Presented by: Dr.

Krishna Das 1st year PG Department of Periodontology and Oral Implantology

Suture : A stitch or series of stitches made to

secure apposition of the edges of a surgical or traumatic wound.
GOALS : 1. Provide an adequate tension of wound closure without dead space but loose enough to obviate tissue ischemia and necrosis. 2. Maintain hemostasis. 3. Permit primary-intention healing. 4. Provide support for tissue margins until they have healed and the support is no longer needed. 5. Reduces postoperative pain. 6. Prevent bone exposure resulting in delayed healing and unnecessary resorption. 7. Permit proper flap position.

1. 2. 3. 4. 5. 6. 7.

Pliability, for ease of handling Knot security Sterilizability Appropriate elasticity Nonreactive Adequate tensile strength for wound healing Chemical biodegradability

NONABSORBABLE:
Surgical silk: Braided Nylon: Monofilament (Ethilon) Expanded Polytetrafluoroethylene (ePTFE; Gore-Tex) Polyester: (Ethibond)

ABSORBABLE:
Surgical gut (plain) Surgical gut (Chromic) Polygalactin 910 (coated Vicryl) Poliglecaprone 25 (Monocryl)

Knots and Knot Tying

Suture security is the ability of the knot and material to maintain tissue approximation during healing process. Failure is generally the result of untying owing to knot slippage or breakage. Since the knot strength is always less than the tensile strength of the material, when force is applied, the site of disruption is always the knot. A secured knot has three components: 1. Loop 2. Knot 3. Ears

Ethicon (1985) recommends the following principles for knot tying: 1. The completed knot must be tight, firm, and tied so that slippage will not occur.
2.

To avoid wicking of bacteria, knots should not be placed in incision lines.

Knots should be small and the ends cut short (2-3mm). Avoid excessive tension to finer-gauge materials because breakage may occur. Avoid using jerking motion, which may break the suture. Avoid crushing or crimping of suture materials by not using hemostats or needle holders on them except on the free end for tying.

3.

4.

5.

6.

7.

Do not tie the suture too tightly because tissue necrosis may occur. Knot tension should not produce tissue blanching.

8.

Maintain adequate traction on one end while tying to avoid loosening the first loop.
The surgeons knot and square knot strength, although generally not needing more than two throws, will have increased strength with additional throw. Granny knots and coated and monofilament sutures require additional throws for knot security and to prevent slippage.

9.

10.

Most surgical needles are fabricated from heat treated steel and posses a microsilicon finish to diminish tissue drag and a tip that is extremely sharp and has undergone electropolishing . The surgical needle has a basic design composed of :
1. 2.

3.

4. 5.

Eye/ eyeless Body : widest part, also referred as grasping area. (round, oval, rectangular, trapezoid or side flattened). Point : conventional cutting, reverse cutting, taper cut, taper, blunt) Chord length Radius

Needles
P3

: Anterior regions (narrower buccolingual interdental dimension); mucosa; mucogingival procedures.

FS-2

: Posterior regions ( wider buccolingual interdental dimension)

G-6

: Periodental plastic surgery

Conventional Cutting Suture Needle

Reverse Cutting Suture Needle

Suturing instruments

1.

INTERRUPTED a. Figure eight b. Circumferential direct loop c. Mattress: vertical or horizontal d. Intrapapillary CONTINUOUS a. Papillary sling b. Vertical mattress c. Locking

2.

The choice of technique is generally made on the basis of combination of the individual operators preference, educational background, and skill level and as well as surgical requirement.

Periosteal suturing generally requires a high degree of dexterity in both flap management and degree of suture placement. Requirements:-Small needles (P-3), -Fine sutures (4-0 to 6-0) -Needle holder Advantage:Permits precise flap placement and stabilization.

Use:To hold in place apically displaced partial thickness flap.

Technique
Five steps are used in periosteal suturing (Chaiken, 1977)
1.

2.
3. 4. 5.

Penetration Rotation Glide Rotation Exit

Periosteal suturing. A, Needle penetration; needle point is perpendicular to bone. B, Rotation of needle body about point. C,D, The needle is moved along the bone below the periosteum. E, Rotation about needle body permitting point to exit periosteum and tissue. F, Completed periosteal suture.

Types of periosteal suture:1.

Holding suture: is a horizontal mattress suture placed at the base of displaced flap to secure it into new position.
Closing sutures: are used to secure the flap edges to the periosteum

2.

Indications:
1. 2. 3.

4.

5. 6. 7.

Vertical incision Tuberosity and retromolar areas Bone regeneration procedures with or without guided tissue regeneration Widman flaps, open flap curettage, unrepositioned flaps, or apically positioned flaps where maximum interproximal coverage is required Edentulous areas Partial- or split-thickness flaps Osseointegrated implants

1) CIRCUMFERENTIAL SUTURE
This suture can be used for all periodontal flaps, particularly when the intention is to join the two flaps without the interposition of suture threads. The circular interrupted suture will enable healing by primary intention. .

2) FIGURE EIGHT SUTURE

This suture is used when the two periodontal flaps cannot be brought into contact with each other as in the posterior interproximal sectors and in some cases of pre-prosthetic surgery. In these cases, healing by secondary intention will take place .

The circular interrupted suture will enable healing by primary intention.

With a figure-of-eight interrupted suture, only healing by secondary intention can take place .

Mattress sutures are used for greater flap security and control; they permit more precise flap placement, especially when combined with periosteal stabilization. They also allow for good papillary stabilization and placement. The vertical mattress (non periosteal ) suture is recommended for use with bone regeneration procedures because it permits maximum tissue closure while avoiding suture contact with implant material, thus preventing wicking.

3A.VERTICAL MATTRESS TECHNIQUE

3B. HORIZONTAL MATTRESS TECHNIQUE

Vertical mattress suture is often used to adapt the papilla in the interdental space

Horizontal mattress suture is used in the vestibular and palatal sectors to obtain a high degree of flap adaptation to the deep planes.

4. INTRAPAPILLARY
This technique is recommended for use only with Modified Widman flaps and regeneration procedures in which there is adequate thickness of the papillary tissue. Permits exact tip to tip placement of flap.

5. INDEPENDENT SLING SUTURE

The sling suture is primarily used for a flap that has been raised on only one side of a tooth, involving only one or two adjacent papillae. It is most often used in coronally and laterally positioned flaps. The technique involves use of one of the interrupted sutures, which is either anchored about the adjacent tooth or slung around the tooth to hold both papillae.
Allows separate facial or lingual flap positioning in isolated tooth

Specialized interrupted suturing techniques for bone regeneration and Retromolar and Tuberosity areas
LAURELL MODIFICATION

Laurell modified mattress suture(1993) for coronal flap positioning and primary flap coverage is a technique which although capable of being employed for all regenerative techniques, is used predominantly when standard interproximal incision is used.

Laurell modified mattress suture

MODIFIED FLAP SUTURING TECHNIQUE

This technique (Cortellini et al 1995) was introduced specifically for achieving maximum interproximal coverage and primary closure over intrabony defect treated by GTR. This technique requires the initial incision be made at the buccal line angle in the area of interproximal defect. It is a papilla preservation technique. The suturing permits: Coronal positioning Flap stabilization Primary intention closure

Modified flap suturing technique

RETROMOLAR SUTURE MODIFICATION FOR PRIMARY COVERAGE

This technique (Hutchenson 2005) is specially designed for gaining intimate tissue-tooth contact where regeneration is being attempted. It is employed where there is an intrabony defect distal to the last tooth on the lower teeth. It not only permits primary flap closure but close approximation of the tissue on the distal aspect of the tooth

Retromolar area modified suture technique

Anchor Suture
Used for closing mesial or distal to a tooth, as in mesial or distal wedge procedures. This flap closes the facial and lingual flaps and adapt them tightly against the tooth

Closed Anchor suture

Another technique to close a flap located in an edentulous area mesial or distal to a tooth.

When multiple teeth are involved, the continuous suture is preferred. Advantages:
1.

Can include as many teeth as required. Minimizes the need for multiple knots. Simplicity. The teeth are used to anchor the flap. Permits precise flap placement.

2.

3.

4.

5.

6.

Avoids the need for periosteal sutures. Allows independent placement and tension of buccal and lingual or palatal flaps. Buccal flaps can be positioned loosely, whereas lingual and palatal flaps are pulled more tightly about the teeth. Greater distribution of forces on the flaps.

7.

8.

DISADVANTAGES The main disadvantage of continuous sutures is that if the sutures breaks, the flap may become loose or the suture may come untied from multiple teeth.

1. Continuous Sling Suture

The continuous suspended suture is similar to the sling suture, but unlike the latter, extends over a number of teeth. It is used when the flap has been suspended unilaterally or when the intention is to suspend the vestibular and palatal or lingual flap at different levels .
Step 1 The first papilla of the flap is caught with the suture needle and a surgeon' s knot is performed

Step 2 The thread is passed around the tooth as far as the following interdental space, exiting with the thread vestibularly. The second papilla is caught with the needle, followed by the third, the fourth, etc .

Step 3 Once the surgical quadrant has been completed, a surgeon's knot is performed as shown in the drawing .

Step 4 The flap is fixed in the required position with the continuous suture . If the lingual (or palatal) flap is also to be sutured ,the procedure is repeated as for the vestibular flap .

Continuous suspended suture in 4- 0 black silk.

MODIFICATION

When two flaps have been reflected and after the first flap has been sutured, it is often desirable to continue about the distal surface of the last tooth, repeating the procedure on the opposing flap and then tying off in a terminal end loop

This technique simultaneously slings together both the buccal and lingual or palatal flaps.
INDICATIONS:1.

When flap position is not critical When buccal periosteal sutures are used for buccal flap position and stabilization. When maximum closure is desired (unreposition or Widman flaps or bone regeneration)

2.

3.

Technique
After

initial buccal and lingual tie, the suture is passed buccally about the neck of the tooth interdentally and through the lingual flap. It is then again brought interdentally through the buccal papilla and back interdentally about the lingual surface of the tooth to the buccal papilla. Then it is brought about the lingual papilla and then the buccal surface of the tooth. This alternative buccallingual suturing is continued until the suture is tied off with a terminal loop.

When greater papillary control and stability and more precise placement are required and to prevent flap movement, vertical or horizontal mattress sutures are used e.g. on the palate where additional tension is often required, or when the papillary tissue is thin and friable. TECHNIQUE:This technique is identical to the independent papillary sling suture, except that vertical or horizontal mattress sutures are substituted for the simple papillary sling. The technique is similar to that previously described for the interrupted mattress sutures.

LOCKING
Indications: for long edentulous areas, tuberosities, or retromolar areas. Advantage: avoiding the multiple knots of interrupted sutures. Disadvantage: if suture is broken , it may completely untie. Technique: the procedure is simple and repetitive. A single interrupted suture is used to make the initial tie. The needle is next inserted through the outer surface of the buccal flap and the underlying surface of lingual flap. The needle is then passed through the remaining loop of the suture, and the suture is pulled tightly, thus locking it. This procedure is continued until the final suture is tied off at the terminal end.

Compression suture
This type of suture is used in association with free flaps for optimum adaptation to the underlying bed. The objectives are to reduce the layer of fibrin between the free grafts and the receiving bed, prevent the formation of hematoma and facilitate take of the graft. Compression sutures also anchor the edge of the graft without perforating it, thus avoiding possible necrosis in the perforation site.

There are two variations : 1. Vertical compression suture 2. Horizontal compression suture

Vertical compression suture.

Horizontal compression suture.

PERIODONTAL DRESSING
Definition : Periodontal dressing or periodontal pack is a productive material applied over the wound created by periodontal surgical procedures. Uses: 1. To protect the wound postsurgically. 2. To obtain and maintain a close adaptation of mucosal flaps to underlying bone. 3. Comfort to the patient. 4. Prevents post-operative bleeding. 5. Prevents formation of excessive granulation tissue.

1.

The dressing should be soft, but still have enough plasticity and flexibility to facilitate its placement in operated area and to allow proper adaptation. Should harden within a reasonable period of time. After setting the dressing should be sufficiently rigid to prevent fracture and dislocation. The dressing should have a smooth surface after setting to prevent irritation to cheeks and lips

2. 3.

4.

5.

The dressing should preferably have bactericidal properties to prevent excessive plaque formation.
Dressing must not detrimentally interfere with the healing.

6.

1.

Zinc oxide eugenol packs:

Packs based on reaction of Zinc oxide & Eugenol include Wondr-Pak developed by Ward in 1923.

The addition of accelerators, such as Zinc acetate gives the dressing a better working time.
It is supplied as a liquid and a powder that are mixed prior to use. Eugenol may produce allergic reaction (reddening of area and burning pain).

2. Non eugenol packs: Coe-Pak Reaction between metallic oxide and fatty acids is the basis for Coe-Pak. Supplied in two tubes One tube contains: Zinc oxide An oil(for plasticity) A gum (for cohesiveness) and Lorothidol (a fungicide). Other tube contains : Liquid coconut fatty acids thickened with colophony resin (or rosin) Chlorothymol (a bacteriostatic agent) Equal parts of both mixed together immediately prior to insertion.

Other non eugenol packs

1. Light curing dressing e.g Barricaid Useful in anterior tooth region and particularly following mucogingival surgery because it has favorable appearance and it can be applied without dislocating soft tissues. Disadvantage: It is not the choice of dressing to be used in situations where flap has to be apically retained due to its soft state before curing.
2. Cyanoacrylates It is applied in a liquid directly on to the wound or spread over the wound.

3.Tissue conditioners ( Methacrylate gel)

4.Collagen dressings example is CollaCote

Improved healing and patient comfort with less odour and taste have been obtained by incorporating antibiotics in the pack.

Bacitracin, Oxytetracycline (Terramycin), Neomycin, and Nitrofurazone have been tried, but all may produce hypersensitivity reactions. The emergence of resistant organisms and opportunistic infection has been reported.

Incorporation of tetracycline powder in Coe-Pak is generally recommended, particularly when long and traumatic surgeries are performed.

Periodontal dressing are kept usually in place mechanically by interlocking the interdental spaces and joining lingual and facial portions of pack. In isolated teeth or when several teeth in arch are missing, retention of pack may be difficult.
So numerous reinforcement and splints and stents placement of dental floss tied loosely around the teeth enhances retention of packs

Ensure

that the bleeding from operated tissues has ceased before the dressing material is inserted.
Carefully

dry teeth and soft tissues before the application for optimal adherence of dressing.
Moistened

the surgical gloves to avoid the material sticking to finger tips.

Zinc

oxide packs are mixed with eugenol or non eugenol liquids on a wax paper pad with a wooden tongue depressor.
The

powder is gradually incorporated with the liquid until a thick paste is formed.

Coe-pack

is prepared by mixing equal length of paste from tubes containing the accelerator and the base until the resulting paste is a uniform color.
The

pack is then placed in a cup of water at room temperature in 2-3 minutes the paste loses its tackiness and can be handled and molded.
The

pack is then rolled into two strips and placed on the surgical wound. The dressing should not be covered more than the apical third of tooth surface.
Excess

pack irritates the mucobuccal fold and floor of mouth and interfere with the tongue.

A, Equal lengths of the two pastes are placed on a paper pad. B, Pastes are mixed with a wooden tongue depressor for 2 or 3 minutes until the paste loses its tackiness (C). D, Paste is placed in a paper cup of water at room temperature. With lubricated fingers, it is then rolled into cylinders and placed on the surgical wound.

Pack

that interfere with the occlusion should be trimmed away failure to do this cuases discomfort and jeopardized the retention of pack
The

pack is kept on for one week after surgery.

Continuous pack over the Edentulous area

.
Periodontal pack should not interfere with the occlusion

With moist gloved hands, a small cylinder of pack is prepared and applied directly to the surgical wound, after having dried the region concerned with air and a surgical aspirator . Exerting a certain pressure, the pack is spread apically and coronally on the surface of the teeth and, using a moist instrument, is inserted in the interdental spaces . The pack is applied both vestibularly and palatally or lingually.

Instructions for the patients after the packs are placed

1. The pack should remain in place until it is removed in the office at the next appointment. 2. For the first three hours after the operation avoid hot foods to permit the pack to harden.

3. Do not smoke.
4. Do not brush over the pack.

A number of reports have indicated that it may not be necessary or desirable to use a periodontal dressing in postsurgical care:
Loe

and Silness (1961) et al (1969) and Addy (1982)

Stahl

Newman

Based on present knowledge, it appears that periodontal dressings do not improve post-operative healing and do not provide a significantly greater degree of patient comfort. They do contribute to plaque retention and may promote bacterial proliferation at the surgical sites.
Some Periodontists, therefore, are routinely omitting the dressing and implementing modified home care procedures during the immediate postoperative time period.

Clinical observations are mixed, but the consensus is that, from a healing point of view, it really does not matter whether a surgical site is dressed or not. After several weeks, dressed and undressed areas look similar.

On the other hand dressing will play some part- in the retention of an apically positioned flap, preventing undesirable coronal movement and - to provide additional support to stabilize a free gingival graft. In addition, denuded bone can be protected from further injury by dressing during the early phase of healing, thereby minimizing postoperative discomfort.

Use of dressing also prevents the formation of excessive granulation tissue.

With regard to comfort, opinions are in conflict as to whether a dressing is required and this problem is not easily studied because of the subjective phenomena involved.

Furthermore the degree of pain and comfort, at least in part, can be attributed to the nature of surgical technique itself rather than the presence or absence of a dressing.

Conclusion
Whether or Not to Use a Dressing? The answer to this question depends on the type of surgery (factors such as amount of surgical trauma or osseous surgery or flap adaptation) employed and personal preference of the dentist.