Volume 23, Number 6 June 2012

Principles of Flap Design

in Dental Implantology
EDITOR
Arun K. Garg, DMD; Editor in Chief
By Mohammed JA, BDS, MSc, SHAIFULIZAN ABR, DDS, MD,
EDITORIAL ADVISORS Hasan FD, BDS, MSc
Editor Emeritus: Morton L. Perel, DDS, MScD

Renzo Casselini, MDT,

Professor of Restorative Dentistry,
Loma Linda University, Loma Linda, CA
T here is no single flap design that serves as the optimal approach for every
implant surgery,1 and as the need for cosmetic procedures with minimally
invasive techniques increases, so, too, does the variability in flap design. In other
Leon Chen, DMD, MS,
Private Practice in Periodontology, words, there is no single technique that is suited to every surgical situation, and
Las Vegas, NV the skilled surgeon must be thoughtful and creative in selecting every incision
Scott D. Ganz, DMD, since the manner in which that incision is designed, executed, and sutured will
Private Practice of Prosthodontics, Maxillofacial Pros-
thetics and Implant Dentistry, Fort Lee, NJ
have an enormous impact on implant success rates and overall aesthetic outcome.
The site of implant placement, whether it is in the aesthetic zone or hidden pos-
Zhimon Jacobson, DMD, MSD,
Clinical Professor, teriorly, also has an impact on the flap design. Another factor to consider is the
Department of Restorative Sciences/Biomaterials, Boston
University
width of the ridge in which the implant is placed. Some ridges are wide enough
to place an implant with minimal tissue reflection, while other ridges are narrow
Jim Kim, DDS, MPH, MS,
Private Practice of Periodontics, and require wide flap reflection for better visualization and ridge width determi-
Diamond Bar, CA nation. Further, narrow ridges sometimes need bone augmentation and guided
Robert E. Marx, DDS, bone regeneration membranes, which necessitate planning for wide flap design
Professor of Surgery,
Chief, Oral & Maxillofacial Surgery
to cover the bone graft and the membrane. This article discusses the principles
of flap design in dental implantology in an effort to summarize techniques to aid
Peter Moy, DMD,
Private Practice, practitioners with optimal procedure selection.
West Coast Oral and Maxillofacial Surgery Center and
Center for Osseointegration, Los Angeles, CA
Principles
Myron Nevins, DDS,
Associate Professor of Periodontology, Principle 1: New scalpel blades and sharp peri-osteal elevators are essential
School of Dental Medicine, Harvard University, for making incisions and elevating flaps to protect the viability of the mucosa.
Boston, MA
The incision should be made clearly in order to avoid retracting, and elevation
H. Thomas Temple, MD,
Professor of Orthopedic Surgery and Director of Univer-
requires flawless use of a dedicated peri-osteal elevator.2
sity of Miami Tissue Bank, University of Miami School of
Medicine Miami, FL
Principle 2: Full visibility of the operative site is essential. It has been sug-
gested that the incision be made longer
The images contained within this issue are from Dr. Jasim
than the amount required to expose the
Al-Jubooris practice.
operative site. This offers greater visibil-
Inside This Issue
ity of the bone. It should be pointed out
that long incisions heal as rapidly as short Wounds and Suturing . . . . 44
The official publication of the ones. (See Figures 1,2.)
2
American Dental Implant Association

NOW AVAILABLE ON-LINE!

Go to www.ahcmedia.com/online.html for access.

Figure 1: The incision is made longer than
the amount required in order to adequate-
ly expose the operative site.
Principle 3: The periosteum serves
as the major vascular supply to the
bone; therefore, at most, only a mini-
mal amount, if any, of the periosteum
should be removed.3
Principle 4: If papillae are involved,
they should not be bisected but elevated
in total.2
Principle 5: If the implant proce-
dure is to involve the alveolar ridge,
the incision should be made at the crest
within the linea alba.2 (See Figure 3.)
Principle 6: If tension-relieving in-
cisions are required to avoid stretching
or tearing the tissues, these incisions
should be made obliquely to ensure
broad-based flaps.2
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Dental Implantology Update June 2012
42
Figure 2: Long incisions heal as
rapidly as short ones.
Principle 7: Flexibility in position-
ing the surgical guide4 must be provided.
Principle 8: Allow for proper iden-
tification of important anatomical
landmarks: The location and path of
the blood vessels and nerves should
be evaluated, protected, and preserved
during the duration of the surgical pro-
cedure. Beyond general knowledge of
these structures, acknowledging their
precise locations is crucial in specific
areas (for example, the mental foram-
ina and incisal canal4). This is an essen-
tional part of preoperative planning.
Principle 9: Identification of the
contours of the adjacent teeth, as well
as the concavities or protrusions on the
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surface of the bone,5 is essential and
will facilitate implant placement.
Principle 10: It is also essential
to ensure that all wounds have clean
edges, which will facilitate closure and
optimize healing by primary intention.3
(See Figure 4)
Principle 11: Permitting the raising
of a full mucoperiosteal flap ensures
that it has a good vascular supply. In-
sufficient blood supply compromises
the survival of the unreflected tissue,
which can lead to necrosis as well as
the potential for a deleterious aesthetic
result. The choice of flap design should
allow for maintenance of optimal and
sufficient blood supply to all parts of
the mobilized tissues as well as the soft
tissues in the surrounding area.3
Principle 12: Flap blood perfusion
must be maintained up to the point at
which the ratio of length to the width
of the parallel pedicle flap equals 2:1.
The length/width ratio requirement
usually favors a slight trapezoidal
shape of the flap.3
Principle 13: The tissue flap must
be kept moist at all times to help avoid
shrinkage and dehydration of the tissue.
With prolonged duration of the surgical
procedure, the involved tissues are at risk
of drying out, especially when a high de-
gree of hemostasis has been achieved.3
Principle 14: The goal is always to
minimize scarring and avoid vestibular
flattening.6
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Figure 3: The incision should be
made at the crest within the linea alba.
Figure 5: Appropriate and careful reflection and manipulation
of the tissue flap is imperative.
Figure 6: Use proper suture material, with an atraumatic needle.
There should be minimal tension during reapproximation.
June 2012 Dental Implantology Update
43
Figure 4: Clean edges are essential to fa-
cilitate primary closure and optimize heal-
ing by primary intention.
Principle 15: It is imperative to
provide for closure away from the sub-
merged fixture installation or augmen-
tation site.6
Principle 16: As with any operative
technique, the minimization of postsur-
gical bacterial contamination improves
outcome and decreases morbidity.4
Principle 17: Minimal tension dur-
ing reapproximation and after suturing
is important to avoid impairment of
the circulation at the wound margins.
Shrinkage of the reflected tissue with
wound dehiscence will ultimately lead
to increased scar formation.4
Principle 18: Tissue trauma, such as
stretching, tearing, or distortion, should
be avoided through appropriate and
careful reflection and manipulation of
tissue flap. Excessive trauma from re-
traction may cause increased swelling
and delay healing.6 (See Figure 5.)
Principle 19: The integrity of the
periosteum should be maintained
throughout. The periosteum will serve
as a barrier against the connective tissue
cells so that these cells cannot invade
the bone cavity during the healing pro-
cess and prevent a complete bone fill.3
Principle 20: Providers should
avoid oblique relieving incisions over
prominent root surfaces because reces-
sion may result if there is an underlying
bony dehiscence.
Principle 21: In cases of reduced
quantity of keratinized tissue, it is
beneficial to position the crestal inci-
sion toward the palatal aspect, the area
where more keratinized tissue as it ex-
tends onto the palatal mucosa.
Principle 22: When graft materials
or membranes are used, it is sensible to
place relieving incisions at least at one
tooth, proximal to the area of augmen-
tation.
Principle 23: If doubt exists as to
the need to expose anatomical struc-
tures, such as the incisive nerve, or if
augmentation techniques may be in-
dicated, then the wider flap design in-
cluding papillae is mandatory .
Principle 24: For larger implant
sites that are 8 mm and larger, choose a

mesiodistal crestal incision of 5-6 mm
to allow for nonreflection of papillary
tissue. For sites that are less than or
equal to 7 mm mesiodistally, there is a
need to reflect the papillae.
Principle 25: Atraumatic wound
handling avoids tension and pressure
to the flap that may lead to impaired
blood flow and interrupted lymph
drainage.1
Principle 26: Controlling intraoper-
ative bleeding (adequate hemostasis) is
necessary to avoid the possibility of he-
matoma formation, another causative
factor in delayed wound healing.1
Principle 27: Practitioners should
strive to eliminate the formation of any
dead space in which fluids might col-
lect after wound closure1.
Principle 28: The use of proper
suture materials with an atraumatic
needle must be practiced.1 Further,
practitioners must have exceptional
surgical knotting and suture selection
techniques. (See Figure 6.)
Principle 29: Avoid any local or ex-
ternal pressure on the wound during the
healing period.1 Educate patients about
the importance of postoperative care.
Principle 30: In cases of non-sub-
merged implants, the flap edge should
be repositioned upward to prevent
overgrowth of the gingiva above the
healing cap or cover screw postopera-
tively; the provider can achieve this by
making the connective tissue (perios-
teum) face the healing cap rather than
the epithelium.7,8 n
REFERNCES
1. Askary ASE. Reconstructive Aes-
thetic Implant Surgery: Blackwell
Munksgaard 2003:66-90.
2. Cranin AN. Implant surgery: The
management of soft tissues. J Oral
Implantol. 2002;28:230-237.
3. Velvert P, Peters IC, Peters AO. Soft
tissue management: Flap design,
incision, tissue elevation, and tis-
sue retraction. Endodontic Topics.
2005;11:78-97.
4. Sclar AG. Guidlines for flapless
surgery. American Association of
Dental Implantology Update June 2012
44
Oral and Maxillofacial Surgeons.
2007;65:20-32.
5. Kleinheinz J, Buchter A, Kruse-
Losler B, et al. Incision design in
implant dentistry based on vascu-
larization of the mucosa. Clin Oral
Implants Res. 2005;16:518-523.
6. Hunt WB, Sandifer JB, Assad DA,
Gher ME. Effect of flap design on
healing and osseointegration of den-
tal implants. International Journal
of Periodontics & Restorative Den-
tistry 1996;16:583-593.
7. Al-Juboori MJ, bin Abdulrahaman
S, Subramaniam R, Tawfiq OF. Less
morbidity with flapless implant. Dent
Implantol Update. 2012;23:25-30.
8. Heydenrijk K, Raghoebar GM,
Batenburg RH, Stegenga BA. Com-
parison of labial and crestal inci-
sions for the 1-stage placement of
IMZ implants: A pilot study. J Oral
Maxillofac Surg. 2000;58:1119-23;
discussion 1123-1124.
Wounds and
Suturing in Dental
Implant Surgery
By Arun Garg, DMD
I
n 2006, french and italian scientists
reported in Nature that Stone Age
humans used dental drills made of flint
some 9,000 years ago.1 The Neolithic
dentists drilled teeth to cure toothaches.
Modern analysis suggests that the drill-
ing was surprisingly effective in re-
moving rotting tooth material.1 Whats
more, and somewhat surprising in light
of the advancements made in modern
medicine and dentistry, including but
not limited to surgical sterility, antibiot-
ic therapy, and novel imagining modali-
ties like X-ray and computed tomogra-
phy (CT) scanning, early dental patients
survived the drilling and went on to use
their teeth after the procedures; this was
assessed by looking at the surfaces of
the teeth that had been drilled. Perhaps
Pierre Fauchard, the man considered to
be the father of modern dentistry, a
French physician who practiced den-
tistry similar to what we know today
from the late 17th to mid 18th centuries,
the man also touted as the individual
who first created dental prostheses, can
be credited with early methods of den-
tal surgical technique. This review ar-
ticle covers types of wounds and wound
healing, the healing process itself, and
basic surgical knotting techniques.
Surgical Wounds
and Wound Healing
Suturing and surgical knotting is an
important component of the surgeons
skill set. Dental implant practitioners
require specific, high-quality technique
in this area, given the importance of
the aesthetic outcome in the evolution
of more advanced implant procedures.
In addition to the aesthetic outcome,
proper wound healing is essential to re-
duce the risk of postoperative infection,
or worse, treatment failure.
Types of Wounds
and Wound Healing
There are four types of surgical
wounds based on risk of infection dur-
ing and after surgery: clean, clean-con-
taminated, contaminated, and dirty and
infected.2,3 Any surgical process in the
mouth almost ensures at least a clean-
contaminated or contaminated wound
secondary to the capacity of infection
of oral flora. Some oral wounds are con-
sidered dirty and infected at the outset
and require a high degree of attention,
such as an oral abscess, for example.
Wound healing in oral mucoperiosteal
tissues after surgical wound healing is
unique relative to other types of surgi-
cal wounds. Flap design plays a large
role in this process. Further, dental im-
plant surgery also conveys the prospect
of approximating a vascular soft-tissue
surface with an avascular root surface.
As mentioned in the previous article
featured in this issue of Dental Im-
plantology Update, flap design should
be trapezoidal in shape, with a wider
portion at the base of the flap to pro-
vide adequate blood supply to healing

Figure 1: The Square Knot
Figure 2: The Granny Knot
tissues, as well as flexibility to help
ensure non-tension primary wound
closure.4 Passive positioning of soft
tissue reduces tears on flap edges dur-
ing the suturing process, which limits
retraction; this can be best achieved
with properly placed vertical releas-
ing incisions and appropriate flap re-
flection.5
Types of wound healing are de-
scribed by rates and pattern of heal-
ing, and are generally divided into
three categories: healing by first in-
tention, healing by second intention,
June 2012 Dental Implantology Update
45
and healing by third intention, also
known as delayed primary closure.
Healing by first intention is a
four-stage process involving normal
wound-healing processes with mini-
mal edema, the absence of local infec-
tion, no serious discharge or separation
of wound edges, and minimal scar-
ring. The four stages of wound healing
are described below. This should abso-
lutely be the goal in many dental im-
plant surgical procedures (specifically,
first-stage dental implants, root cov-
erage, bone grafting, and membranes
used for tissue regeneration), where
appropriate. Healing by second inten-
tion involves a more complicated or
prolonged healing in which infection,
trauma, lost tissue, or poor approxi-
mation of wound edges has occurred.
An example of a procedure wherein
healing by secondary intention occurs
is gingevectomy. Healing by third in-
tention involves bringing two surfaces
of granulation tissue together because
of contaminated, traumatic wounds
with high risk of infection3,6 (extrac-
tion sockets without flap or advanced
soft-tissue graft). Generally, there
is significant scarring in this type of
wound healing.
Wound healing follows a step-by-
step process that includes hemostasis,
inflammation, and repair known
formally as hemostasis, inflamma-
tion, proliferation or granulation,
and remodeling or maturation. When
skin is punctured, the bodys immune
system reacts. Polymorphonucleo-
cytes (PMNs), platelets, and plasma
proteins enter the wound, causing lo-
cal vasoconstriction. Platelets at the
wound help to form a stable clot to
seal punctured vessels, and local acti-
vating factors lead to aggregation and
clumping. Adenosine diphosphate
from surrounding tissues causes ad-
hesion with local collagen, and plate-
let production of thrombin leads to
the production of fibrin from fibrino-
gen. Platelet-derived growth factor
and transforming growth factor beta
(TGF-beta) attract PMNs, which lead
to the inflammation stage.
Inflammation, classically appear-
ing as swelling and warmth, is a fac-
tor associated with this second stage
of healing. Macrophages replace
PMNs after approximately 48 hours
to continue the inflammation process,
removing wound debris and releasing
more growth factors.
Approximately 72 hours after tis-
sue puncture, the proliferation stage
begins, wherein fibroblasts are drawn
to the site by inflammatory cell growth
factors, which synthesize collagen.

Figure 3: The Surgeons Knot
Clinical signs of granulation include
granular red tissue at the base of the
wound, dermal and subdermal tissue
replacement, and wound contraction. In
this stage, fibroblasts release collagen,
which forms a framework for increased
dermal growth. New collagen is sup-
ported by angiogenesis as new capillar-
ies appear. Further, keratinocytes start
epithelialization of the wound, causing
further contraction and the formation
of a layered wound covering.
The final stage of wound healing,
known as remodeling, involves the
continued work of collagen as it re-
structures itself over weeks to repair
the skin. Wound tensile strength in-
creases as dermal cells are remodeled
by fibroblasts over the course of many
months to years.
Periodontal healing patterns can
involve the downgrowth of epithelial
cells into the wound, resulting in a long
junctional epithelium. Proliferation of
connective tissue can cause connec-
tive tissue adhesion and root resorp-
tion. Bone cell predominance can also
cause root resorption, ankylosis, or
both. Ingress of the periodontal liga-
ment and perivascular cells from bone
Dental Implantology Update June 2012
46
can regenerate periodontium with new
cementum.7
Factors Affecting
Wound Healing
Wound healing, described above, is a
physiologic process and, as such, is af-
fected by a variety of physiologic vari-
ables and determinants. Age, weight,
nutritional status, fluid status, the pres-
ence or absence of other chronic under-
lying diseases, the status of a patients
immune status, and history of chemo-
therapy and radiation exposure all affect
a bodys ability to heal. Certainly, loss
of tissue elasticity, slower metabolisms,
and poor circulation seen in elderly in-
dividuals provide unique challenges to
the implant surgeon, as do vitamin and
protein deficiencies or tobacco expo-
sure history, diabetes, and hypertension
(which are also more prevalent in older
populations). In this setting, and in light
of the fact that aging populations are
more likely to seek implant procedures,
dental implant surgeons must know
about tissue mechanics, factors that in-
fluence wound healing, and strategies to
employ when wound healing is thwart-
ed or prolonged.
The most essential aspect to insure
proper wound healing is practicing a
sterile and aseptic surgical technique.
Attention to the length and direction of
the incision, as well as dissection tech-
niques, tissue handling, hemostasis,
tissue irrigation, debridement, closure
material selection, elimination of dead
space, closure tension, and postsurgi-
cal wound stressors are also impera-
tive, and some of these were described
in this issues previous article on flap
design.
Suture Materials
A primary goal of dental surgery is
to establish nontension closure of pri-
mary wounds for soft-tissue flaps so
that wounds heal properly. Nontension
primary closure is essential to implant
success (for the implant and for any site
requiring a bone graft), but several flap
designs can facilitate surgical wound
healing with minimal complications. In
order to obtain optimal positioning and
securing of surgical flaps to provide
ideal conditions for wound healing,
practitioners must understand three ar-
eas of suturing: types of sutures, sutur-
ing techniques, and surgical knotting
techniques.8,9
A large study of the effect of suture
materials on wound healing revealed
no significant difference between su-
ture materials and suture techniques.10
There are two basic categories of su-
tures nonresorbable and resorb-
able, and each has advantages and
disadvantages. Nonresorbable suture
materials are naturally elastic, which
helps secure knotting. Conversely, re-
sorbable sutures tend to reduce postop-
erative inflammation. Suture size refers
to the diameter of the suture material,
measured from 1-0 to 10-0, and grow-
ing increasingly smaller in diameter
and lower in tensile strength. As size
decreases, cost of suturing materials
tends to increase.2 Dental surgeons tend
to use the 3-0 and 4-0 diameter suture
materials most commonly; the 5-0 and
6-0 are reserved for delicate muco-
gingival surgery. The principle rule of

thumb in suture selection is to choose
the smallest diameter suture that will
hold the wound tissue together during
healing. Smaller diameter fibers allow
the provider to complete more sutures
without decreasing blood supply to
the tissue.
Nonresorbable sutures are made of
silk or polyester (monofilament and
polytetrafluoroethylene). While knot
tying is facilitated with the use of non-
resorbable materials, there does tend
to be a localizing process that draws
fluids and bacteria to the wound site.
Braided strands of polyester fibers can
be coated with a lubricant to facilitate
passage through tissue, although this
certainly diminishes the capacity of
the knot to stay tied.
Resorbable sutures have become
more popular because they tend to
reduce postoperative inflammation,
and patients prefer them because they
do not require a return visit for su-
ture removal. Natural resorbable su-
tures include plain gut (lost 24 hours
after insertion into the oral cavity)
and chromic gut (treated with chro-
mium salt to resist oral enzymes for
7-10 days). These materials are con-
traindicated in patients with severe
gastroesophageal reflux disease and
bulimia with purging, as breakdown
will occur much faster. Synthetic re-
sorbables do exist and are made from
a naturally occurring polymer of the
body: polyglycolic acid; these tend to
resorb naturally within 21-28 days.
Poliglecaprone 25 sutures have a 90-
day resorption rate, with high tensile
strength, but many patients consider
them to be stiff and abrasive.11
Suturing Techniques
Maximizing healing requires the
proper choice of surgical technique,
and different clinical scenarios war-
rant different technique application.
Sutures are typically placed distal to
the last tooth, in interproximal spaces,
and should be inserted first through
the most mobile tissue flap with a
circular needle. Suture needles must
be grasped by needle drivers (never
June 2012 Dental Implantology Update
47
a practitioners direct grasp), and ten-
sion should be limited to secure the
flap without reducing blood flow to
the tissue being closed. Blanching
must be avoided. The clinician should
grasp the needle in the center, avoiding
the needle and suture juncture; needle
entry should be made at right angles
to the tissues. Periosteum-to-perios-
teum and tissue-to-tissue techniques
should be employed when multiple
levels are being sutured.11 Swelling,
as described above, occurs within the
first 48 hours postoperatively, and,
as such, sutures should not be placed
closer than 2-3 mm from the edge of
the flap to prevent tearing. The most
common suturing techniques are in-
terrupted, sling, mattress, continuous
inter-locking, and anchor sutures.
Continuous sutures: These su-
tures are used for securing flaps more
than several centimeters long and for
repositioning surgical flaps apically or
coronally; they can be used for joining
two or more inter-dental papillae of
the same flap. The advantages of this
suture are that it minimizes multiple
knots, employs teeth-to-anchor flaps,
and enables independent placement
and tension of buccal, lingual, and
palatal flaps. Disadvantages include
loose flaps or untied sutures. In Fig-
ure 8, modification of this technique,
specifically for highly restricted ar-
eas and for coapting tissue and re-
sembling the simple loop interrupted
suture technique with second needle
penetration through the outer surface
of the lingual flap. The knot is tied at
the buccal aspect of the flap after the
needle passes back under the contact
point.
Mattress suture: These sutures
are used for increased security and
control of the flap to enable a more
precise placement of the flap. This
technique is often used with perios-
teal stabilization. It is used to resist
muscle pull, to adapt flaps to bone,
as a regenerative barrier, implant or
tooth, and to avert surgical flap edges.
It also facilitates papillary stabiliza-
tion and placement.
Periosteal suturing: These su-
tures are used to penetrate the peri-
odontal/peri-implant tissues and
periosteum to the bone, and then ro-
tate the needle back to the original
direction through the periosteum and
keratinized tissues
Simple loop modification to the
interrupted sutures: These sutures
are used to approximate and coapt
surgical flaps. There is no placement
of suture material between the tissue
flaps.
Single interrupted sling sutures:
These sutures are used for a flap el-
evated on one side of the arch or for
positioning facial and lingual flaps at
different levels. It involves only two
papillae to adapt the flap around the
tooth or implant, started on the mesial
side of the site, with the needle encir-
cling the tooth before being passed
under the distal point.
Sling suture about single tooth:
This suture is used principally for a
flap raised on one side of the tooth,
and involves only one or two adjacent
papillae most often in flaps posi-
tioned coronally and laterally, requir-
ing one of the interrupted sutures,
anchored about the adjacent tooth or
slung around the tooth, for holding
both papillae. The buccal or lingual
is reflected, and the clinician passes a
3/8 circle reverse cutting needle under
the distal contact point of the most
distal interdental papilla, then the in-
ner side of the elevated surgical flap 3
mm from the papilla tip. The clinician
then passes the needle under the next
contact point in a mesial direction be-
fore piercing the inner surface of the
elevated surgical flap 3 mm from the
tip of the interdental papilla.
There are other suture techniques
available to clinicians, including
modifications of standard techniques
described above.
Knot tying is used in a multitude
of disciplines outside of healthcare,
and the principles are the same even
if the scales of purpose are vastly dif-
ferent. Surgical knotting techniques

are also a relevant skill for the implant
surgeon to master. There are more than
1,400 available knots, but only a few
of these are used in implant dentistry.
Knots should have the following: firm-
ness, simplicity, smallness, avoidance
of instrument damage to the suture or
surrounding tissues, adequate but not
too much tension, approximation of tis-
sues, traction, flatness, and avoidance
of extra throws (wherein bacteria can
settle). The most important knots for
the dental implant practitioner include
the square knot (Figure 1), the slipknot,
and the surgeons knot (Figure 3).
The square knot involves two over-
hand knots completed in opposite di-
rections. First, the clinician makes a
loop over the jaws of the needle holder,
grabs the end of the suture, and pulls
the knot to the flap. Then, the clinician
makes a second overhand knot, plac-
ing a loop under the jaws of the needle
holder again. The suture is caught, and
the two ends of the suture are pulled
together.
The slipknot is similar to the square
knot, except two single overhand knots
are made in the same direction. Further
tightening of the knot is possible before
it is locked by an overhand knot made
in the opposite direction.
The surgeons knot is the most com-
monly used in implant surgery, and it
is generally used with braided sutur-
ing material and a standard mattress
technique. It consists of a modified
square knot made up of two overhand
knots completed in opposite direc-
tions. The first is a double overhand
knot; the second is a single. Doubling
the first overhand knot can prevent
knot loosening. n
References
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