S Table of _\ Contents The Suture Procedure The primary objective of dental suturing is to position and secure the surgical flaps to promote optimal healing, Chapter 1 discusses needle and suture knot recommendations and the utilization of each suturing technique. Suture Materials 12 Nonresorbable suture materials demonstrate natural elasticity which ensures knot security; resorbable sutures result in less postoperative inflammation, Chapter 2 reviews the characteristics and applica- tions of nonresorbable and resorbable sutures. Suturing Needles 18 Suturing needles consist of three basic components: the attachment (swaged or eyed); the body; and the point, Chapter 3 discusses the elements and utiliza- tion of the types of suturing needles,ch mates outlines the advantages and disadvantages of jal required for suturing during specific clinical situations, such as tissue or bone sneration or implant placement, Mast importantly, the author iden- and definitively describes the techniques utilized during dental suturing, and emphasizes the clinical situations for which each is most effectively utilized, This long-awaited manual is the quintessential resource for the student and general practitioner accomplishing sin 11 fills what has been a tremendous void in available practical mate- rial related 10 this specific aspect of dentistry. The indications and sal dental closure. contraindications are clearly outlined and inclusive of current sututing methods. The anatomical illustrations significantly increase the clarity of the text while providing full-color examples of the procedures discussed. This manual will serve as a valuable tool to the clinician, expanding the repertoire of restorative capabilities; and to dental students, introducing them to the variety of techniques and materials associated with dental suturing. Further, Principles of Dental Suturing ‘The Complete Guide to Surgical Closure provides a cornplete, up-to-date guide on the most eff eotive suturing needles, materials, techniques, and closure: protocols. Dr Roland M. Meffert, Clinical Protessor Department of Periodontics University of Texas Health Science Genter Sun Antonio, TX vChapter 4: Chapter 5: Suturing Instruments 24 A variety of instruments are utilized for suturing procedures: tissue pickups, such as tissue pliers and forceps, needle holders, hemostats, and scissors. Chapter 4 defines each of these instruments and their significance to the suturing procedure. Chapter 6: Suturing Techniques 34 Suture positioning, essential to ensure adequate healing, is accomplished by utilizing a number of suturing methods. Chapter 5 provides detailed step- by-step illustrations of the various types of suturing techniques used in dentistry. Chapter 7: Surgical Knotting Techniques 70 Of the more than 1,400 knots available, only a limited number are utilized in dentistry and implantology to approximate oral tissues. Chapter 6 discusses the considerations and characteristics of conventional knotting techniques. Suture Removal 76 Suture removal may be accomplished when a wound has developed sufficient tensile strength Chapter 7 explains the techniques necessary for safe suture removal TABLE OF CONTENTS| ™4‘The Suture Procedure The term “sutmre" describes any strand of material utilized to ligate (tie) blood vessels or approximate (sew) tissues. Written references have been identified from as far back as 2,000 B.C., which describe the utilization of strings and animal sinews for suturing. Through the following centuries, a wide variety of materials—silk, linen, cotton, horsehair, animal tendons and intestines, and wire fabricated from precious metals—have been employed in operative procedures. Some of these: alternatives are still utilized in moder clinical practice. The cvolution of suturing material has presented the clinician with such refinements as sutures designed for specific surgical proce- dures, ‘These innovations not only eliminate some of the difficulties the surgeon may have previously encountered during closure, but also decrease the patential of postoperative infection.However, despite the sophistication of the suture materials and surgical nitial same € techniques available today, closing a wound still involves th procedure used by physicians to the Roman emperors. The practitioner still utilizes a surgical needle to pull the suture strand as it is placed within the tissue. ‘The primary objective of dental suturing is to position and secure surgical flaps in order to promote optimal healing. Therefore, accurate apposition of the flap is significant to patient comfort, hemostasis, reduction of the wound to be repaired, and prevention of unmecessiry bone destruction. If flaps are not approximated, and theretore, inadequate hemostasis is present, plood and serum may accumulate under the flap, delaying the healing process ‘by separating the flap from the underlying hone. This would necessitate healing by secondary intention rather than first/primary intention. Tmadequate suturing may also result in the Map skipping up onto the tooth. Further, the inability to approximate tissue Daps may result in an exposed area of alveolar bone, contributing to necrosis, pain, significant bone Joss, and delayed healing ‘The intricacies of needle design and the: needle’s role in the suturing process will be discussed throughout this text. The following, however, is an introduction to the attributes of various suture materials. THE SUTURE PROCEDURE | @TYING THINGS TOGETHER ‘SUTURE TECHNIQUE Interrupted suture Figure eight suture Sling suture Horizontal matcress suture Vertical mattress Vertical sting matress Continuous indepin- dont sing suture DISCIPLINE UseD Perio, dental implane, and oral surgery Perio and dental implant surgery, extraction sites Perio, dental implant, and oral surgery Dental implant ane oral surgery Perio, dencal implant, and oral surgery Perio, dental implant, and coral surgery, especially when performing guided tissue and bone regenerative techniques Perio, dental implane, and oral surgery TENSILE STRENGTH REQUIREMENTS Minimal co mederate Minimal to moderate Moderate High Moderate High High TYPES OF NEEDLES RECOMMENDED 3/8 reverse cutting, tapered 12 oF 5/8 reverse cutting, ‘tapered 318 reverse cutting. ‘tapered 3/8 reverse cutting, tapered 3/8 reverse cutting, tapered 3/8 oF [/2 reverse cutting, tapered 3/8 reverse cucting, tapered 3/8 reverse cutting, tapered “Restricted areas such as buccal vestibule maxillary molars or mucogingival surgery (eg, soft tssue ratte) 10DIAMETER OF MATERIAL RECOMMENDED 40 40 50 50 40 40 40 10 30 40 30 10 30 40 30 4.0 or 3-0 TYPE OF MATERIAL RECOMMENDED Chromic gut, sik, polytetrafluoro- ethylene (PTFE) Polyester “color” braided, poly- propylene, ‘monoflament nylon Chromic gut, gut Polyester “color” braided, poly- propylene. monafiament nylon Chromic gut, gut, si, PTFE Chromic gu, sik, PTFE Polyester “color braided, poly- propylene, ‘monofilament nylon Polyslycalie acid (PGA) site Chrome gu se PGA sik PGA sik PGA silk RECOMMENDED KNOTS Slip knot Surgeons knot Slip knoe Surgeon's kor Slip knot Slip knot Surgeon's knat Surgeons knot Sp ko Sip eo Surgeon's knot Slip knot Surgeon's knot Slip knot Surgeon's knot Slip knot GENERAL AND SPECIFIC SITUATIONS USED I a J S a a yu e = = w @ 5 5 a Ineerprocmal suturing Flaps not under eension Primarily lingual of mandibulary molar region Use when a flap has only been elevated on one side Used in anterior mandible or posterior region to resist muscle pull. Used te reset muscle pull and closely ‘adapt fps to alveolar bone and eles teeth of dental implants, Can also be sed to apically or coronal positon fps Used co resise muscle pull, closely adapt flaps to bone. regenerative barriers and dental implants, along wich maineaining, approximation of fap edges. Used primarily in edentulous areas such as mandibular anterlor or posterior region to resist muscle pull Used often in dental implant and bone augmentation procedures and in hyperplasticfibrous ridge reduction for denture stably‘Suture Materials Suture materials may be classified as nanresorbable and resorbable. NONRESORBABLE SUTURES 1. SILK These sutures consist of silk Mlaments twisted or braided together to form a strand (Figure 2.1), ‘The braided silk suture is preferred as a result of its superior handling qualities, ‘The advantages of silk sutures are smooth tie-downs and the material's natural elasticity, which ensures knot security. However, sill sucures are nonresorbable and may resull in a "Wick Effect,” which causes the suture material to draw bacteria and fluids into the wound site. Black sifk sutares were previously the most commonly used suture in periodontic and implant surgery as a tesult of their easy visibility and ability to be tied with a stip knot.24 Diagram of the suture strand filaments Diagrammatic representation of the filaments that are twisted or braided together to form a suture strand. 2. POLYESTER Tio types of manufactured sutures are available: monofilament type (nylon used 90% of the time) and polytetrafluoroethylene (PTFE) sutures. The braided strand of these polyester fibers is uniformly coated with a lubricant, which ues and knot improves passage of the suture through tis ‘ing, Further, the polyester fiber and polybutilate coating are biologically inert. However, nylon and polyester sutures are nonresorbable, and the knois are likely to untie due (a the smoothness of the suture material, RESORBABLE SUTURES Resorbable sutures have gained popularity in periodontal and implant surg- eries because they result in less postoperative inflammation and a more com- fortable postoperative appointment, since no obligatory suture Temoval is nec- essazy. Presently, two categories of resorbable sutures are available, natural and synthetic, SUTURE MATERIALS | = w14 4, NATURAL ‘Natural resorbable sutures are broken down by body enzymes and include two types of surgical gut sutures fabricated from processed strands of highly purified collagen: a) plain gut and b) chromic gut. The advantages of surgical gut sunates are thal they are: resorbable, save chairtime at postsurgery appoint- ments, and reduce patient anxiety, since obligatory suture removal has been eliminated. Surgical gut suture material demonstrates mild-lo-moderate tensile strength. The disadvantage is that the clinician should be cautioned not to use this type of suture material if the patient reports a history of epigastric reflux bulimia, Sjigren’s disease, esophagitis, and radiation therapy, which involve exposure of the salivary glands. Due to the lower pH within the oral cawity, this could result in significantly quicker dissolution of these natural tesorbable sutures. A. Plain Gut Plain gut sutures demonstrate only mild tensile strength and lose 50% of suture strength after 24 hours of exposure to intraoral fluids. There is no obliga- tory suture removal, and the resorplion rate is three to five days intraorally. 8. Chromic gut Chromic gut sutures are treated in a chromium salt solution, which conditions the material to resist body enzymes through a prolonged period of time trom. seven to 10 days intraorally. Its primary advantages are that it is resorbable, with a prolonged rate (ie, seven to 10 days). Further, utilization of these sutures saves chairtimne at postsurgery appointments and reduces patient anxiety suture removal is climinated. ‘This suture material maintains approximately 40% to 50% of ils strength for approximately five days. since2. SYNTHETIC RESORBABLE SUTURES Synthelic resorbable sutures are hydrophobic and, therefore are primarily broken down, through the process of hydrolysis (cleavage by water molecules). PGA (Polyslycolic Acid) sutures are fabricated from a polymer of lactide and glycolide, which exist naturally in the body as part of the metabolic process. Since the polymer is also hydrophobic, it slows the penetration of water into the filaments, providing a slower rate of resorption. The advantages of PGA sutures inclu ¢ its resorption, at a rate of 21 lo 28 days intraorally. Additionally, this suture material is inert and elicits only mild tissue reaction. Further, this suture material demonstrates an increased material tensile strength and, therefore, is best utilized when the suture material must resist muscle pull, Poliglecaprone 25 suture is another synthetic: resorhable alternative that demonstrates a 90-day resorption rate intraorally. This suture material exhibits tremendous tensile strength, but 4s very stiff. When properly Ued with a sur- ;on's knot, th ame ds may be abrasive to the patient’s cheek or tongue, depending on the location of che suture knot SUTURE SIZE Suture size refers to the diameter of surface material and is measured in sizes 1-0 to 10-0, with 10-0 having the smallest thread diameter and the least amount of suture tensile strength. Thread size 4-0 is most commonly used in dentistry, ‘Thread size 5.0 is also commonly used in dentistry, but typically for delicate amucogingival surgery. The accepted surgical practice is to utilize the smallest diameter suture that will adequately hold the mending wound tissue, This minimizes trauma as the suture is passed through the tissue to effect closure. The smaller the size of the suture, the less tensile strength the suture will demonstrate. Tensile strength of a suture should never exceed the tensile strength of the tissue il holds. However, sutures should be at least as strong as the healthy tissue. through which they are being placed. wu SUTURE MATERIALSCHARACTERISTICS AND APPLICATIONS OF RESORBABLE AND NONRESORBABLE SUTU SUTURE TYPES ‘COLOR OF MATERIAL RAW MATERIAL TENSILE STRENGTH RETENTION AN YIVO} RESORPTION RATE TISSUE REACTION INDICATIONS) CONTRAINDICATIONS 16 Surgical Gut Pain Yellowish-tan Blue dyed Collagen derived from healthy beef and shesp_ Individual patient characteristics may affeet rate of tensile scrength loss Resorted by proteolytic ‘enzymatic digestive process three to five days Moderate ‘Approximates tissues wich lle tension Resorbable, should fot be utilized where ‘extended approximation of tissues under stress 's required Should not be used in patients with known senskivias or allergies to collagen or chromium Surgical Gut Chromic Brown Blus dyed Collagen derived from healthy beat and sheep Individual patent characteristics may affect rate of tance strength loss Resorbad by proteolytic enzymatic cigestve process saven co 10 days Moderate Approximates tissues ‘with fede cension, perio oneal and other implant surgeries Resorbable, should rat be utilized where ‘extended approximation ‘oftissues under stress Is required Should not be utlzed in patients with known sensitivities or allergies te collagen or chromium Polyglycolic Acid (PGA) Braided Monofilament Violet Undyed (nacura) Copolymer of lactide and plyeolide, Agproximataly 6546 remains at owo weeks ‘Approximately 40% remains at chree: weeks Resorbed by slow hydrolysis Essentially complete between 56 and 70 days Minion Used to resist muscle pull (¢g, horizoneal mattress suture) Rezorbable, should nat be uslized whore ‘extended approximation of tissues is requiredPoliglecaprone 25 Moncfilament Undyed (nacural) Copolymer of aycolide and epsilon ‘caprotactone Approximataly 50% 0 6096 remain a one week Approximately 12036 to 30% remains a ‘wo weeks; lost within three weeks Resorbed by hydrolysis Complete at 91 29 119 days Slight ‘Approximation of tissues ‘without tension for ‘extended period of time Resorbable, should not be utlized where ‘extended approximation of sues under scress it required Braided Black ‘Organie proeein called fibroin Progressive degradation of ber may resule in ‘gradual loss of tensile strength Gradual encapsulation by fibrous connective tissue Acute inflammatory reaction Periodontal surgery Implant surgery, coral surgery Should not be utilized in pacients with known sensithities or allergies tosk Monofilament Nylon Manafilzment Undyed (clear) Black LLong-chain aliphacie polymers Progressive hydralyis may resue in gradu loss of tensile strength Gradual encapsulation by fibrous connective tissue Minimal acute inflammatory reaction Periodontal surgery, implant surgery, oral surgery Should not be utilized where permanent retention of tensile strength is required ~ Peiyestar “color” braided Braided SUTURE MATERIALS [= Green White Polyester palyettyiene ‘erephthalave coated with pobybuciate No significant change known te eceur in vive Gradual encapsulation by fibrous connective tissue Minin sete invlarmmatary reaction Periodoneal surgery. soft cssue grafts None knowsSuturing Needles e Regardless of its intended use, every surgical needle has three: basic components: the attachment end (swaged or eyed); the body: and the point (Figure 3.1). Today, most needles are: permanently attached to the suture material, eliminating the need for threading; the attached “press fitted end, referred to as the swaged end, enables the clinician to draw the needle through tissue more easily and with less tissue: trauma, The measurements of these specific components determine, in part, how they will be utilized most effective! Needle Chard length point al swaged end Three basic components (press-fit) of a surgical needle Presently, every surgical needle has three basic components: the press- Needle length fitted end (swage); the body, referred to as circle size; and the needle point (standard or more tapered, sharp, and delicate). 18Needle size may be measured in inches or in metric units, but inches are the standard in the North American medical industry. A 3/8 circle suuure needle is most commonly uulized in dentistry (eg, oral, periodontal, and implant surgery). A 1/2 cirele suture needle is utilized in areas of restricted space (eg, f measurements determine the size of a needle. Chord length: ‘Ihe straight line distance het and the swage, Needle length: ‘The distance measured along the needle itself from point to end. Radius: The distunce from the center of the circle ta the body of the needle, if or maxillary molars, or when suturing soft issue autografts), ‘The following n the point of a curved needle the curvature of the needle was continued to make a full circle Diameter: The gauge or thickness of the needle wire. Very small needles of fine gauge: are required for microsunget Large, heavy-gauge needles are utilized to ‘penetrate the sternum and (o place retention surutes in the abdominal wall. A broad spectrum of sizes is available between the two extremes Sizes of Suture Needles swage 3/8 circle needle swage | 1/2 circle needle swage 5/8 circle needle o SUTURING NEEDLES |i TYPES OF SUTURE NEEDLES 1. REVERSE CUTTING SUTURE NEEDLES These are the most commonly used needles in periodontal, otal maxillofacial, and implant surgery (Wigure 3.2). These suture needles feature two opposing cutting edges, with a third cutting edge on the outer curvature of the needle (Pigure 3.3), which reduces the danger of ‘cut-out’ (the suture material tearing through the tissues being sutured) (Figure 3.4), Reverse cutting needles are utilized for tough, difficultto-penetrate tissues. Sharp point of the standard or reverse cutting needle (press-fit) Body: Reverse cutting suture needles have a triangular cross section, with the base on the inner portion of the body and the point in arder to create resistance to the suture material when tying the suture knot. Reverse cutting suture needle penetrating tissue Cutting edges Third cutting edge 2034 Resistance to suture pull demonstrated by the reverse cutting needle SUTURING NEEDLES|N Nate the resistance to suture pull created by the reverse cutting needle to prevent “cut-out.” 2. CONVENTIONAL CUTTING SUTURE NEEDLES These needles consist of two opposing cutting edges (Figure 3.5), with the third on the inside curvature of the needle (Figure 3.6). The needle changes ectional shape from a t:iangular cutting tip to a flattened body. in cro: Asa Tesult, conventional cutting suture needles are not utilized in dentistry or implantology, since the cutting edge on the inside curvature tends to pull through the edge of the flap, “cut-out,” being sutured (I'igure 3.7), especially in areas of limited access (eg, oral cavity). Point and body ofa conventional Note the triangular cutting needle le shape of needle tip. Only reverse cutting suture needles should be used in dentistry, because this type of needle prevents the suture material from tearing through the surgical flaps. Needle is square in cross section.22 3.6) Conventional cutting needle has third cutting edge on inside curvature of needle. Third cutting edge of ‘the conventional cutting needle Tissue sliced by sharp inside edge of needle Tearing of the suture material through the surgical flap Suture material tearing through surgical flap, called “cut-out,” created by a conventional suture needle Conventional cutting suture needles are not utilized in dentistry, since the cutting edge on the inside curvature of the needle tends to cause suture material to pull through the edge of the surgical flap. 3. TAPERCUT SUTURE NEEDLES ‘Tapercut suture needles are specifically designes Gelicate tissues (og, soft tissue graft or fascia) (Figure 3.8), The point of this needle has a sharp reverse cutting tip, and all three edges of the tip are sharpened to provide uniform catting action (Figures 3.9 and 3.10). for use on tough and/or3.8) Taper—standard tapered point found on most reverse cutting suture needles (for example, 3/8 circle reverse cutting needles) \ ‘Types of tapered points of surgical needles Blunt not used Tapercut—very sharp point inedentistry used for atraurnatically passing through delicate tissues as needed for mucogingival pro- cedures (eg, 1/2 and 5/8 circle reverse cutting suture needles) 39 Point and body shape of ‘the tapercut surgical needle A tapercut surgical needle has a more tapered, sharp, and delicate needle point for mucogingival surgical procedures. Usually found on 1/2 and 5/8 circle reverse cutting needles with a small-diameter thread size such as 5-0 and 6-0 size suture material The point of this more tapered suture needle has all three edges of the tip more sharpened to easily pierce through either tough or delicate tissues. swage | 3.10 Tapercut needle the sharp reverse cutting tip easily penetrates through Cutting tip and taper body delicate tissues. of the tapercut needle Tapercut needles are especially designed for mucogingival surgery, presently referred to as periodontal plastic surgery. w SUTURING NEEDLES |N4 Suturing Instruments A variety of instruments are utilized in conjunction with suturing (Figure 4.1) | TISSUE PICKUPS ‘These instraments have fine delicate fingers, so they are only utilized to hold, not pierce or crush, the tissue to be sutured. Tissue pliers and forceps are examples of tissuc pickups (Figures 4.2 and 4.3), ‘The needle holder, hemostat, and postoperative scissors are alll crucial surgical instruments used for very different purposes. 2442 4.3) ‘Three types of tissue pickupsforceps are available to the lini Heads of tissue forceps Tissue pickups/forceps are used to handle surgical flaps very delicately. Various types of tissue forceps Plain Tip, (No teeth limits control) 1x2Tip (The single tooth may pierce delicate tissues) Multiple Teeth (preferred tissue pickup) SUTURING INSTRUMENTS) NS I™@ NEEDLE HOLDERS Stainless steel and cungsten carbide inserts (preferred) are: currently available needle holders, 1. SELECTION AND UTILIZATION OF NEEDLE HOLDERS The needle holder must be of an appropriate size for the size necdle: selected and should be constructed from high-quality steel, with a secure jaw design (igure 4.4), Needles should be grasped in an area about 1/3 to 1/2 the dis: tance from the swaged area to the point (Figure 4.5). Placement on or near the swaged area should be avoided. ‘he needle should then be placed securely in the needle holder jaws 2.0 mm to 3.0 mm from the tip (Figure 46), ‘Tb avoid damaging the taper points or cutting edges when using the agedle holder to pull the needle out through the tissue, the needle should be grasped as far back as possible (Figure 4.7). When placing the needle in the tissue, any force should be applicd in the direction following the curve of the needle. The needle should not be forced or twisted to bring the point out through the tissues; the needle should be withdrawn and replaced in the ti Further, a dull needle should not be forced through the tissue; the clinician should stop and use a new sharp needle. ‘The clinician should avoid taking excessive! se, large bites of tissue with ed lo bridge or approximate ussues for suturing, When the ncedle is held too tightly in a sharp or defec- small needles. ‘Ihe needle should not be uti tive neodle holder, it may be damaged or notched in such a manner that it may bend or break on snecessive passes through the tissue, When the needle holder with the needle is passed by the surgeon, the needle should be pointing in the direction in which it will be used, without the need for readjustment, In adeep, confined arca, ideal positioning of the needle may not be possible, and the clinician should proceed with caution or use a heavier ¢ In some patients, the tissues may be tougher or fibrosed more and require the utilization of a heavier gauge needle Currently, most manufacturers of suture needles provide a type of dual packaging that consists of an outer, nonsterile covering (Figure 4.8) and an inner, sterile package to house the suture needle and material (Figure 4.9) Since suturing around teeth or dental implants usually involves the utilization of various suture needle sizes, types, materials, and techniques, the assistant/ nurse can spray the outer package with an ADA-approved disinfectant so that multiple types of sutures can be placed on the surgical tables, but not opened if they are not used, they can be resprayed and returned to the storage shelves. Following :emoval of the suture from the packaging (igure 4.10), addi- tional suture straightening should be minimal. If the suture strand must be straightened, the clinician should hold the armed needle holder and gently pull the strand, ensuring not to disatm the suture from the m and 4.12). le (Figures 4.11assure a firm grip. Optimal position on the needle body for grasping by the needle holder Needle point Suture needles should be grasped in the body portion and not near the point or swage: otherwise, the needle will be damaged. Needle holder with tung- sten carbide inserts Preferred needle holders have tungsten carbide inserts built into the jaws, 50 as not to deform the suture needle when properly used. These tips can be replaced when ‘worn aut. Tungsten carbide inserts Swage (press-fit of thread into the needle) Body of needle where jaws of holder should be placed SUTURING INSTRUM ENTS) BNeedle is grasped 2.0 mm to 3.0 mm from the tip of, the holder. Suture needles should be grasped in the middle of the body portion of the needle, not at the needle point nor the swaged area. ‘The areas of the needle that should not be grasped 1) Sharp point of suture needle4.8) Suture needles are presently sald in a dual package, with the outer portion being nonsterile andl sterile needle and the inner portion ssuture material being sterile. Nonsterile outer package containing sterile needle and suture mate SUTURING nnn 3 Swage end: Bo not grasp with needle holder. Nonsterile outer packaging 4. Once the inner package is removed and the flap that indicates “Open here” is pulled, the suture needle and material are exposed. Proper removal of the suture needle and material from Body of needle where the sterile inside holder should grasp packaging Pull this area to expose suture material Sterile inside packagingThe sequence for proper removal of the suture needle and suture from the packaging Needle holder grabs body, not swaged portion of the needle. Body position of suture needle is grasped by the needle holder. Grasping of the suture and material by the needle holder When straightening a suture strand, both the suture needle and material must be grasped by the needle holder, so as not to pull the suture material from the swage (press fit). 30Suture straightening involving surgical gut-type sutures | HEMOSTATS Hemostuts are utilized to clamp olf blood vessels, remove small root tips, and grab loose objects and surgical sponges (Figure 4.13). Hemostats should never be used to grab suture needles. Hemostat for clamping off blood vessels or grabbing loose objects w SUTURING mraemen@ SCISSORS A variety of scissors are available, including curved and other postoperative models (Figures 4.14 through 4.16) 414 Curved scissors with small narrow beaks for tissue and suture removal Serrated blade of the scissors preventing tissue or suture slippage Preferred type of surgical scissor cutting edges to be used to thin the inner side of the surgical flap and suture material Postoperative scis- sors for removal of nonresorbable sutures Notch utilized to lift suture material from tissue 32SUTURING INSTRUMENTS SUMMARIZED INSTRUMENT Tisue pickupsforceps Needle holder Roverse curing suture needle ‘Curved selesors Postoperative scissors UTILIZATION EXAMPLE Delsey tne pagel tps a Hold needle during procedure Perce issue Clamp blood vessels, remove small root tips 0 Tissuefsuoure removal “ Removal of nonresorbable sutures eo ¢ SUTURING meme i34 Suturing Techniques ‘Sutures arc generally placed distal to the last tooth and in each inter- proximal space. They should always be inserted through the more mobile tissue flap first A circular form of the needle is used duc to the restricted space in the mouth. Suture needles are grasped only by needle: holders, and are inserted and pulled Uhrough the tissue in line with the circle. The suture is pulled just tightly enough to secure the flap in place without restricting blood supply, The flaps should not be blanched when tying a suture. Sutures should be placed no closer than 2.0 mm to 3.0 1mm from the edge of the flap to prevent tearing through the flap during the swelling that occurs 24 to 48 hours postoperatively,When suturing, the needle is grasped in the center with a needle holder. The needle shoulder should be placed a few millimeters from the tip of” the needle holder; grabbing the notdle at the junction of the needle and suture (swage) should be avoided (Figure 5.1). ‘When penctsating through ussues, the needle should enter at right angles to the tissue, The goal when suturing multiple tissue levels is to suture ulilizing a periosteum-to-periosteum and tissue-to-tissue technique, similar to what is performed when suturing the site from which a biopsy was obtained. This technique, as outlined below, is required for periosteal suturing, Proper location on the needle body for grasping by the needle holder Swage (press-fit of thread into the needle) Needle point Body of needle where jaws of holder should be placed Suture needles should be grasped in an area 1/3 to 1/2 the distance from the swaged area to the tapered point of the needle. SUTURING TECHNIQUES | B36 @ PERIOSTEAL SUTURING TECHNIQUE In this procedure, the needle point is positioned perpendicular (90°) to the tissue surface and underlying bone (Figure 5.2) and is then inserted completely through the tissue until the bone is engaged (igure 5.3). The body of the needle is then totated about the needle point in a direction opposite to thar in which the needle is intended to travel (Figure 9.4). ‘he needle point is held lightly against the bone to avoid damaging or dulling it, The needle point is then glided against the bone for a short distance. Care rnust be taken not to lift or damage the periosteum. As the needle glid about the body, following its circumferenced outline (Figure 5.5), In this man- ner, the needle will not be pushed through the tissue (Figure 5.6), preventing lifting or tearing of the periosteum. ‘he final slage of gliding and rotation is against the bone, it is rotated needle exit through the gentle application of pressure from above, thus allow- ing the tip to pierce the tissue (Figure 5.7). Lf digital pressure is utilized, care must be taken to avoid personal injury. Penetration of the suture needle ‘through the gingival tissue to the periosteum 5.3 The periosteal suture tech- nique involves penetrating the periodontal/peri-implant tissues and periosteum all the way to the bone, followed by rotation of the needle back toward the direction it started, while penetrating through the periosteum again, then back through the keratinized tissues, Suture needle periosteum to the bone penetrating the54) A 180° rotation of the needle grabbing the periosteum y ‘4 The needle is 10 moved along the bone below the periosteum. Rotation about the needle body, permitting the point to exit the periosteum and tissue Sagittal view of a completed periosteal suture einai e ees SUTURING “me s38 | Ml SIMPLE LOOP MODIFICATION OF INTERRUPTED SUTURE TECHNIQUE The simple loop modification of the interdental technique is utilized when facial and lingual flaps have been elevated and is the most commonly used suturing technique in dentistry. To successfully utilize this technique, the clinician should 1. Fass the needle through the facial flap from the outer (epithelial) surface (Figure 5.8). 2, Pass the needle under the contact point (Figure 5.9). 3. Pass the needle through the lingual flap from the inner surface (Higure 5.10). 4. Pass the needle under the contact point again. 5. Ti¢ on the facial surface: of the tooth so that the knot is not in the line of the incision (Figure 5.11) 6. Cut suture material 2.0 mm to 3.0 mm from the knot (Figures 5.12 and 5.13). This can easily be accomplished by clamping just above the surgical knot with the needle holder, and then cutting the suture material just above the needle holder jaws, initial needle penetration through the buccal flap at the papilla base Passage of the needle under the contact pointThe simple loop type of inter- rupted suture technique is used to approximate/coapt surgical flaps only, not to resist any sort of flap te This technique approximates/coapts the surgical flaps without interposing suture material between the tissue flaps. This technique will not allow resistance of tension from muscle pull Needle passage ‘from the inner surface through ‘the lingual flap SUTURING TECH woes 5.11) Tying of the suture knot on the buccal flap No suture material demonstrated between the surgical flaps Suture knot tied ‘on the buccal aspect of the surgical flap© FIGURE 8 MODIFICATION OF INTERRUPTED SUTURE TECHNIQUE The figure 8 modification of interrupted suture technique is utilized in very restricted areas (ic, lingual second molar} (Figures 5.14 and 5.15), To successfully utilize this technique (Figures 5.16 through 5.20), the clinician should: 1, Pass the needle through the facial flap from the outer (epithelial) surface (Figure 5.21), 2. Pass the needle under the contact point. 3. Reverse the needle and onter the lingual flap from the epithelial (outer) side (Figure 5.22), 4. Pass the needle back under the contact point (Figure 5.23). 5. Tic the suture on the facial surface so that the knot is not in the line of the incision. 6. Cul suture material 2.0 mm to 3.0 mm from the knot. Although the figure 8 modification suture technique interposes suture material, usually with a 40 size thread material, the sumgical flaps are still coapted to allow primary closure of the flap edges (Figure 5.24) Initial needle penetration— figure 8 modification of the interrupted suture technique Top view of the itial steps during ‘the figure & modification of ‘the interrupted suture techniqueThe second step involves passing the suture needle under the cantact. 5.17 The third step involves making the second needle penetration, which is through the outer surface of the lingual flap. Note that the second needle penetration is through the outer surface of the lingual flap, not the inner surface, as is the case with the simple loop interrupted suture technique. 5.18. Fourth step of the figure & modification of the interrupted suture ‘technique The suture needle and material are passed back under the contact point and the knot is tied at ‘the buccal aspect of the buccal flap. SUTURING TECHNIQUES | &42 This technique coapts tissue, as does the simple loop tech- nique, but interposes suture material between the tissue flaps being sutured. Note that the suture thread is interposed between surgical flaps. The final step of the figure 8 modification of the interrupted suture technique is the knot- ting of the suture on the buccal aspect of the buccal flaps. Passage of the needle through the facial flapReversal of the needle to enter the lingual flap Passage of the needle under the contact point Coaptation of the surgical flaps allows primary closure of the flap edges w SUTURING TECHNIQUES)CONTINUOUS SUTURES As the name implies, continuous sutures are utilized to join twe or more inter- dental papillae of the same flap and are usually chosen when the buccal flap is sutured med. jerately from the Iingual flap, or when no lingual flap is pe Ina continuous suture, the suture needle is first passed through an interdental papilla on the buccal aspect of a flap or where there is a large edentulous area tobe sutured. The needle is then passed through the interdental space to the lingual or palalal aspect, where it engages the lingual /palatal surgical Qap 3.0 mm from the edge of the flap, and a suture knot is tied (Figures 5.254, B, G, D). The needle is passed under the contact point (if applicable), where it repene- trates the buccal flap 3.0 mm from the flap eds and approxim: lateral from the previous needle peneiration, The needle is again passed under the contact point and penetrates the lingual /palatal flap from the immer aspect of the lingual flap 3,0 mm from the flap edge and 5.0 mm lateral to the previous al flap. This sequence is repeated until the end jan may tie the suture by providing some slack penetration of the lingual. of the incision, where the clin in the last loop and utilizing this loop of suture material as the Lag end with which to tie a knot (Figure 5.26) Continuous sutures may also be utilized to secure: flaps that extend from. two to several interdental spaces. Lf the lap involves many ceath, it is tied differ ently. First, a knot is tied at the most distal extent of the flap. Then the surgeon may He the suture at che mesial end by providing some slack in the last loop and utilizing this loop of suture material as the tag end with which to tie a knot. In addition, continuous sutures may be utilized to position flaps either coronally or apically, depending upon the tightness of the knot, Assuming die flap extends beyond the mucogingival junction, a tight knot will pull the Dap whereas a loose knot will enable the flap to be coronally raped apically. 1, ADVANTAGES OF CONTINUOUS SUTURES 1. May involve as many teeth as required Minimizes the utilization of multiple knots Employs teeth to anchor the flap Enables precise flap placement wRON Avoids utilization of periosteal sutures Enables independent placement and tension of buceal, lingual, or palatal flaps 2 2. DISADVANTAGES OF CONTINUOUS SUTURES Tf the suture breaks, the flap may become loose or the suture may come untied from rnultiple: teeth The choice of continuous sutures depends on the operator's 1 and includes: continuous locking sutures; mattress sutures (vertical ar hori- zontal); and independent sling sutures. mee,Initial step— continuous suture technique This technique is used to secure flaps over several centimeters long. tt also may be utilized to reposition surgical flaps apically ‘or coronally. The needle penetrates through the outer surface of the buccal flap 3.0 mm from the flap edge and then penetrates through the inner surface of the lingual flap just coronal to the level of the mucogingival junction. The distance between the needle penetration on either the buccal or lingual sides. should be 5.0 mm Sequential steps— continuous suture technique Tap view af sequential steps involved in the continuous suture technique » uw SUTURING TECHNIQUESCompleted continuous suture ‘The suture knot is tied at the most mesial extent of the surgical site. 3. CONTINUOUS LOCKING SUTURE TECHNIQUE The continuous locking suture is indicated primarily for long edentulous areas, tuberosities, or retromolay areas. To successfully ulilize this technique, the clinician should: 1. Complete a single interrupted suture first (Figure 3.27). 2. Insert the needle through the outer surface of the buccal flap and the underlying surface of the lingual flap 3. Pass the necdle through the remaining loop of the suture (Figure 5.28), and pull the suture tightly (Figure 5.294), thus locking it (igure 5.298) 4, Continue this procedure until the final suture is tied off at the terminal, endl (Figures 5.30A through D, 5.31) Initial step— continuous locking suture technique The suture needle pene- trates the outer surface of the buccal flap and then through the inner surface of the lingual flap, followed by a suture knot tied at the most distal extent of the surgical flaps. 46The lacking portion of this suture technique is formed when the nee- dle, after emerging through the lingual lap, is passed through the remaining laop of the suture, then pulled tightly, thus locking it. Elements of the continuous locking suture technique The locks are usually placed on the buccal aspect of the surgical site and are best used for long edentulous areas, tuberosities, or the retromolar area. Pulling of the suture material “Locking” of the suture material The procedure is continued until the final suture is tied off at the mesial end. > a | | SUTURING TECHNIQUES}Top view of a continuous locking suture The continuous locking suture will be termina- ted at the mesial end by providing some slack in the last loop and utiliz- ing this loop of suture material as the tag with which to tie a knot. Tying of the suture knot on ‘the buccal aspect 484. CONTINUOUS HORIZONTAL MATTRESS SUTURE TECHNIQUE ‘This suture technique enables greater flap security by approximating the everted surgical flap edges while concomitantly resisting any tension of the flaps from the associated muscle attachments, Tb successfully utilize this technique, the cli- nician should: 1, Pass the 3/8 circle reverse: cutting needle at the distal end of the surgical site (Figure 5.32). 2. Penetrate with the needle 3.0 mm from the flap edge through the outer surface of the buccal flap, and then darough the inner surface of the lin- gual/palatal flap 3.0 mm from the flap edge. 3. Tie the suture knot on the buccal aspect of the buccal flap and cut the short end of the suture material 3.0 mm fram the knot 4, Subsequently penetrate with the needle just above the level of the mucogingival junction and 5.0 mm lateral in a mesial direction to the first penetration of the buccal flap. contact point, piercing through the inner side of the lingual flap, emerging just above the level of the mucogingival junction (Figure 5.33), 6. Repenctzate the outer surface of the lingual flap again at the level just above the mucogingival junction, but 5.0 mm lateral in a mesial direction to the previous penetration (Figure 5.34). 7, Pass the needle under the contact point and penetrate the inner surface of the buceal flap just above the Level of the mucogingival junction and 5, Pass the needle under tl 5.0 mm lateral in a mesial direction to the previous needle penetration on that side of the surgical lap. 8. Follow steps 4 to 6 (Figures 5.35A and B). 9. Tie the suture knot on the mesial end of the incision by leaving some slack in the suture, creating a loap. This loop should then be utilized as the tag end with which to tie the knot (Figure 5.36). Needle penetration through the buccal flap—continuous horizontal mattress: suture technique SUTURING TECHNIQUESNeedle penetration through the outer surface of buccal flap, then through the inner surface of lingual flap The suture needle penetrates the outer surface of the buc- al flap and then through the inner surface of the lingual flap, followed by a suture knot tied at the most distal extent of the surgical flap. Repenetration of the lingual flap View demonstrating knot at the distal end Note the distance between the needle penetrations on either the buccal or lingual flap should be at least 5.0mm. 50Top view of the last step in the continuous horizontal mattress suture technique This technique closely approximates while also slightly everting the edges of the surgical flaps. This suturing tech- nique affords the abili to resist being pulled apart by the tension cre- ated by muscle attach- ments associated with the surgical site. Completed closure of the surgical incision MATTRESS SUTURE TECHNIQUE Mattress sutures are utilized for greater Map security and control and enable ‘more pre + flap placement, especially when combined with periosteal stabi- lization. The mattress sutures are mostly utilized to resist muscle pull, adapt the surgical flaps to the underlying bone, regenerative barrier, implant and/or tooth, and evert the surgical flap edges. They also facilitate good papillary stabi- lization and placement. The: vertical sling mattress suture is recommended for utilization with bone regeneration procedures, since it resists muscle pall in the surgical area and permits maximum tissue closure while avoiding suture contact | with the implant material. SUTURING TECHNIQUES| U1 | 152 1. VERTICAL MATTRESS SUTURE TECHNIQUE "Tp successfully utilize the vertical mattress suture technique, the clinician should: 1 3. x Penetrate the tissue flap from the outer surface, 4,0 mm to 6.0 mm from the flap margin, just above the level of the mucogingival margin, with the lip of the needle ina coronal direction (ie, the buccal flap is penetrated from the buceal surface) (igure 5.37), Pass the needle under the contact point. Penetrate the inner surface of the lingual surgical flap 4.0 mm to 6.0 mm from the flap edge, and then repenetrate the outer surface of the lingual flap 2.0 mm to 3.0 mm from the flap edge (Figure 5.38). Pass the needle back under the contact pore (Figure 5.39) Pencerate the buccal surgical flap from the inmer surface, 2.0 mm to 3.0 mm from the flap margin (Figure 5.40). Tie on the surface of the original suture penceration, which should be ‘the buccal surface. ‘Cut the suture material 2.0 mm to 3.0 mm from the knot (Figure 5.41), Vertical mattress suture technique— initial penetration of the suture needle into tissue of the initial steps involved in the vertical mattress suture technique Needle penetration of the buccal flap emerging through the lingual flap vertical mattress suture technique% F sage of the Tuatlle back under ct point The suture needle [flpassed back through the conta) "area and the needle penetrates | inner surface of the buccal flap, Bmnerging through the bucea_urgical flap 3.0 mm from the4 > edge. ‘teps involved in he vertical mattress uuture technique This telfrique adapts the tis to the tooth or iemplarggiwhile concomi- tantly Beerting the flap edges. fis suture tech- nique 1 resist tension in the fla produced by var- ious m de attachments. Completed vert mattress sutu technique "ass 5 1G 8 3 TECHNIQUES |W1 w IN SUTURI is passed ba ct area and 1 the inner su emerging | surgical fia ‘lap edge. chnique aday sue to the to ‘t, while cone everting the This suture will resist ter Ps produced uscle attach ical2. CORONALLY REPOSITIONED MATTRESS SUTURE ‘To successfully utilize this technique, the clinician should: 1, Penetrate the tissue flap from the outer surface, 4.0 mm to 6.0 mm from the flap margin, with the tip of the needle in a coronal direction (ie, the buccal Map is penetrated from the buccal surface) 2. Penetrate through the surgical flap from the inner side, 2,0 mm to 3.0 mm from the flap maxgin (Figure 5.42). 3. Pass the needle under the contact point. 4, Penetrate the lingual flap from the outer surface, 4.0 mm to 6.0 mm from the flap margin, with the tip of the needle in a coronal direction. 5. Repenetrate the undersurface of the Dap, 2.0 mm to 3,0 mm from the flap margin (Figure 5.43) 6, Pass the necdle through the interproximal area beneath the contact ‘point 7. Tie the knot on the surface of the original suture penctration, which should be on the buceal surface. 8. Cut the suture material 2.0 mm to 3.0 mm ftom the knot (Figure 5.44). This method of suturing will slighiy repos ion the tissues caronally. 5.42 . Initial needle pene- tration through the buccal surgical flap Note that the initial needlle penetration through the buccal surgical flap is at the level of the mucagingival junction and then the needle travels coronally to emerge at the base of the papilla or 3.0 mm from the flap edge. Repenetration through the buccal surgical flap Suture knat on the buccal aspect of each tooth 54‘To apically reposition the flap using this suture technique, move the tip of the needle in an apical direction as the needle penetrates through the tissue. This is known as a reverse vertical matiress suture (Figures 5.45 through 5.49). 5.45. Apical repositionina/ reverse vertical mattress suture technique Suture needle pene- tration through the lingual surgical flap Diagram of the reverse vertical mattress suture technique SUTURING TECHNIQUES | aTying of suture knot on buccal aspect of surgi- cal site Completed suture knot— apically repositioned vertical mattress suture technique 3, HORIZONTAL MATTRESS SUTURE TECHNIQUE To successfully utilize the horizontal mattress suture technique, the clinician should: 1, Utilize a 8/8 circle reverse cutting needle. Penetrate the buccal surgical flap just above the level of the mucogingival junction, approximately 5.0 mm distal to the object being sutured around (ie, tooth, dental implant, regenerative barrier). A 3.0-mm size suture is recommended, but if not available at the Lime of surgery, a 4.0mm size suture may be used. 2. Pass under the comlact. 3. Penetrate the inner surface: of the Hap just above the level of the mucogingival junction, emerging through the outer pithelialized sur- face, again 5.0 mm Tateral (to the side) of the object being surared (Figure 5.50)4, Penetrate the outer surface just above the level of the mucogingival junction, 5.0 mm from the other side of the object being sutured, so that the suture material forms a horizontal tine approximately 10.0 mm in length (Figure 5.51). 5. Pass under the contact (Figure 5.52). 6. Fenetrate the undersurface of the flap just above the level af the mucogingival junction, 3.0 mm lateral to the object being sutured (Figure 5.53). 7. Tie the suture buceally (Figure 5.54). Initial steps of the horizontal mattress suture technique 5.0 mm laterally from the object (ie, tooth or implant) being sutured. Third step—needle Penetrations 5.0 mm lateral to either tooth or implant Note that all needle penetrations are at least 5.0 mm lateral (mesial o distal) to either the tooth or dental implant. Note that needle penetrations at the level of the mucogin- gival junction and are at least } 1 a o > g 2 = o a B @ =| = 3 = 3 a58 Final steps— horizontal mattress suture technique Diagram of the steps for the horizontal mattress suture ‘technique Completed horizontal mattress suture4, VERTICAL SLING MATTRESS SUTURE TECHNIQUE 1 2 3 4 See Section 1 Follow steps 1 to 5 (Figures 5.55 and 5.56) Pass the needle back under the contact. Pass the needle and suture through the loop created by the vertical mattress suture on the lingual aspect of the lingual surgical flap (Figure 5.57). Pass the needle back under the contact (Figure 5.58). Be sure when tightening the suture material that the newly created sling/loop is tightened onto the: Lingual aspect of the lingual flap and ‘not pulled over to and tightened on the buccal flap. ‘Tic the knot on the surface of the original suture penetration, which should be the buccal surface. Cut the suture material 2.0 mm to 3,0 mm from the knot (Figure 5.59) Initial steps of the vertical sling mattress suture technique Steps 1 through 4 are the same as those performed during the vertical mattress suture technique. Sequence of steps— vertical sling mattress suture technique uw ) SUTURING TECHNIQUES |Final step—vertical sling mattress suture technique Note that the suture material is being passed back under the contact point and through the loop on the lingual aspect of the surgical site. The suture material must be tightened so that the sling rem; the lingual flap. son Components of the vertical sling mattress suture technique Completed vertical sling mattress suture is technique should be used for all interproximal guided tissue/bone regenerative procedures. 60@ SINGLE INTERRUPTED SLING SUTURE TECHNIQUE ‘The interrupted sling suture technique is indicated when a flap has been elevated on only one side of the arch (ie, facial flap reflected, but not palatal) or when facial and lingual flaps are to be positioned at different levels. This ‘technique involves only two papillae, ‘Ib successfully utilize this technique, the clinician should: 1. Pass the needle through the outer surface of the more mesial papilla (Figure 5.60). 2, Move the suture around the tooth. 3. Pass the suture needle under the distal contact point of the same tooth (Figure 5.61). 4, Penetrate the flap with the suture needle from its inner (connective tissuc) side (Figure 5.62). 5. Pass the needle back under the distal contact point, around the tooth, under the mesial contact point, and tie a knot (Figure 5.63). 6. Cut the suture material 2.0 mm to 3.0 mm from the knot Repeat steps 1 through 6 to secure an opposing flap. Needle pene- x tration is dependent upon the desired positioning of the flap (ie, coronal or apical) Single interrupted sling suture technique— buccal view This technique is used to adapt the flap being sutured around the object (ie, taoth or implant). ‘Always start on the mesial aspect of the surgical site. 5.61 Suture needle encircling the tooth—buccal view Note that the suture needle encircles the tooth prior to passing under the distal contact point. SUTURING TECHNIQUES |@¥Passage of the suture needle under the contact point and through the buccal flap Note that the suture needle penetrates through the inner surface of the buccal flap at the base of the interdental papilla, followed by passing of the needle back through the distal contact point. Final steps—single interrupted sling suture technique @ SLING SUTURE ABOUT SINGLE TOOTH The sling suture is ulilized primarily for a flap that has been taised on only one side of the tooth and involves only one or two adjacent papillae, It is most often utilized in coronally and laterally positioned flaps and zequires one of the | interrupted sutures, which is either anchored about the adjacent tooth or stung around the tooth to hold both papillae (Figures 5.64 through 5.69)Lateral view, initial steps— sling suture about a single tooth suture technique Note that only one side, buccal or lingual, has been reflected. A3/8 circle reverse cutting needle passed under the contact pi ‘The 3/8 circle reverse cutting needle is first passed under ‘the distal contact point of ‘the most distal interdental papilla, then the suture nee- le pierces through the inner side of the elevated al flap 3.0 mm from ‘the tip of the papilla. Passage of the suture needle back under the contact point w SUTURING TECHNIQUES |ONPassage of the suture needle, piercing the surgical flap The suture needle is then passed under the next contact point in a mesial direction, and then the needle pierces through the inner surface of the elevated surgical flap 3.0 mm from the tip of the interdental papilla. Passage of the needle back under the contact point Tying of the suture knot on the nonelevated tissues 64@ INDEPENDENT SLING SUTURE TECHNIQUE safully wilize this technique, the clinician should: L. Create a looped suture about the terminal papilla (buccal, linguall, or palatal). 2. Continue the suture through the next interproximal embrasun cling the neck of the tooth. 8, Pass the needle either aver the papilla and through the outer epitholial- ized surface, or under and throngh the connective tissue undersurface of the papilla 4, Pass the needle through the embrasure again and continue anteriorly, 5, Repeat this procedure through each successive embrasure until all papillac have been engaged. 6, Utilize a terminal end loop if a single Map has been reflected, or if the flaps are to be sutured independently. 7. Tie off the suture against the tooth, as opposed to the other flap, by leaving a loose loop of approximately 1.0 cm of suture material prior to the last embrasure. 8. Tie the final knot with a terminal end loop when the last papilla is sutured and the needle is returned through the embrasure, @ CONTINUOUS INDEPENDENT SLING SUTURE TECHNIQUE ‘The continuous independent sling suture technique is indicated for a flap with three or more papillae on only one surface, suich as the buccal or Lingual. This technique is an extension of the vertical sling suture technique. Tb successfully ‘utilize this technique, the clinician should: 1, Begin on the distal aspect by tying an interrupted suture and cutting the short end only (Figure 5.70) 2. Pass the needle under the contact point Lo the opposite side (ie, if initiated on the buccal, pass through to the lingual). 3, Loop the needle and thread around tooth (ie, lingual side) (Figure 5.71) 4. Pass the needle through the next intendental area helow the contact point (ie, toward the buccal) without penetrating tissue flap (Figure 5.72). 5, Penetrate the flap from the outer surface (ie, from the buccal toward the bone). 6. Repeat the procedure until the last interdental area, with the needle ending, on the side opposite the flap (ie, lingual) (Figures 5.73 and 5.74) 7. Prior to tying the suture, adjust the suture tension along the length of flap in order to obtain the desired flap position 8, To tie the suture, leave a loop 15.0 mm to 20.0 mm in length on the flap side of the last tooth during the final pass through (Figure 5.75). 9, Utilizing a needle holder, the slack suture material is handled as if it were a free end suture and tied in the usual manner on the side opposite the elevated mucoperiosteal flap (Figures 5.76 and 5.77) 10. Cut the suture material 2.0 mm to 3.0 mm from the knot (Figure 5.78). on un SUTURING TECHNIQUES |Initial needle penetration— continuous independent sling suture technique This technique is utilized to adapt the buceal and lingual flaps without tying the buccal flap to the lingual flap. With this technique, the teeth or dental implants are used to suspend each flap against the bone. Second step—needie penetration through tthe inner surface of buccal flap Note at the distal end a suture knot was made while cutting the short end of the suture, The long end of the suture with its suture needle has then passed through ‘the next distal most contact point from the lingual side of the teeth. The needle then penetrates the inner surface of the interdental papilla at the level of the base of the papilla. Third step—suture loop encircling lingual of tooth Note that the 3/8 circle reverse cutting needle emerges through the outer surface of the interden- tal papilla. This forms a loop of suture material that encircles ‘the lingual surface of the teeth being suturedFourth step—needle passage under contact point to inner surface of pa The suture needle is passed back through the interdental contact point. The needle then passes through the contact of the next most distal tooth, The needle penetrates the inner sur- face of the interdental papilla and emerges through the outer surface of the papilla. This again forms a loop of suture that encircles the lingual of the toath being sutured. Formation of continuous suture loops around lingual of teeth Repeat steps 3 through 5 until the last tooth to be sutured. Passage of suture needle through contact point Note the large loop of suture material left on the gual aspect. This loop will serve as the terminal end of the suture. SUTURING TECHNIQUES | sNeedle holder grasping loop around the last sutured tooth The needle holder grabs the loop around the last tooth to be sutured, after having the suture needle and remaining suture wrapped around the needle holder in either a clockwise/counterclockwise direction. The direction depends on the type of suture material itself, Tightening of the suture around the lingual surface The suture is tight- ened around the lingual surface of the last (most mesial) tooth to be sutured. Completed continuous independent sling suture technique 68| &@ CROSS (CRISSCROSS) SUTURE ‘This technique is a variation of a continuous mattress suture in which the mattress sutures are placed horizontally, not vertically, and is particularly helpful in mucogingival surgery where root coverage is desired. When utilized at an edentulous space with buccal and lingual flaps, the suture needle enters the buccal flap at the distobuccal line angle and exits the buccal flap at the ‘mesiobuccal line angle (Figure 5.79). The same maneuver is duplicated on the Jingual or palatal aspe¢ Jine angle and exits through the mesiobuceal line angle, The knot is tied and will form a cross on top of the flap (Figure 5.80). This is especially useful with and then the needle enters the flap at the distobuccal extraction and socket pre: servation procedures, Initial needle penetration through buceal flap— crisscross suture This suture is used over edentulous ‘spaces. When beginning this tech- nique, a 3/8 circle needle penetrates at the level of the mucogingival junction at the mesiobuccal line, ‘travels horizontally under the flap, and emerges at the distobuceal line angle. The procedure is dene on the lingual aspect. Tying of suture knot on buccal aspect forming a cross on the flap Note when this suture is tied, the suture material crosses over the surgical field. SUTURING TECHNIQUES| 3 |70 ‘Surgical Knotting Tec niques ‘Of the more than 1,400 knots described in the encyclopedia of knots, only a limited number are utilized in dentistry and implantology to approximate oral tissues, ‘The type of knot employed is dependent upon the suture material utilized, the depth and location of the inci- sion, and the amount of stress to be placed upon the wound post- operatively, Mullifilament sutures, for example, are generally easier to handle and tie than monofilament sutures. Additionally, prolene sutures, unlike many other polypropylene sutures, permit a controlled degree of stretching prior (o breaking, All synthetic sutures require specific knotting techniques. Llowever, the greatest variable factor affecting knot security is the human factor, and it has been proposed that knot security is a much more variable characteristic dhan the breaking strength of the suture. Further, it has been suggested that there is considerable variation between knots lied by different individuals and even between knots tied by the same individual at different times.The clinician must work slowly and meticulously. Speed in knot tying frequently results in leas than desirable placement of the suture strands, When ‘ying a knot, the practitioner must consider the amount of tension being placed upon the incision and must account for postoperative ederna. ‘CONSIDERATIONS FOR CONVENTIONAL KNOTTING TECHNIQUES An important aspect of good suturing is the method of knot tying. A seesaw ‘motion (when one suture strand saws down over the other while the knot is formed) usually weakens suture material to the point that it may break when the next throw is made, or during the postoperative period when the suture is further weakened by increased tension, motion, or decreasing tensile strength. In order to assure that the suture knot will be tied more securely, the twa ends of the suture should be pulled in opposite directions at a uniform rate and with uniform tension. ‘The general principles of knot tying which ave applicable to all suuare materials follow. 1. The completed knot must be firm to prevent any slippage 2. The simplest knot, based upon the sucure material utilized, is the most desirable, 3. The knot should be tied as small as possible, with the ‘cut as short as possible (2.0 mm to 3.0 mm) 4, When utilizing surgical instruments in instrument tics, care should be taken to avoid damaging the suture material and needle. 5. Exe avoided. Practic ends (ears) sion, which may break sutures and cut tissue, should be contributes to successfull ulilization of finer gauge materials 6. Sutures employed for tissue approximation should not be tied too Ughtly, since this may contribute to tise strangulation (‘Approximare—Don’t Strangulate") 7. action at one end of the strand should be loop is tied +o avoid loosening the throw maintained alter the first 8. The final throw should be made as nearly horizontal as possible. 9. The suture stance or position in relation to the patient may be modi- fied in order to place a knot securely and flat 10. Extra throws of the suture do not increase the strength of a properly tied knot, only its bulk SURGICAL KNOTTING TECHNIQUES | JKNOTTING CHARACTERISTICS OF SUTURES ‘The coefficient of friction (in monofilament sutures), which affects the tendency of the Imot to loosen after it has heen tied, is relatively low. Greater friction results in a more secure knot, Many surgeons have experienced the loosening of a carefully tied monofilament nylon knot. In larger sizes, monofilament nylon sutures are the most likely to slip. When knot security is critical, synthetic multifilament or braided sutares are advocated. When utilizing muliifilament resorbable sutures (polyglycolic acid) and nontesorbables (silk), the knots do not tend to slip, since braided/ twisted construction provides a high coefficient of friction. Variability in knot strength among multifilament sutures may result from the mode in which the material was fabricated (ie, braided or twisted), 1. KNOTS ‘The purpose of knots is to join the two ends of the suture in a secure but gen- Ue manner. Knots are held by the friction of the suture material, and different suture materials will require different types of knots, Knots must be placed tighly enough to prevent slippage and loosening of the Hap, but not so tightly as to blanch the tissues, which may compromise the blood supply and cause. flap necrosis. Knots arc generally placed on the buccal aspects of flaps, where they are less likely to irritate the patient's tongue. There are three types of knots that are useful to the periodontal surgeon: the square knot, the slip or *granny* knot, and the surgeon's knot. A sutured knot has three components: 1. The loop created by the knot. 2. The knot itself, which is composed of a number of tight “throws"; each throw represents a weave of the two strands (Figure 6.1), 3. The ears, which are the cut ends of the suture (Figure. 6.2) 6.1 Ears Tension —7 ‘Tension Knot components prior to tying LoopKnot 3.0 mm length Knot components— completely tied suture knot Loop ' A, Square Knot This is a simple k 1 tie and consists of two overhand knots, each completed in opposite directions. ‘Ihe first overhand knot is achieved by making a loop cover the jaws of the needle holder, grabbing the tag end of the suuure material, and pulling the knot snugly to the flap. A second overhand knot is then made ‘by creating a loop under the jaws of the needle holder again, grabbing the tag end of the suture, and tightly pulling the ovo ends of the surure (Figures 6.3 and 6.4}. 6.3 6.4 View of a square knot This suture knot is made by tying two overhand knots, each done in opposite directions. For example, the first loop is. made by making a loop over the jaws of the needle holder, and the second knot is subsequently made by forming a loop under the jaws of the needle holder. Square knot Completed square knot This knot is easy to tie, but may loosen when a synthetic or monofilament suture material is used. ~d w SURGICAL KNOTTING TECHNIQUESB. Slip Knot ‘This extremely usefill knot is sometimes called a granny knot, A variation of the square knot, it is achieved with two single overhand knots, With the slip knot, however, both overhand knots are made in the same direction, ‘Ihe first overhand knot involves making a loop over the needle holder, grabbing the free end of the suture, and pulling the ends tight, ‘Lhe second overhand knot is made in the same manner, so that the loop aguin goes over the needle holder Once tied, this knot can be tightened further. Once tightened to the desired extent, it can be locked into place by another overhand knot, made in the opposite direction of th rst two (INigures 6.5 and 6.6), es slip The slip knot is similar to a knot square knot in that it is made | with two overhand knots, but both knots are made in the Ears Ears same direction. With a needle holder, one overhand knot is made so that the loop forms over the jaws of the needle holder and is then tightened. slipigranny knot A second overhand knot is ‘Two overhand knots then made so that the loop goes in the same direction ‘over the needle holder and is tightened. Loop: 6.6 The slip/granny knot is advantageous, since when the second overhand knot is tied, the knot can be tightened even further and locked into place with one Slip/granny knot additional overhand knot Completed going in an opposite slipfgranny direction. knotC. Surgeon's Knot ‘The surgeon's knot. fied square knot with two overhand knots, cach completed in opposite direc tions. The first knot, however, is a double overhand knol, and the second is a single, Doubling of the first overhand knot prevents slippage and loosening, especially when the flaps are under tension (Figures 6.7 and 6.8), he most commonly used in implant surgery —is a modi- Surgeon's knot This knot is used primaril | braided suture material, whether synthetic or natural. The surgeon's knot is a modified square knot in which the first overhand knot is doubled; therefore, two loops of Double the suture are formed over the overhand jaws of the needle holder and surgeon's tightened. The last loop is formed knot under the jaws of the needle holder in a direction opposite from the first loops. This is the standard suture knot used in conjunction with the mattress technique of suturing. Note: When synthetic or natural Completed resorbable sutures are used, one surgeon's additional overhand knot may be knot added to the surgeon's knot to prevent unraveling. When silk suture material is utilized, only wo overhand knots are required as a result of the superior frietional resistance of silk. Hawaver, sore of the newer synchetc suture materials are very slippery and demonstrate poor frictional resistance (0 loosening, therefore requiring sevezal additional overhand knots to prevent loosening, uw SURGICAL KNOTTING TECHNIQUES | “J16 The longer suture material remains “in place, the more scarring i will produce, Llowever, sutures can be safely removed when a wound has developed suificient tensile strength. Generally, postoperative appointments are performed between seven and 10 days from the date of surgery. Any suture material utilized | extraorally can be removed earlier if che wound is reinforced with | materials such as skin closure tapes. | | @ SUTURE REMOVAL TECHNIQUES Diluted hydrogen peroxide or a disinfecting mouthwash such as chlorhexidine gluconate can be utilized to clean the wound of all debris, such as clotted blood and serum, The suture knot is then elevated off the tissue utilizing cotton pliers. ‘Ihe suture is cul as close (0 the Lissuc as possible in order to avoid dragging a *dircy suture" through the wound (Figure 7.1). When removing continuous sutures, each section should be cut and pulled out individually,71 Cotton pliers Note: Any pus that ‘escapes from the culture tract should be culture-tested for sensitivity in order to prescribe the appropriate antimicrobial treatment. Cotton pliers Scissors, cutting suture close to the tissue, = I SUTURE =738 Continuing Education (CE) Exercise « TOM To submit your CE exercise answers, please use the answer sheet enclased in the manual and complete as follows: 1) Place an X in the appropriate box for each question; 2) Clip the answer sheet from the page and mail it to the CE Department at Montage Media Corporation. The CE examination is valued at 3 CE credits, The multiple-choice questions for this Continuing Education (CE) Exercise are based on the manual, Principles of Dental Suturing—The Complete Guide to Surgical Closure, by Lee H. Silverstein, DDS, MS. Learning Objectives This manual reviews the principles of dental suturing, including guidelines for the suturing procedure, dications for the variety of suture needles and materials, and selection of the proper instruments for suturing. Upon reading and completing this exercise, the reader should be able to: Describe the instruments utilized for suturing and tissue manipulation. & Describe the various types, sizes, and indications of suture needles and materials 8 Describe the clinical indications of suturing techniques and suture knots. Disclaimer: Completion of this CE exam is not a guarantee of the clinician's ability to perform the procedures described. 1. Suture material can be used to accomplish each of the following objectives EXCEPT ONE. Which one is the exception? A. Ligate blood vessels. B. Approximate surgical flap edges C. Tosition and sccure periodonial Naps. D. Pull tissues togecher 2. Proper suturing of the flap is necessary to prevent which of the following? A. Healing by primary intention, B Inadequate hemostasis, , Premature connection between the Hap and the bone 1D, Bone lass, 3. Inadequate steturing that results in nonapproximation of surgical flap edges will lead to each of the following EXCEPT ONE. Which one is the exception? A. Numbness in the surgical area. B. Thap necrosis. 6. Exposed alveotwr bone: D. Healing by secondary intention 4. Sutures are primarily classified into which two categories? A. Natural and unnacural B. Hard and soft C. Reaothable and nonresorbable, 1D, Hydrophobic and hydrophilic 5. Braided silk sutures are preferred for many procedures because of what characteristic? A. They are nonzeserbable. B They ensure knot security. repel bacteria and fluids D. They have minimal elasticity. 6. Which of the following is an example of a resorbable suture material? A. Polyesier "color" braided. 1B. Polytecrafluoroethylene, C. silk D. Polyglyealic acid 7. What is a primary characteristic of synthetic resorbable sutures? A. "They are hydrophobic. B They are hydrophilic. C. They resord within 21 days. D. They take longer than 90 days co resort, 8. Which of the following is an example of a natural resorbable suture? A. Surgical gut, » Silk. . Polyglycolic acid. 1D. Poliglecaprone 25.Principles of Dental . Suturing The Complete Guide to Surgical Closure LEE H. SILVERSTEIN, DDS, MS With Editorial Contributions by: Gordon J. Christensen, DDS, MSD, PhD David A. Garber, DMD Roland M. Meffert, DDS Carlos R. Quifiones, DMD Brought to you by: rH Giz First Because We Last.