Wound Dehisence with Implants: Discussion

Hi Thanks for posting. I had a similar problem for a while in some cases and found the causes of this is to be either sutures being close to the surgical wound edges +/- swelling post surgery. I addressed this by placing a mixture of interlocking sutures and simple interrupted sutures and also ensuring a good width of tissue, i.e. the sutures not being too close to the wound edges. This was especially the case where you would expect post surgery swelling to more than normal (e.g. grafting / periosteal release). Also when grafting ensure periosteal release is sufficient to close the surgical wound edges with no tension at all. Check for any muscular pulls from any buccal fraenum that may be closeby. Hope that helps.

I also try to suture well below the flap margins to pull them together somewhat loosely. I will sometimes place a couple smaller sutures 5-0 or so once my initial suture is complete. I have also begun using dental superglue on the tissues. I forgot the scientific name I am home right now. It's fairly cheap and holds everything together.

Hi, thank you for posting this interesting topic. I think we must use surgical principles properly such as not to place incision line close to surgical site, placing sutures not only on the mucous but also on the periosteal layer considering that we open mucoperiosteal flap previously. Don't forget to apply aseptic principles during entire processed. Thank you

One of the main culprit is improper tissue manipulation, either by the dr. Or by the assistant during retraction or with the suction.

Try doing single stage. Put a healing abutment on it. Works well for me.

I was having a similar problem because I liked my flaps nice and secure, so I would tend to place my sutures a little tight. I've since started placing little to no tension to allow for swelling and I've actually been able to remove sutures at the post op appointment instead of the patient coming in and saying they fell out or clipping some danglers. I agree with the other posters above about distance from flap edges as well.

If it is a consistant problem it is the operator, don't blame the patient or the situation. Surgical principle need to be respected and understood. This is hard to obtain in a post grad course or by trial and error. This can cause patient discomfort and time, money and chair time. Post surgical sequela , management and complications are not business or practice builders. If it is complicated work with an experienced surgeon. Some of the recommendations I see posted are not the best and mirror this.

CRS, I totally agree that most of the time is operators error. See my previous posting. I am in disagreement that you need to Have any special training to handle this surgery. Laying a flap repositioning it and suturing is Surgery 101. Hope that doctors are not going through Oral Surgery Training to learn how to lay a flap. How about orthognathic, fractures, oral lesions including cancer, that Is were an Oral surgery training is for, not for placing implants. From your postings I assume that you are also applying prosthetic principles to your implant cases and I respect that. Many Oral surgeons are deciding to be involved with implants and not using to full capacity the knowledge that they obtained in their training for different reasons. Some because they want to avoid the strenuous hospital routine some because the competition has drained out the orthognathic cases, others because in their area accident cases are in the hands of the reconstructive surgeons And Craniofacials. The chalanges knowledge wise and economic wise are tremendous I understand. I routinely see good and bad surgeries done by all type of dentists all over the USA and many parts of the world. If you don't agree with the advice that others have posted, pleas post yours, And it will be welcome by all. Many on this forum and specially you have much to offer, but I suggest that we keep the specialty training out of the equation every time someone asks for advice. Very respectfully yors Raul Mena

Unfortunately perhaps because of the area I practice in I see a lot of poorly done surgery which I fix. And actually my program took particular care to learn how to lay a flap in both the OR and in the dental clinic. Dental implants are very much part of Oral Surgery training in the U.S. It is also part of the Board exam and featured in our journal. I'm sorry but these Surgery 101 principles seem to be the bulk of problems posted in this forum. I honestly don't think you have the right perspective to opine on the speciality of Oral Surgery. I gave my opinion on how complications can be avoided by careful judgement on case selection. It find it interesting that you who take offense to that. I find that your response defensive and that was not what I posted, just sound practical, advice. I respectfully disagree one needs a lot of special training and judgement to do this well. Talent while key is helpful this stuff cannot be learned in a weekend or online course judgement needs to be applied. My point is complications are not great for an implant practice and cost time money and patient dissatisfaction.

Dear CRS, I am neither offended of defensive regarding your posting. The reason that I made the comment is because every time there is a question posted by some of the less experienced colleagues there is always the remark of the specialty training. I stick to my opinion that the specific case on the posting can be handle by Surgery 101. Of course when I went to Dental School the professors teaching Surgery 101 were Dr. Richard Topazian, Larry Peterson and Wade Hamer. Dental Implants can be part of Oral Surgery Training , but they are also part of Perio training and many GPS are extremely well trained in implantology. I also know Prosthodontist and Endodontist placing implants and doing a good job at it. I have many dear friends that are Oral Surgeons, and I highly respect them, as a matter of fact my father was an MD DDS, an Oral and Maxillofacial Surgeon, Otorinolaringolotist and a Head and Neck Surgeon, I am only a Simple GP that place implants and that have 3 years Hospital based Residency on Oral, Maxillofacial and Craniaofacial Implants under Dr. Anthony Wolfe a Craniofacial Reconstructive Specialist, one of the virtuosos that trained under Dr. Paul Tessier. I also have training on Nobel Bone Anchoring Hearing Implants. Have placed many implants in the Orbit, for patients that have lost their eyes either by cancer, accident or fungal infection, have placed implants for ear prosthesis and have also placed implants in many vascularized Scapula and vascularized Fibula grafts . Oh also in some cases have done distraction osteogenesis, and many bone and soft tissue grafting. So you see that gives me at least a basic perspective on what a 101 flap is. The only purpose for my postings is to stop this “Trumpism “ every time a colleague asks for an opinion. Read OMS posting right before yours and you will se a good example on “Trumpism” response. From many of your postings I see that you have a vast experience on implantology, so please share it with us, so it can be a learning experience for all of us in this Forum. I really mean it and I am not being sarcastic. Sincerely GP

My post was not about you or Trump, it is about judgement and experience for patient benefits. Your background which is extensive and privileged was not learned in a weekend course which was my point. When I have a case that is challenging I get colleague imput, but I think some of these errors are pretty basic. Thank you for the resume with that background and perspective I am surprised we are not more like minded, perhaps I am not as tactful in my posts but in this forum, an honest post trying to get the clinician to really think about what they are doing is what I am trying to share. I may have a bit more "shock value" in the delivery but that is my style think about this why would I take the time to post this! I really think about all the posts and find the information a valuable assessment. Would love to hear more about the Nobel Bone anchored hearing implant, I have an ENT colleague who would like to team with me. Thanks for posting.

This is why I rarely read and even more rarely post comments. Dude asked a simple question and instead of answers got a debate on who should do the implant. So my .02 anyone who damn well pleases. As long as they follow sterile surgical protocol. Use approved products and procedures. If they ask questions try to get off your soap box and help a brother(or sister) out.

Brian, We are in agreement. Now to give a brief answer to the case in question. As I first posted, trauma by the operator during flap reflection is one of the culprits, another is poor suctioning technique. I often see on the training courses that we offer, the assistants or the doctors usually over suction both the hard and soft tissue. Repositioning the flap under to much tension, too many sutures or over tightening of the sutures. Another culprit is rinsing and trauma and in some cases patients place aspirin in the area. Also if the abutments or the implants are too close to each other and there is no bone to support the healing process of the soft tissue you see this phenomenon. and last but not least, removable temporaries causing too much pressure over the surgical site. Would like to hear suggestions from others. Raul .

It's all about blood supply. So let's review the obvious 1. Flap design needs to respect the blood supply 2. The actual thickness of the flap must sustain a blood supply (for all the split thickness flaps out there. 3. Lack of tension which will cause the flap to retract and also will compromise the blood supply if it is too tightly sutured. 4. Minimize smoking and trauma (again both will interrupt blood supply) 5. Make sure the sutures are in the direction of the vessels and don't cross the vessels. You can try placing sutures wherever you want, you can use cyanoacrylate cements you can stick plumbers putty for gosh sakes, but the blood supply is the secret. A well designed flap will rest closed so passively it will virtually need no sutures to stay closed.

Well released flap, sutured without tension. Once it dehisces then it must heal by secondary intention. Poor blood supply and traumatic handling cause flap necrosis. The problem is that sometimes the bone needs to be reduced to allow closure which is not helpful in implant surgery. A broad based curvilinear flap with release and periosteal release will help. One must be mindful of displacing the keratinized tissue too far palatial or lingual, a ct graft may be required at exposure. Trying to do too much in one surgery, blood supply disrupted, infection or bone necrosis will cause the flap to be compromised. That's all I can think of. I don't have an agenda, attitude or teach courses, and your welcome!

Dr. CRS Regarding your question For the training on bone anchoring hearing aid check Misericordia Hospital in Alberta Canada. A very well run hospital, at least when I went there in the early 90s. Raul