procedure and then discarded.• Reusablemedicaldevicesshallbereprocessedandsterilizedaccordingtothemanufacturer’sdirections.• Anyitemthatfallsbelowtablelevelisconsideredunsterile. • BOX 26.8 General Principles for a Sterile Technique 622PART VI Implant Surgeryborder may also be used to position the drape within the surgical eld. When placing sterile items onto the surgical eld, items may be “dropped” from approximately 6 inches above the sterile eld. Surgical Scrube surgical scrub is the process that removes as many microor-ganisms as possible from the nail beds, hands, and forearms by mechanical washing and chemical antisepsis for a surgical pro-cedure. is will result in a decrease in microbial count, and it inhibits the regrowth of bacteria. ere are two dierent types of scrubbing techniques: a sterile sponge/brush with antimicrobial agent or a brushless technique with alcohol/chlorhexidine gluco-nate (Figs. 26.41 and 26.42). All rings, watches, bracelets, and jewelry should be removed before starting the hand scrub. Surgi-cal hats, protective eyewear, headlights, and a surgical mask must be donned before surgical hand asepsis. Drying of the hands and arms is a priority because moist surfaces allow bacteria to multiply. Gowning, gloving, and tying the front tie of the gown occur after the hand scrub (Figs. 26.43 and 26.44). Utilization of Ideal SuturingMaterials and Techniquese objective of the proper suturing of the surgical wound is to position and secure the margins of the incisions to promote ideal and optimal healing. e goal of the suture material and technique is to hold the margins of the wound in close apposition until the wound has healed enough to withstand normal functional tension and stress on the incision line.32 If surgical wounds are not prop-erly approximated, separation of the margins will occur, which leads to increased postsurgical morbidity. e clinician must select a suture with qualities that include high tensile strength,33 tissue biocompatibility that prevents tissue irritation, ease of knot tying, and the ability to prevent minimal knot slippage (Table 26.2). Suture TypeAbsorbableAbsorbable sutures are popular and advantageous in implant den-tistry because of the elimination of a suture removal appointment. ere are two types of resorbable sutures: natural and synthetic. Natural Natural sutures are mainly broken down by body en-zymes. e most common natural sutures are plain and chro-mic gut (Fig. 26.45).Plain gut. Plain gut is a monolament derived from highly puried collagen from sheep intestinal submucosa. It is highly antigen-ic, losing 50% of tensile strength after 24 hours. Gut has unpre-dictable absorption because of the enzymes and macrophages that break it down. is type of suture has been shown to have a high incidence of tissue reactions, which impede healing.Step 1: Prescrub WashA short prescrub wash is completed, including the hands up to the elbow. This is to remove superficial microorganisms and gross debris.• Beforethescrub,makesuresurgicalattireiswornandremovealljewelry.Glasses(loops,lights,etc.)shouldbeplacedintheidealposition.• Performarinsefromthengertipstotheelbowssothewaterowsfrom the cleanest area (fingertips) to the less clean area (elbows). Use a sink that is wide and deep so that both arms are contained within the borders so that water is not splashed out of the sink.• Openthescrubbrushandperformapreliminaryscrubfromngerstothe elbows. The next part of the prescrub is to clean the subungual area of each cuticle. With the disposable nail cleaning device, remove any debris from under each cuticle. The brush side of the scrub brush may be used over each cuticle. Step 2: Primary ScrubDependingonthehospitalorsurgicalcenter,scrubbingmethodsandprotocol will vary. The counted stroke method seems to be the most efficient to guarantee sterility. With the sponge side of the scrub brush, complete five strokes for each side of each finger (four sides), five strokes foreachsideofthehand,andfivestrokesforeachforearmside.Rinsehands and arms under running water in only one direction, from fingertips to elbows. Care must be exercised to ensure fingers, hands, and arms do not touch any nonsterile surface (e.g., faucet). The hands should remain above the waist and below the axilla. If the water is controlled by hand-control levers, a nonsterile surgical assistant should turn the water off. Usually the prescrub and primary scrub will take approximately 3 minutes. Step 3: GowningThe hands should be dried with a sterile towel. Care should be exercised to prevent the sterile gown or gloves from water contamination. When moving from the scrub sink to the sterile area, keep hands in front of the body, above the waist, and below the axilla. The neckline, shoulders, underarms, and sleeve cuffs are considered nonsterile.The sterile gown should be immediately donned after complete drying of the handsandforearms,beforegloving.Eventhoughthecompletegownissterilewhen placed on the sterile table, once the gown is donned, only the front from the waist to the axilla is sterile. The gown should be lifted upward and away from the table, and allowed to open by locating the neckline and armholes. Hold the inside front of the gown at the level of the armholes to allow the gown to unfold.Donottouchtheoutsideofthegownwithbarehands.Extendbotharmsinto the armholes, and the gown and sleeves will unfold. The gown is pulled ontothebodywiththecuffsofthesleevesextendedoverthehands.Donotpush the hands completely through the cuffs.Surgical gowns establish a barrier that minimizes the possibility of contamination from nonsterile to sterile areas, which is commonly referred to as a “strikethrough” barrier. They are made of a material that is resistant to blood and fluid penetration. Step 4: Sterile GlovingSterile gloves are packaged in a sterile package. The closed gloving technique is most widely used. It ensures the hands touch only the inside of the gown and gloves. With the dominant hand, pick up the nondominant glove by the inner wrapstraightup,placingitonthenondominanthand.Guideandwigglethefingers into the glove. Using the gloved hand, pick up the remaining glove and guide it on the nondominant hand, making sure the gown cuff is covered. The nondominant glove will then pull the dominant glove cuff over the gown. Step 5: Tying of the GownAfter the gown and gloves are in place, the front tie of the gown must be secured. The surgeon holds the left string with the left hand and holds the right large string and tag with the right hand. The tag is separated from the small string and handed to an assistant. The surgeon rotates 360 degrees and the assistant tears off the tag, leaving the right and left for the surgeon to tie. • BOX 26.9 Sterile Scrub Technique 623CHAPTER 26 Basic Surgical Techniques and ArmamentariumChromic gut. Chromic gut is also derived from purified collagen from sheep intestinal submucosa that is treat-ed with chromic salts, which decrease absorption. This material is highly antigenic and loses 50% of tensile strength after 5 days. As a monofilament, it causes sig-nificant tissue reactivity. Chromic gut causes inflamma-tion, loses tension, and resorbs too quickly to maintain soft tissue approximation over an augmented site. It is not recommended when the tissues are advanced for a bone augmentation. Hypersensitivity reactions have been shown to occur because of the chromate particles present in the suture.34Synthetic Synthetic sutures are broken down by hydrolysis be-cause of their hydrophobic nature. e most common synthet-ic, absorbable suture in implant dentistry is polyglycolic acid (PGA) (Fig. 26.46).PGA (Vicryl). Because PGA sutures are absorbed by hydrolysis breakdown, they are not aected by a low pH. Because they are manufactured by synthetic polymers, their resorption is slower and they will maintain the incision line with a tensile strength much longer than most suture materials. is suture material will maintain sucient tension over the rst 2 weeks (75%), 50% after 3 weeks, and 25% after 2 weeks. PGA sutures have varying resorption rates, which consist of regular breakdown (≈21–28 days) and fast absorbing (≈7–14 days). e suture material is inert and has a relatively low tissue reaction. NonabsorbableNonabsorbable sutures are composed of human-made materi-als, which are not metabolized by the body. e most commonly used nonresorbable suture in dentistry is a natural ber, silk, which undergoes a special manufacturing process to make it adequate for its use in surgery. Other nonabsorbable sutures are made of articial bers (e.g., polypropylene, polyester, nylon), which may contain coatings to enhance their performance characteristics (Fig. 26.47). Silk: Over time, silk has been the most universally used suture ma-terial in dentistry because of its low cost and ease of handling. However, silk has many disadvantages with respect to implant dentistry. First, it is nonresorbable and must be removed. Because silk is a multilament, is has been shown to “wick,” which results ABC• Fig. 26.40 Sterile Operatory Setup. (A) A sterile surgical eld includes sterile table drapes to cover any areas that are going to contain surgical materials. Ideally the chair is covered; however, it is considered nonsterile. (B) All sterile supplies are placed within the connes of the sterile drapes. (C) A sink area should be present to allow for a sterile scrub area and gowning. 624PART VI Implant SurgeryABCDEF• Fig. 26.41 Prescrub Technique. (A) Make sure hat, mask, glasses, and light source are worn and in place before the initiation of the scrub technique. (B) With lukewarm water, prerinse from ngertips to elbow. (C) Open surgical scrub brush with ngertip cleaner. (D) Complete a preliminary scrub from hands to the elbow with the soap brush. (E) Use ngertip cleaner to clean under ngernails, and (F) use the “brush” side of the scrub brush to complete ngernail cleansing.in accumulating bacteria and uid to the surgical wound.35 And lastly, silk has been shown to release less tension during early retraction of the ap from healing, along with eliciting greater inammation reactions, which may contribute to incision line opening more often than synthetic materials.36,37Polypropylene (i.e., PROLENE): is suture, which is a mono-lament, will not lose tensile strength over time. It is inert, has very little tissue reaction, possesses a low coecient of friction, passes through tissue very easily, and has good knot security. e main disadvantage of this suture material tissue is irritation from the cut ends of the suture material.Polytetrauoroethylene: e polytetrauoroethylene (PTFE) suture material is a monolament, which has a relatively high tensile strength and is nonwicking (low bacteria accumula-tion). In addition, PTFE sutures have good handling qualities, are easy to tie with excellent knot security, are soft and com-fortable for patients, and are biologically inert.e main disadvantage of PTFE is that it is very expensive. PTFE sutures are slippery and have poor frictional resis-tance to knot loosening. At least seven equally tensioned, at square throws are required to produce a secure knot when using PTFE material.  625CHAPTER 26 Basic Surgical Techniques and ArmamentariumSuture Qualitiese selection of the suture material should be made with regard to the location and type of surgical procedure provided. However, an ideal suture material should exhibit high tensile strength, low tissue reactivity, and be absorbable.High Tensile StrengthHigh tensile strength is the measured force, in pounds, that the suture will withstand before breaking. A suture material with low tensile strength will lead to suture breakdown, which will most likely compromise the healing of the incision line. e tensile strength of the tissue to be sutured will ideally determine the tensile strength of the suture selected. e tensile strength of the suture should be at least as strong as the tensile strength of the tissue being sutured. Low Tissue ReactivityTissue reaction from the suture material has been shown to be exhib-ited through an inammatory response, which will usually develop during the rst 2 to 7 days after suturing the tissue. e suture material selected should have an inherent low tissue reactivity.38 Low tissue reactivity means that the suture material should exhibit a minimal inammatory response, which will not delay wound heal-ing or increase infection rate. Tissue reaction is reected through an inammatory response, which develops during the rst 2 to 7 days after suturing the tissue. Several studies published over the past forty years have reported that synthetic materials exhibit superior behavior to oral tissues in terms of tissue inammatory reactions compared with nonsynthetic suture material. AbsorbableAbsorbable suture material allows for the convenience of no suture removal. ese types of sutures undergo degradation and absorption in the tissues; thus the sutures do not have to be removed. ere are two mechanisms of degradation of absorbable sutures: enzymatic breakdown or degradation by hydrolysis (PGA). Sutures derived from a biologic origin (i.e., plain and chromic gut) are digested by intraoral enzymes. Usu-ally these types of sutures lose their tensile strength quickly (within days of surgery) and are not ideal for dental implant procedures. Secondly, these sutures may break down even faster when the intraoral pH is low. A decreased pH may result from infection, medications, metabolic disorders, or dry mouth. Trauma from suture removal may sometimes lead to incision line opening. Treatment ImplicationsFor dental implant procedures involving dental implant place-ment and bone grafting, the ideal suture material should exhibit a ABCD• Fig. 26.42 Scrub Technique. (A) Scrub each side of the nger approximately ve times. (B) Scrub each side of hand. (C) Scrub up to the wrist, then up to the elbow. (D) Rinse from the ngertips to the elbows. The theory is to remove all debris/bacteria away from the ngertips to the wrist. The entire scrub process should take approximately 3 minutes. 626PART VI Implant Surgeryhigh tensile strength, low tissue reactivity, and be absorble or easily removed. e most common today include the use of PGA (“Vic-ryl”). A nonresorbable alternative would be a PTFE suture (e.g., Cytoplast), which exhibits a high tensile strength and is nonwicking. Suture SizeSurgical threads are classied by diameter, ranging from 1 to 10, with the highest number being the smallest thread size. In implant dentistry the most common diameter is 3-0 for incision lines and 4-0 or 5-0 around tissue release margins or areas that exhibit thin-ner tissue. In some situations a 2-0 suture will be used, usually as a tie-back for the lingual tissue when performing mandibular surgery. Ideally the smallest-diameter suture material that will ade-quately hold the tissue in approximation should be used. As diam-eters of suture decrease, so do their respective tensile strengths (Fig. 26.48). Suture Needlee surgical needle is composed of three parts: (1) point, (2) needle body, and (3) swaged end. e needle type is classied by the curvature, radius, and shape. e most commonly used suture needles in implant dentistry are the 3/8 and 1/2 circle needles.37 e 3/8 needle allows for the passage of the needle from buccal to lingual in one pass. e 1/2 is usually used in more restrictive areas such as maxillary molars and in periosteal and mucogingival surgery.39 e clinician should always be aware that there exist two types of needle designs: reverse cutting and conventional. In implant dentistry the reverse cutting should always be used because this will minimize severing of the tissues. e reverse cut-ting needle has a smooth inner curvature, with its third cutting edge located on its convex (outer) edge (Fig. 26.49). Suturing TechniqueInterruptedSimple loop. e simple loop is the most common suture used in implant dentistry. It is used to approximate mobile surgical aps in edentulous areas. Each suture is tied and cut after insertion through the tissue. e disadvantage of this suture is it is more time consuming than a continuous suture. However, it does have the advantage that, if one of the sutures would loosen or break, the remaining sutures would most likely hold the wound together to minimize wound dehiscence (Fig. 26.50). Figure-eight. e gure-eight suture is placed as a simple loop on the buccal; however, on the lingual the needle passes through the outer aspect of the ap. e main disadvantage of the gure-eight is the suture material is interposed between the aps after full closure. e gure-eight suture is most commonly used with extraction sites and around papilla (Fig. 26.51). ABCD• Fig. 26.43 Sterile Gowning and Gloving. (A) Sterile gown and gloves (Sensicare, Medline, Northeld, Ill.). (B) Dry hands thoroughly, because moist hands will impair glove positioning; always maintain hands between waist and chin for sterility. (C) Pick up the gown from the sterile eld from the inside surface of the gown; step back from the sterile eld, allowing the gown to unfold from the body; and place arms into the sleeves of the gown. (D) When gown is in the ideal position, hands are at the seam of the inside cuff. Keep hands between waist and neck level to maintain sterility. 627CHAPTER 26 Basic Surgical Techniques and ArmamentariumA BCDEGFHI• Fig. 26.44 Gloving and Gown Tying. (A) Pick up the rst glove by the cuff, touching only the inside por-tion of the cuff. (B) While holding the cuff in one hand, slip your other hand into the glove. (C) Pick up the second glove by sliding the ngers of the gloved hand under the cuff of the second glove. (D) Put the sec-ond glove on the ungloved hand by using the cuff. (E) The surgeon holds left string (short) with left hand, holds tag and right string (long) with right hand, then pulls off tag with right hand. (F) The surgeon hands the tag to the assistant. (G) The surgeon spins around 360 degrees, and the assistant hands the long string to the surgeon, who ties the front of the gown. (H) The surgeon ties the front ties, and the assistant or circulator ties the Velcro back. (I) The surgeon is gowned and the hands are below the sterile area. The sterile area is below the axilla and above the waist. 628PART VI Implant Surgery Suture Materials Used in Oral ImplantologySuture TypesColor of Material Raw MaterialTensile Strength Retention In Vivo Absorption Rate Tissue Reaction Contraindications WarningsSurgical gut Plain Yellowish-tanBluedyedCollagen derived from healthy mammals (i.e., cow, sheep)Lostwithin3–5days;indi-vidual patient character-istics can affect rate of tensile strength lossDigestedbyproteolyticbody enzymes within 7–10daysModerate Should not be used in tissues that heal slowly and require support or under high-tension areasAbsorbs relatively quicklySurgical gut Chromic BrownBluedyedCollagen derived from healthy mammals (i.e., cow, sheep); treated to resist digestion by body tissuesLostwithin7–10days;indi-vidual patient character-istics can affect rate of tensile strength lossDigestedbybodyenzymeswithin7–10daysModerate, but less than plain surgical gutBeingabsorbable,should not be used where prolonged approximation of tissues under stress is requiredProtein-basedabsorbable sutures have a tendency to fray when tiedCoatedVICRYL (polyglactin 910)Braided Violet undyed (natural)Copolymer of lactide and glycolide coated with polyglactin 370 and calcium stearateApproximately 60% remains at 2 weeks; approximately 30% remains at 3 weeks (dependent on the type)Minimal until about 40th day; essentially com-plete between 60 and 90 days; absorbed by slow hydrolysisMild Eventhoughahightensile strength, may not be suffi-cient for high-stress areasNoneknownPDS(polydioxanone) Monofilament VioletClearPolyesterpolyethyleneterephthalate coated with polybutilateApproximately 70% remains at 2 weeks; approximately 50% remains at 4 weeks; approximately 25% remains at 6 weeksMinimal until about 90th day; essentially complete within 210 days; absorbed by slow hydrolysisSlight Beingabsorbable,should not be used where prolonged approximation of tissues under stress is requiredNoneknownSurgical silk Braided BlackWhiteNaturalproteinberof raw silk spun by silkworm (i.e., fibroin)Losesallormostinabout1 yearUsually cannot be found after 2 years; encap-sulation by fibrous connective tissue may resultAcute inflammatory reactionShould not be used in any area where suture removal would be difficultSlowly absorbs, tissue reactione-PTFE(expandedpolytetrafluoroeth-ylene)Monofilament White Cytoplast Nonresorbable Nonresorbable BiologicallyinertComfortable to patientsNone NoneSurgical steel MonofilamentMultifilamentSilver metallic An alloy of iron-nickel-chromiumIndefinite Nonabsorbable:remainsencapsulated in body tissuesLow Should not be used when a prosthesis of another alloy is implantedMay corrode and break at points of bending, twisting, and knottingTABLE 26.2 629CHAPTER 26 Basic Surgical Techniques and ArmamentariumSuture TypesColor of Material Raw MaterialTensile Strength Retention In Vivo Absorption Rate Tissue Reaction Contraindications WarningsETHILONnylon Monofilament BlackGreenClearPolyamidepolymer Loses15%–20%peryear Degradesatarateofabout15%–20%peryearExtremelylow None NoneNUROLONnylon Braided BlackWhitePolyamidepolymer Loses15%–20%peryear Degradesatarateofabout15%–20%peryearExtremelylow None NoneMERSILENEpolyesterfiberBraided GreenWhitePolyesterpolyethyleneterephthalateIndefinite Nonabsorbable:remainsencapsulated in body tissuesMinimal None NoneETHIBONDpolyesterfiberBraided GreenWhitePolyesterpolyethyleneterephthalate coated with polybutilateIndefinite Nonabsorbable:remainsencapsulated in body tissuesMinimal None Has not been evaluated in ophthalmic surgeryPROLENEpolypro-pyleneMonofilament Clear blue Polymerofpropylene Indefinite Nonabsorbable:remainsencapsulated in body tissuesMinimal transient acute inflammatory reactionNone NoneAdapted from Suzuki JB, Resnik RR. Wound dehiscence: incision line opening. In: Resnik RR, Misch CE, eds: Misch’s Avoiding Complications in Oral Implantology. St. Louis, MO: Mosby; 2018. Suture Materials Used in Oral Implantology—cont’dTABLE 26.2 630PART VI Implant SurgerySecond-Stage Surgery: Permucosal Abutment Suturing. A modi-cation of the interrupted suture may be completed on second-stage surgery with a permucosal abutment that has a suture groove. A suture groove 3 to 5 mm above the platform connec-tion may be incorporated in the healing abutment (e.g., Exter-nal implant system, previously known as the Maestro dental system [BioHorizons IPH, Inc.]) (Fig. 26.52). When the tissue requires apical repositioning or when it is 3 to 4 mm thick and may grow over the healing abutment, the suture groove may be used. A suture is placed next to the healing abutment. Tissue forceps lift the suture from the incision line, and the suture is then rotated to form a loop. e loop is placed over the enlarged healing abutment and into the suture groove or under the healing cap. e suture may then be tied, securing the tissue at the height of the suture groove. A similar tech-nique is used on the other side of the healing abutment. ese two sutures (one on each side) hold the tissue at the level of the suture groove and prevent it from lifting up and over the healing cap during soft tissue healing. ContinuousSoft tissue spans necessitating four or more interrupted sutures are best approximated with continuous nonlocking sutures. is suture design places less tension on the suture line and soft tissue, and allows faster vascularization of the reected soft tissue aps. How-ever, whether locking or nonlocking, this suture knot has a ten-dency to loosen with uneven distribution of tension, which results in a compromise to the integrity of the suture knot (Fig. 26.53). Horizontal/Vertical MattressMattress sutures are a variation of the interrupted suture and are used most commonly where there exists muscle pull or AB• Fig. 26.45 Resorbable fast-resorbing sutures (Integra LifeSciences, Plainsboro, N.J.) with low tensile strength. (A) Plain gut. (B) Chromic gut.AB• Fig. 26.46 Resorbable Fast-Resorbing Sutures With High Tensile Strength. (A) Synthetic absorbable suture: polyglycolic acid (PGA) sutures, which are supplied in various resorption rates (Salvin, Charlotte, N.C.). (B) Clinical image of PGA suture, which has the advantage of being resorbable with excellent tensile strength. 631CHAPTER 26 Basic Surgical Techniques and Armamentariumhigh tension. This type of suturing technique will evert the surgical wound edges, which keeps the epithelium away from underlying structures and maintains the tissue flaps to the underlying structures (i.e., dental implant, graft material, membrane).40ere are two types of mattress suture, horizontal and verti-cal. Both of these suture types allow for greater tension to be applied on the soft tissue closure without risk for tearing the soft tissue ap. It should be emphasized they are not used to obtain primary closure when tension on the soft tissue aps is present at surgery. e tissues should rest passively together before suturing. However, during functional/parafunctional movement of the tissues, the tension on the incision line may be reduced with a horizontal mattress suture. ey are often used in the mandible when the oor of the mouth is in proxim-ity to the lingual ap and the tissue is thin. ey may also be used on a facial ap with a strong muscle pull on the soft tissue. In addition, horizontal mattress sutures evert the soft tissue margin and ensure primary closure without epithelium entrap-ment. A combination of a few horizontal mattress sutures with a continuous suture may be indicated to close large soft tissue spans (Figs. 26.54 and 26.55; Box 26.10). ACDEBF• Fig. 26.47 Nonabsorbable Sutures. (A) Silk (Integra LifeSciences, Plainsboro, N.J.). (B) Wicking pres-ent on silk sutures. (C) Polypropylene (Hu-Friedy, Chicago, Ill.). (D) Polyester (Hu-Friedy, Chicago, Ill.). (E) Polytetrauoroethylene (PTFE) (Osteogenics Biomedical, Lubbock, Tex.). (F) Clinical image of PTFE suture that exhibits exceptional tensile strength. 632PART VI Implant Surgery2Suture size(traditional system)Use102/0Microsurgery3/04/05/06/07/08/09/010/0DentalImplantSurgery3/04/05/06/0• Fig. 26.48 Suture Size Chart. Suture size increases in size with increasing number. The most common suture size in oral implantology is 3-0 and 4-0. For ner tissue procedures, 5-0 and 6-0 are most com-monly used.SwageABCSwage1/2 circle needleSwage5/8 circle needle• Fig. 26.49 Common needle sizes used in implant dentistry: (A) 3/8 circle; (B) 1/2 circle; and (C) 5/8 circle. (From Suzuki JB, Resnik RR. Wound dehiscence: incision line opening. In: Resnik RR, Misch CE, eds. Misch’s Avoiding Complications in Oral Implantology. St. Louis, MO: Mosby; 2018.) 633CHAPTER 26 Basic Surgical Techniques and ArmamentariumACEBDFHold flap withtissue forcepsHold the tissueExit tissue atright anglesOver twicePull knot tight• Fig. 26.50 Simple Interrupted Suture. (A) Tissue is held with tissue pickups. (B) Enter tissue at a 90-degree angle. (C) Exit tissue at a 90-degree angle. (D) Two throws over needle holders. (E) Needle hold-ers engage the opposite end of the suture. (F) The rst knot is pulled tight to lay at. 634PART VI Implant SurgeryGIKHJLOver oncethe same wayas first throwOver once theopposite waySuture held readyfor cuttingFig. 26.50, cont’d (G) One throw the opposite way from the rst throw. (H) Second knot is secured. (I) One throw the same way as the rst throw. (J) Needle holders engage opposite end of suture. (K) Third knot secured. (L) Suture ends are cut approximately 3 mm in length. (From Suzuki JB, Resnik RR. Wound dehiscence: incision line opening. In: Resnik RR, Misch CE, eds. Misch’s Avoiding Complications in Oral Implantology. St Louis, MO: Mosby; 2018.) A BCDE• Fig. 26.51 Figure-Eight Suture That Is Usually Placed Around Abutments. (A) Enter buccal tissue at 90 degrees. (B) Do not enter lingual ap. (C) Enter from lingual at 90 degrees. (D) Do not enter buccal ap. (E) Tie suture ends. (From Suzuki JB, Resnik RR. Wound dehiscence: incision line opening. In: Resnik RR, Misch CE, eds. Misch’s Avoiding Complications in Oral Implantology. St. Louis, MO: Mosby; 2018.) 636PART VI Implant SurgeryAB• Fig. 26.52 Suture Groove Technique. (A) A suture groove in the permucosal extension may be posi-tioned 3 to 5 mm above the bone. (B) The suture groove helps to apically reposition the tissue, so it will remain less than 3 to 5 mm thick, therefore to reduce the sulcus depth. 637CHAPTER 26 Basic Surgical Techniques and ArmamentariumKeep tightKeep tightABCDEFGHContinuoussuturesI• Fig. 26.53 Simple Running or Continuous Suture. (A to E) Enter tissue at 90 degrees and use the same protocol as a simple interrupted suture. (F) Instead of both strands (ends) being cut, cut only the short strand, leaving a 2- to 3-mm tail. The second stitch should be made approximately 3 mm from the rst suture. (G and H) Multiple stitches are made encompassing the entire incision line. (I) The last stitch is not pulled completely through the tissue. Instead the loop is held with the needle holder and used as the short strand to tie off the distal end of the suture closure. 638PART VI Implant SurgeryHorizontalmattress sutureABCDEF• Fig. 26.54 Horizontal Mattress Suture. (A) The needle enters the tissue at 90 degrees and exits on the lingual side of the incision. (B to E) The needle is then placed backward in the needle holder and is inserted approximately 4 mm farther down from the rst stitch. The needle passes from the far side to the near side (buccal). (F) The suture is then tied gently on the side of the wound where the suturing originated. 639CHAPTER 26 Basic Surgical Techniques and ArmamentariumVerticalmattress sutureABCDE• Fig. 26.55 Vertical Mattress Suture (Far-Far-Near-Near). (A) The needle should enter the tissue at 90 degrees approximately 5 to 6 mm from the margin of the incision and exits on the opposite side (same distance on the lingual aspect of the tissue as the facial). (B and C) The needle is placed backward in the needle holder and enters the lingual tissue toward the buccal (approximately the distance from the incision line). (D and E) The stitch is then tied off on the facial aspect. 640PART VI Implant SurgerySuturing InstrumentsIt is imperative that the implant clinician has a complete understanding of the instrumentation used in the suturing technique.Tissue Pickupse goal of the tissue pickup is to hold tissue (i.e., ap) while suturing. Care should be exercised not to crush or sever the tis-sue. ere are various types of tissue pickups, with the serrated being the most popular. e 1 x 2 teeth pick-ups will usually result in tearing of the tissue, especially when the tissue is thin (Fig. 26.56). Needle HoldersMost needle holders are made from stainless steel, titanium, and tungsten carbide tipped. e tungsten carbide tipped needle hold-ers tend to deform the suture needle the least amount. Correct use of needle holders includes:• Alwaysusetheappropriate-sizeneedleholderforthesizeofthe needle. e larger the needle size, the wider and heavier the needle holders should be. In contrast, with thinner tis-sue with a smaller size needle and suture material, smaller, more delicate needle holders are recommended (e.g., Cas-troviejo).• Avoidplacementoftheneedleholdersneartheswageoreyeof the needle. Needles should be grasped approximately one-fourth to half their length from the swaged area.• Check the alignment of the needle holder tips, makingsure there is no opening between the tips. The needle should not be able to rock, twist, or turn within the needle holder tips.• Alwaysclosetheneedleholderontherstorsecondratchet.If the needle is grasped too tightly, the needle may break or weaken. Hemostats should never be used as a replacement for needle holders because they will damage the suture needle and material (Fig. 26.57). Suture ScissorsMany dierent types of scissors may be used in the suturing pro-cess. ere are straight, curved, and special suture scissors that are used for cutting sutures, especially for removing sutures postop-eratively (Fig. 26.58). When using suture scissors to cut the ends of the tied knot, make sure both tips of the scissors are visible to avoid inadvertently cutting tissue beyond the suture. Suturing KnotsSurgical suture knot tying is the most important aspect of suturing and often the most common problematic area. Sur-gical knots in the oral cavity must be particularly secure to overcome the potential of loosening with saliva and normal function.41 ere are three components of a sutured knot: (1) loop, which is created by the knot; (2) knot, which is composed 1. Suture from mobile to immobile tissues: This allows for better control and manipulation of the tissue. 2. Do not hold needle at swage: This may result in bending of the needle. 3. Enter tissue at 90 degrees: This allows for easier passage of the needle through the tissue and prevents tearing. 4. Keep ngers in needle holder (index nger for security): Usually the thumb and index ngers are used to hold the needle holder. The ngers should always remain in the needle holders because this will expedite the suturing process, along with allowing for better control. 5. Enter 2 to 3 mm and exit from tissue margin: Less than 2 mm will lead to tearing of the tissue margin. 6. Suture 3 to 5 mm apart: Too many sutures will impair blood supply to the incision line and increase possibility of incision line opening (ILO). 7. First throw must lie at: After the rst loop is tied, it is mandatory the loop lie at. If folded, the loop will lose tension and knot security will be lost. Final tension of the rst tie should be as horizontal as possible. 8. Avoid excessive tension: Tying knots too tight leads to tissue ischemia and ILO. Knot tension should not cause tissue blanching. In tying the knot, a “sawing” motion should be avoided because this may result in weakening the integrity of the suture. 9. Evert tissue, not invert: This makes it less likely that ILO will occur. 10. Cut sutures approximately 2 to 3 mm at completion of knot: Less than 2 mm leads to loss of knot tension, and more than 3 mm leads to patient irritation. When the ends are too long, patients will tend to irritate the area with their tongue. 11. Complete knot: The nal knot should be tight and rm so that slippage will not occur. Ideally the smallest knot possible should be used to prevent tissue and foreign body reactions. • BOX 26.10 Basic Suturing PrinciplesAB• Fig. 26.56 Tissue Pickups. (A) Serrated. (B) 1 Å∼ 2 tips. (Courtesy Sal-vin Dental Specialties, Inc., Charlotte, N.C.) 641CHAPTER 26 Basic Surgical Techniques and ArmamentariumACB• Fig. 26.57 Needle Holders for Suturing. (A) Convention Mayo needle holder. (B) Ideal needle holder placement. (A and B: Courtesy Hu-Friedy Mfg. Co., LLC, Chicago, Ill.) (C) Castroviejo needle holder.AB• Fig. 26.58 (A) Various types of straight versus curved scissors. (B) Postoperative scissors. (B: Courtesy Salvin Dental Specialties, Inc., Charlotte, N.C.)of multiple throws, each of which represents a weave of two strands; and (3) ears, which are composed of the cut ends of the suture.41 For knots to be eective, they must contain all three parts and possess attributes of both knot security and loop security. Knot security is dened as the ecacy of the knot at resisting slippage when load is applied. is depends on three factors: friction, internal interference, and slack between suture throws.Loop security is the ability to maintain a tight suture loop as a knot is tied.42 Any tied knot may have good knot secu-rity but poor loop security (a loose suture loop). Loose suture loops may be ineffective in approximating tissue edges to be secured. Ideally the knot should have minimal volume and be tied so that it fails only by breakage, rather than by slippage. A three-throw surgeon’s knot square (2/1/1) should be used.43 Security of the knot will depend on the material used, the depth and location of the wound, and the amount of stress that will be placed on the wound postoperatively. Operator experience is an important factor because considerable varia-tion may result between knots tied by different surgeons and even between knots tied by the same individual on different occasions (Fig. 26.59).44Treatment Implicationse type of surgical knot is directly related to the suture material being used. When using silk, expanded PTFE, chromic, or plain gut, a slip (granny) knot should be used. With synthetic resorb-able and nonabsorbable synthetic suture materials, a modied sur-geon’s knot is recommended.45For most dental implant procedures the surgical knot of choice is the modied surgeon’s knot. e basic surgeon’s knot is composed of two overhand knots. e rst overhand knot is a double (i.e., composed of two loops or throws) and the second overhand knot is a single (loop) wound in the opposite direc-tion. Additional knot security can be achieved with the common modication to the surgeon’s knot, consisting of the addition of a third knot (composed of two loops) in the same direction as the rst loop.46 642PART VI Implant SurgeryReferences 1. Cameron J. Williams Stewart Halsted: Our Surgical Heritage. Ann Surg. 1997;225(5). 265–258. 2. Mormann W, Ciancio SG. Blood supply of human gingiva follow-ing periodontal surgery. A uoresceinangiographic study. J Periodon-tol. 1977;48:681–692. 3. Froum SJ, Wang WC, Hafez T, etal. Incision design and soft tis-sue management to maintain or establish an interproximal papilla around integrated implants: a case series. Int J Periodontics Restorative Dent. 2018;38(1):61–69. 4. Tsutsui J, Wang J, Suzuki M, etal. Incision Design and Soft Tissue Management to Establish an Interproximal Papilla Around Inte-grated Implants: A Case Series. Int J Periodontics Restorative Dent. 2018;38(1):61–69. 5. Hunt BW, Sandifer JB, Assad DA, Gher ME. Eect of ap design on healing and osseointegration of dental implants. Int J Periodontics Restorative Dent. 1996;16(6). 6. Hupp J. Principles of more complex exodontia. In: Contemporary Oral and Maxillofacial Surgery. Elsevier; 2014. 7. Hunt WB, Sandifer JB, Assad DA, Gher ME. Eect of ap design on healing and osseointegration of dental implants. Int J Periodontics Restorative Dent. 1996;16:583–593. 8. Pfeifer J. e reaction of alveolar bone to ap procdeures in man. Periodontics. 1965;3:135–141. 9. Burkhardt R, Lang NP. Role of ap tension in primary wound clo-sure of mucoperiosteal aps: a prospective cohort study. Clin Oral Implants Res. 2010;21(1):50–54. 10. Koymen R, Karacayli U, Gocmen-Mas N, etal. Flap and incision design in implant dentistry: clinical and anatomical study. Surg Radiol Anat. 2009;31(4):301–306. 11. Hermann JS, Buser D. Guided bone regeneration for dental implants. Curr Opin Periodontol. 1996;3:168–177. 12. Velvert P, Peters IC, Peters AO. Soft tissue management: ap design, incision, tissue elevation, and tissue retraction. Endodontic Topics. 2005;11:78–97. 13. de Sanctis M, Clementini M. Flap approaches in plastic periodon-tal and implant surgery: critical elements in design and execution. J Clin Periodontol. 2014. 14. Greenstein G, Greenstein B, Cavallaro J, Elian N, Tarnow D. Flap advancement: practical techniques to attain tension-free primary closure. J Periodontol. 2009;80(1):4–15. 15. Zarb GA, Albrektsson T, Branemark PI. T Issue-Integrated Prostheses: Osseointegration in Clinical Dentistry Illinois. Quintessnce; 1985. 16. Buser D, Dahlin C, Schenk R. Guided Bone Regeneration. Chicago: Quintessence; 1994. 17. Langer B, Langer L. Overlapped ap: a surgical modication for implant xture installation. Int J Periodontics Restorative Dent. 1990;10:208–215. 18. Misch CE. Bone augmentation for implant placement: keys to bone grafting. In: Misch CE, ed. Contemporary Implant Dentistry. 2nd ed. St Louis: Mosby; 1999. 421–267. 19. Park JC, Kim CS, Choi SH, etal. Flap extension attained by vertical and periosteal-releasing incisions: a prospective cohort study. Clin Oral Implants Res. 2012;23:993–998. 20. Oliver R. Flapless dental implant surgery may improve hard and soft tissue outcomes. J Evid Based Dent Pract. 2012;12(3):87–88. 21. Sclar AG. Guidelines for apless surgery. J Oral Maxillofac Surg. 2007;65:20–32. 22. Misir AF, Sumer M, Yenisey M, Ergioglu E. Eect of surgical drill guide on heat generated from implant drilling. J Oral Maxillofac Surg. 2009;67:2663–2668. 23. Greenstein G, Tarnow D. Using papillae-sparing incisions in the esthetic zone to restore form and function. Compendium. 2014. 24. Park JC, Kim CS, Choi SH, etal. Flap extension attained by vertical and periosteal-releasing incisions: a prospective cohort study. Clin Oral Implants Res. 2012;23:993–998. 25. Hutchens LH, Beauchamp SD, Mcleod SH, etal. Considerations for Incision and Flap Design With Implant erapy in the Esthetic Zone. Implant Dentistry. 2018;27(3):381–387. 26. Zadeh HH. Minimally invasive treatmetn of maxillary anterior gingival recession defects by vestibular incision subperiosteal tun-nel access and platelet derived growth factor BB. Int J Periodontics Restorative Dent. 2011;31:653–660. 27. Kleinheinz J, Buchter A, Kruse-Losler B, Weingart D, Joos U. Inci-sion design in implant dentistry based on vascularization of the mucosa. Clin Oral Impl Res. 2005;16:518–523. 28. Flanagan D. An incision design to promote a gingival base for the creation of interdental implant papillae. J Oral Implantol. 2002;28:25–28. 29. Al-Juboori MJ, bin Abdulrahaman S, Dawood HF. Principles of ap design in dental implantology. Dent Implantol Update. 2012;23:41–44. 30. Peterson LJ, Ellis E, Hupp JR, etal. Oral and Maxillofacial Surfery. St Louis: Mosby; 1998. 31. Cavallaro J, Tsuji S, Chiu TS, Greenstein G. Management of the nasopalatine canal and foramen associated with dental implant ther-apy. Compend Contin Educ Dent. 2016;38(6):367–372. 32. Wound Closure Manual, Somerville, NJ: Ethicon Inc;1985:1–101. 33. Silverstein LH. Principles of Dental Suturing: e Complete Guide to Surgical Closure. Mahwah, NJ: Montage Medgia; 1999. 34. Engler RJ, Weber CB, Turnicky R. Hypersensitivity to chromated catgut sutures: a case report and review of the literature. Ann Allergy. 1986;56:317–320. 35. Manor A, Kae I. Unusual foreign body reaction to a braided silk suture: A case report. J Periodontol 1981;53:86–88. 36. Leknes KN, Selvig KA, Boe OE, etal. Tissue reactions to sutures in the presence and absence of antiinfective therapy. J Clin Periodontol. 2005;32:130–138. 37. Cohen ES. Atlas of Cosmetic and Reconstructive Periodontal Surgery. New York: PMPH-USA; 2007. 38. Lilly GE, Armstrong JH, Salem JE, et al. Reaction of oral tis-sues to suture materials, Part II. Oral Surg Oral Med Oral Pathol. 1968;26(4):592–599.Square knot Granny knotSurgeon’s knot• Fig. 26.59 Various Suture Knot Types. Most knots in implant den-tistry use a modication of the surgeon’s knot. (From Suzuki JB, Resnik RR. Wound dehiscence: incision line opening. In: Resnik RR, Misch CE, eds. Misch’s Avoiding Complications in Oral Implantology. St. Louis, MO: Mosby; 2018.) 643CHAPTER 26 Basic Surgical Techniques and Armamentarium 39. Silverstein LH. Suture selection for optimal ap closure and tissue healing. Perio-implant showcase. Pract Periodontics Aesthet Dent. 2005;16:2–3. 40. Silverstein LH, Kurtzman GM. A review of dental suturing for optimal soft-tissue management. Compend Contin Educ Dent. 2005;26:163–166. 41. Edlich RF, Rodeheaver GT, Morgan RF, etal. Principles of emer-gency wound management. Ann Emerg Med. 1988;17:1284–1302. 42. Burkhart SS, Wirth MA, Simonich M, etal. Knot security in simple sliding knots and its relationship to rotator cu repair: how secure must the knot be? Arthroscopy. 2000;16:202–207. 43. Drake DB, Rodeheaver PF, Edlich RF, etal. Experimental studies in swine for measurement of suture extrusion. J Long Term E Med Implants. 2004;14(3):251–259. 44. Herrmann J. Tensile strength and knot security of surgical suture materials. Am Surg. 1971;37:209. 45. Silverstein LH. Principles of Dental Suturing: e Complete Guide to Surgical Closure. New York: Montage Media; 1999. 46. Alzacko SM, Majid OW. “Security loop” tie: a new technique to overcome loosening of surgical knots. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104:e1–e4.

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