Gingival flap breakdown

RE: Gingival flap breakdown

vanessab — Sun, 15 May 2022 12:14:30 GMT

Am going to look at some dental CPD I think and switch to triangular flaps instead to help preserve blood supply. Happy to report that the site looks about 90% healed and patient seems back to normal...

RE: Gingival flap breakdown

Evelyn Barbour-Hill — Thu, 12 May 2022 01:08:53 GMT

I'm not suggesting for a moment that the OP's use of 5/0 Monocryl contributed to the breakdown in question,just pointing out that long ends of Monocryl can be prickly, and in our patients, especially the cat, that can be significantly irritant.

I don't really recognise Rob's experience with Monocryl and excessive tension. I knot 5/0 or 4/0 Monocryl with 3 throws, 1 throw, 1 throw and tug lightly, that's it. Of course, as with any monofilament, the tyro knotter must recognise that each knot must distort the material, otherwise they end up putting a series of half-hitches with one end around the other, which contribute almost nothing to knot security, just provide a longer tunnel for the other end to slide through.

Catgut used to be the standard gingival suture in humans, mostly because it was soft when wet. – but that was 40 or 50 years ago. There's no need to use it now.

I do maintain that for gingival and mucosal surgery the disadvantages of a capillary material are much oxaggerated – and if it really bothers you, use that Vicryl (the name escapes me) that has an antibacterial impregnation.

Human oral surgeons often use fine gauges of Vicryl in, for instance, very demanding palate surgery in children.

My guiding principle is that the material used should be no thicker than necessary (and the suture pattern no more complicated than necessary, but that's another thread!).

I use nothing but 6/0 Vicryl or 5/0 Monocryl in the mouth (just occasionally 4/0 Monocryl in major surgery, maxillectomy for instance, in dogs). I'd use 6/0 Monocryl but I find it too hard to see and it's not available dyed in the UK. These gauges are perfectly adequate. And remember that a finer material means a finer needle, and that's got to be good.

I must say that many veterinary surgeons are still using suture material far heavier than necessary in all surgery, especially in skin. 6/0 monofilament is perfectly adequate in the skin of the cat in many situations, perhaps 5/0 in others. In the dog, 5/0 or 4/0. If these are adequate in the skin, why would you want something heavier in suturing the gingiva, where practically no strength at all is required?

RE: Gingival flap breakdown

Simon Vogel — Wed, 11 May 2022 18:28:05 GMT

Pharmaceutical not pharmacy, can’t edit.

RE: Gingival flap breakdown

Simon Vogel — Wed, 11 May 2022 18:25:26 GMT

Yes, but only in humans! Has been touted as the ideal in implantology, but used in human dentistry since the late 60s after a major US pharmacy company may or may not have pioneered it as a wound dressing in a major conflict of the time.

RE: Gingival flap breakdown

Rob Davis — Wed, 11 May 2022 17:46:50 GMT

[quote userid="19446" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30287/gingival-flap-breakdown/237145#237145"]I have used cyanoacrylate in conjunction with suturing for a second attempt at repair of a nasty degloving injury in a 6mo pomeranian who had been left attached to the tow ball of the car when the owner drove off[/quote]

Sounds nasty! I agree that it can work well on skin, but I was wondering if anyone had any experience of using it on oral mucosa.

RE: Gingival flap breakdown

Maoriwrasse — Wed, 11 May 2022 17:35:42 GMT

I have used cyanoacrylate in conjunction with suturing for a second attempt at repair of a nasty degloving injury in a 6mo pomeranian who had been left attached to the tow ball of the car when the owner drove off. 1st repair soon gave up but second worked beautifully. No way to know if the glue was the major factor in successful repair, but I would try it again.

RE: Gingival flap breakdown

Rob Davis — Wed, 11 May 2022 17:05:28 GMT

[quote userid="2211" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30287/gingival-flap-breakdown/237137#237137"]Perhaps cyanoacrylate is the answer[/quote]

Maybe you're right. I know there is a fair amount of literature about using it in human mouths, but I haven't come across any vets using it - anyone tried?

RE: Gingival flap breakdown

Rob Davis — Wed, 11 May 2022 17:01:59 GMT

[quote userid="7031" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30287/gingival-flap-breakdown/237141#237141"] I used 5-0 monocryl I think.[/quote]

I personally think this is a good choice. It is probably worth saying that monocryl is slightly more difficult to knot correctly than vicryl. It is easy to inadvertently overtighten the knots - I teach people not to apply any significant tension until the 4th or 5th throw as even on the 3rd throw it will often pull the whole thing tighter.

[quote userid="7031" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30287/gingival-flap-breakdown/237141#237141"] I did use vertical releasing incisions and have since read some articles advising against this, but have done this for some time with no issues in healing[/quote]

As with choice of suture material, if you ask 10 different surgeons you will get 10 different opinions.... Personally I try to avoid vertical incisions if possible, however sometimes they are necessary to ensure you have good visibility and to avoid traumatising the flap. If I use them, I prefer to use a single rostral incision creating a triangle flap, rather than rostral and caudal creating a trapezoid flap, my logic being that the majority of the blood supply to the flap comes from caudally.

As Evelyn said, sometimes dehiscence just happens for no obvious reason, but it is always useful to review one's technique - there is always room for improvement in all of us!

[quote userid="7031" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30287/gingival-flap-breakdown/237141#237141"]Am still applying a little bit of sucralfate but don't know if this is just an owner placebo or is beneficial[/quote]

I've not heard of sucralfate being used in this way before, do you have any more information or experience with it?

RE: Gingival flap breakdown

vanessab — Wed, 11 May 2022 16:10:21 GMT

Hi Rob thanks for the reply. I used 5-0 monocryl I think. I did use vertical releasing incisions and have since read some articles advising against this, but have done this for some time with no issues in healing. Am wondering if in my haste to recover from GA that I had placed the sutures inappropriately and these had then irritated him and the subsequent chewing in the area eventually led to the flap being damaged. Since we cleaned the area on Sunday, he hasn't made the chewing motion at all so am wondering if we dislodged something that was irritating him rather than a significant painful stimulus. Am still applying a little bit of sucralfate but don't know if this is just an owner placebo or is beneficial.. The extraction site has filled in further and can no longer identify bone when looking, so am happy that he is healing and hopefully feeling ok. Thanks V

RE: Gingival flap breakdown

Simon Vogel — Wed, 11 May 2022 11:01:05 GMT

Indeed most papers conclude that no suture material fits all of the ideals laid down by Koshak, and we know the limitations of silk as a suture material. I fell into the common pit of reflecting my personal experiences, and those of the patients I see after oral surgery, with a variety of suture materials used. Perhaps cyanoacrylate is the answer.

RE: Gingival flap breakdown

Rob Davis — Wed, 11 May 2022 10:15:47 GMT

[quote userid="2211" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30287/gingival-flap-breakdown/237135#237135"]There is an undeniable benefit to using softer ‘gentle’ sutures in the mouth from the patient’s perspective - hence the routine use of silk by dentists. [/quote]

You may be right, but I'm not sure this is "undeniable". A quick search has shown very little research into the patient comfort aspects of intraoral sutures in people, and the one or two papers I have found suggest little difference being reported between different materials. There are also other factors to consider such as wicking effect, inflammatory response etc. Silk is consistently reported to cause more significant local inflammation and to increase the risk of infection, both or which are likely to cause more discomfort and/or impaired healing.

RE: Gingival flap breakdown

Simon Vogel — Wed, 11 May 2022 09:24:14 GMT

There is an undeniable benefit to using softer ‘gentle’ sutures in the mouth from the patient’s perspective - hence the routine use of silk by dentists.

RE: Gingival flap breakdown

Rob Davis — Wed, 11 May 2022 09:01:07 GMT

[quote userid="7031" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/30287/gingival-flap-breakdown/237125#237125"] I did use a larger gauge than you recommend and did use Monocryl.[/quote]

While Evelyn's reply is, as always, excellent, I would not feel that using monocryl is likely to contribute to the breakdown. Monocryl, or one or the equivalents, is the most commonly used material for gingival sutures. While I am in no doubt that Evelyn achieves good results using 6-0 vicryl, I generally opt for 5-0 monofast (Kruuse's monocryl equivalent) and find this works well. Many of the textbooks and papers recommend using larger sizes and there was a paper recently published in the Journal of Veterinary Dentistry which described using chromic catgut sutures (this by a very well-respected Americal Diplomate), so it would appear that choice of suture material may not be critical as presumably all the authors achieve consistent results with their respective choices.

What size monocryl did you use? Did you use any vertical releasing incisions?

I agree with Evelyn that there is probably not much to be gained by rushing in to do further surgery at this stage - most of these heal well by second intention.

Do keep us posted with progress!

RE: Gingival flap breakdown

vanessab — Tue, 10 May 2022 12:28:08 GMT

Hi Evelyn thanks for the comprehensive reply and reassurance. I feel the most likely reason for the breakdown is operator error unfortunately - I did use a larger gauge than you recommend and did use Monocryl. I think I was in a bit of a rush to finish the GA as it was my own cat and I probably didn't make sure the ends were short enough and not going to rub. I took him into work on Sunday for a second opinion and it is difficult for me to hold him and check myself. My colleague gave it a gentle irrigation and advised that she had used sucralfate to act as a local protectant. I can't find any info on this really online but have been gently flushing the area and applying a small blob locally tid and he hasn't made the chewing/licking action since she first cleaned it - not sure if there was a bit of material or food there that she had dislodged. I have reduced his meds to bid with no change in pain score.

In terms of SCC, the gingiva/tissue in that area was visually normal at GA. The resorptive area was wholly within the crown but the tooth externally looked normal until you got really close to it and could see that it was a little pink tinged. The socket does seem to be looking better also so I am pretty confident it was my error rather than something suspicious but will of course be observing the area closely. Thank you again, V.

RE: Gingival flap breakdown

Evelyn Barbour-Hill — Sun, 08 May 2022 18:15:25 GMT

I guess Saturday afternoon is not the most rewarding time to post a question...

There are of course several reasons why the repair might break down, but you seem to have covered and eliminated most of them – technique good, no tension,no protruding bone, everything properly checked. Just occasionally it may happen without any identifiable factor. But, after factors that are anything to do with technique, the next commonest cause is neoplasia, and that would be practically synonymous with squamous cell carcinoma (SCC).

Just a small question –not criticising, just wondering – what gauge of material did you use? Sometimes people use material that's too thick – in a cat 6/0 is perfectly adequate. And despite the supposed disadvantage of a capillary material, Vicryl is soft whereas Monocryl means spiky ends.

Now only you can say whether there are any other signs or symptoms that might lead to a suspicion of SCC. If there are not, of course you can't rulle it out but it would be fair to wait 3 weeks or so to see what happens at the site. If it gets on and heals by granulation, there you are. If not, you will want to invade again.

In my opinion, if there is nothing that must defintely be attended to (like protruding bone, foreign matter, etc.) then attempts at re-entering the area, "freshening" and resuturing are a waste of time and effort. The inflamed tissue will be difficult to suture and in any case it will probably break down again. Healing by second intention is fine, the oral tissues are very good at it.

On the other hand, if you have any cause at all to suspect SCC, or if the site looks worse day by day instead of looking better day by day, don't wait but invade again straight away. You'll need to get a biopsy from quite deep in the site – no point in taking a biopsy of inflamed more superficial tissue. I got into trouble once (quite deservedly) for advising that you "have a good guddle round" in the alveolus, but you get the point.