Suturing in Dental Surgery

Hasanain Alani, 18’July 21, 2016

Overview• Objectives• Review of suturing materials• Techniques used in Oral Surgery

What is Suturing?• The primary objective is to position

and secure surgical flaps to promote optimal healing.

• When performed properly, healing by primary intention occurs.

• Performed intra- and extra-orallyoAchieve functional and esthetic

resultsoDecreasing the potential for

postoperative infections occurance

Suture Armamentarium

• Needle Holder Suture scissors

Adson forceps Suture Needle

Suture Materials: Needle

A surgical needle has 3 parts: the needle point, the needle body, and the swaged (press-fit) end The most commonly used are the 3/8 and ½ circle needles.

The common shapes:• ROUND

o Less traumatic than the other two, requires more force

• REVERSE CUTTING: o The sharp TIP is DOWNWARD. o More safe when working in delicate tissue.

• Cuttingo Sharp TIP is UPWARD. o Extra sharp tip in is more likely to tear the tissue.

Suture Materials: Thread

• Propertieso Tensile strengtho Biocompatibilityo Ease of tyingo Least tissue irritation and reactiono Diameter and sizeo Coefficient of friction

• Classificationo Origino Structureo Duration

Durability• Resorbable

o Natural• Plain gut• Chromic gut

o Synthetic• Polyglycolic acid (PGA)• Poliglecaprone 25

How do sutures resorb?o Antigenic Reactiono Acidic Environment

NonresorbableSilkPolyester

Monofilament type ‘nylon’Polytetrafluoroethylene (PTFE)

Silk Sutures• This is the most universally used material in

dentistry

• Advantages:o Inexpensiveo Easy to handle and tie

• Disadvantages:o It must be removedo It is multifilament

• When Should we avoid using silk? And what are the alternatives?

Example• Patient diagnosed with bulimia presented to

OS clinic for #30 extraction, and it was determined that the flap edges need to be positioned by sutures.

• What is the minimum coaptation time for tissue flaps?

• Synthetic vs Organic thread?

• Fast Absorbing Polyglycolic Acid (PGA-FA)

Diameter• Thread materials range in diameter from 1

to 10, and the higher number corresponds to the thinner, more delicate thread.

• periodontal plastic surgery: 5–0 for soft tissue grafts, 4-0 mucoperiosteal grafts and implants surgery.

Knots• Art of suturing!• An appropriate type of

know should be used for the specific suture material

• Slip knot: used with silk, chromic or plain gut suture

• Surgeon’s knot: used with synthetic resorbable and other nonresorbable synthetic suture materials to prevent untimely knot untying.

Techniques• Interrupted Suture• Simple Continuous Suture• External Horizontal Mattress Suture• External Vertical Mattress Suture• Figure-of-eight Suture• Criss-cross Suture

Interrupted Suture• Do the pass technique, two loops

around the needle holder, then grab the tail and do the knot.

• Indications: Single tooth extraction, third molar extraction flap, biopsies, implants, ..etc.

• Advantages: It is the most commonly used technique, preferred in urgent situations and it is easy to remove. Failure of one is inconsequential of the others.

• Disadvantages: It does not bring all surfaces into contact and less supportive for healing of the flap margins.

Simple Continuous Suture

• Start it with simple interrupted suture• Then you cut the tail off and leave that last

piece loose then you can do your loops.

• Indications: Bone graft, removal of mandibular tori, tuberosity reduction and where esthetics are not important

• Advantages: It is very easy to produce and offers a more water tight closure

• Disadvantages: if you cut one part of it, you lost all of it.

Horizontal Mattress Suture

• The strongest type of sutures, very far away (8 mm from the edge)

• Indications: large distances between tissues, bone grafts and implants, and closure of extraction socket.

• Advantages: Good for hemostasis, less prominent scarring.

• Disadvantages: Leave a gap between flaps and it is difficult to remove.

Vertical Mattress Suture

• The far far, near near technique.

• Indications: where the wound edges tend to evert

• Advantages: greater closure strength and better distribution of wound tension

• Disadvantages: Scar formation and the formation of edge necrosis.

Figure of 8 sutures• Pattern goes 1-2-3-4-1

• Indication: Extraction socket closure, adaptation of ginigival papilla around the tooth, and bone graft placement in socket

• Advantages: Rapid closure• Disadvantages: Due to its orientation, it is difficult to

remove and it leaves a significant amount of suture threads inside the socket.

General Principles• 1- Grasp the needle 2/3 front, and 1/3 behind

the needle driver.• 2- The needle should pass perpendicular to the

tissue• 3- The needle should pass at an equal depth

and distance on both sides of the wound• 4- Pass from the thinner to the thicker tissue• 5- The suture should never be closed under

tension (no blanch).• 6- The knot should be placed at 2-3 mm from

the incision• 7- Suture should pass over the dental papilla,

not the empty socket.

Conclusion• Due to the daily surgical procedures carried

by dentists, a greater knowledge of suturing armamentarium and materials and is needed.

• The success of technique-sensitive surgeries depends on the clinician’s knowledge and skills to close the wound and achieve optimal healing

• The innovations in suturing materials decrease the potential for postoperative infections.

Refrences• 1- Silverstein, Lee H., Gregori M. Kurtzman,

and Peter C. Shatz. "Suturing for optimal soft-tissue management." Journal of Oral Implantology 35.2 (2009): 82-90.

• 2- Chu, Chih-Chang, J. Anthony Von Fraunhofer, and Howard P. Greisler, eds.Wound closure biomaterials and devices. CRC Press, 1996.

• 3- Int J Periodontics Restorative Dent. 1998 Oct;18(5):474-87. Oral tissue reactions to suture materials.Selvig KA(1), Biagiotti GR, Leknes KN, Wikesjö UM.