The “Washing Line” Suture Technique for Securing the Subepithelial Connective Tissue Graft

Case 1. (a) Initial presentation of a 76 year old white male with hyperdontia. (b) Following removal of impacted supernumeraries, an implant has been inserted. (c) The alveolar void and buccal defect have been filled with Bio-Oss granules. (d) Bio-Gide membrane in place. (e) Harvested connective tissue securely fixed at recipient site using the washing line suture. (f) Wound coverage with the coronally advanced buccal flap. (g) 18 months postsurgery, or 12 months postloading of the implant, there is now a creation of a normal-appearing muco-gingival junction and width and volume of keratinized gingival tissue. Additionally, a central papilla has formed. (h) Schematic of suture technique in Case 1. For the mesio-distal fixation, 5.0 Prolene is introduced at point A through the fixed buccal mucosa. The suture then penetrates the donor connective tissue (CT) through the four points as shown, to re-emerge freely at the other side and penetrate the underside of the fixed buccal mucosa at point B. The suture then re-enters the fixed mucosa at point C to further penetrate the connective tissue in another 4 penetrations before penetrating the fixed mucosa again through point D where it is tied off. Crestally, the suture passes through the palatal mucosa and into the coronal portion of the connective tissue where it is returned back through the CT, and under the palatal mucosa to penetrate it and re-emerge on the palatal surface where it is tied off—this is repeated as shown.

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

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

Case 4. (a) Initial presentation. The lower incisors exhibit grade 3 mobility and will be extracted together with the lower right canine which has a failed root-treatment. (b) The teeth have been extracted, followed by the raising of a mucoperiosteal flap. The sockets have been debrided. (c) The osteotomies have been prepared in the vacated sockets of teeth 43 and 32 with their axis centralized to account for the certainty of both buccal and lingual bony resorption. The implant depth is such that the collars of the implants are submerged 2 mm below the bony level of the adjacent teeth 44 and 33. (d) Bio-Oss granules have been placed into the alveolar void. (e) Bio-Gide covering the wound site. (f) The connective tissue is secured in place with the washing line suture of 5.0 Prolene. (g) The flap is coronally advanced and secured with 5.0 Prolene crestally and 6.0 Prolene sutured in an apico-coronal direction at the relieving incisions. (h) At 5 months the implants have been exposed with simple crestal incisions. (i) Gingival margins at 6 months prior to impressions for a fixed prosthesis. The morphology and volume of the edentulous ridge have been maintained. (j) Fixed prosthesis after 12 months in occlusal function. (k) Periapical radiographs taken of the implants after 12 months in occlusal function.

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

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