SUTURING

ppt only!!

functions of suture

aid in maintaining a blood clot in the socket → ex: figure-of-eight suture

to coagulate wound margins → most obvious and important function

help hold soft tissue flap over bone → if bone not covered = necrosis

aid in hemostasis → act as tamponade in oozing areas
caution: in underlying tissue is bleeding = hematoma

figure-of-eight suture

this suture is usually performed to help maintain a piece of oxidized cellulose in the tooth socket and to aid in hemostasis

armamentarium

needle holder

suture needle

tissue forceps

suture material

needle holder

15cm (about 6”) in length and has a locking handle

held with the thumb and ring finger through the rings

index finger along the length of needle holder to provide stability and control

suture needle

made of either stainless steel or carbon steel

• 2 shapes:

  • straight & curved

• 3 basic components:

  • point, body, eye (swage)

• most common needle shapes:

  • three-eighths

  • half-circle cutting needles

tissue forceps & suture material

soft tissue forceps

allis tissue

adson forceps

stillies forceps

adson forceps

most commonly used (esp anteriors)

fine, small, delicate tips (toothed or smooth)

used to gently stabilize soft tissue for suturing or dissection

if toothed: secure hold with minimal pressure to reduce trauma (use gently)

stillies forceps

preferred for posteriors

typically 7–9” long, allowing good reach, grip and control

allis tissue

for large tissue removal (epulis)

has locking handles and teeth

suture material classification

by resorbability

by filament type

by diameter/size (ex: 3-0, 4-0, 5-0)

• smaller sizes = more zeros (ex: 5-0, 6-0) → less scarring is desired

• larger size = fewer zeros (ex: 2-0 > 3-0)

resorbable sutures

• made of gut (sheep intestine)

  • chromic gut

    • resorbs in 7–10 days

  • plain catgut

    • resorbs in 3–5 days

• synthetic types

  • polyglycolic & polylactic acid → last up to 4 weeks, rarely needed

nonresorbable sutures

ex: silk, nylon, vinyl, stainless steel

silk → most commonly used in oral surgery

suture material by filament type

monofilament

• ex: gut, nylon, stainless steel

• less wicking, but harder to tie and may irritate tissue

polyfilament

• ex: silk, synthetic braided

• easier to handle and tie

• more comfortable, but can wick fluids

suture removal timing

oral mucosa sutures typically removed in 5–7 days

package of suture

principles of suturing

from free to fixed tissue

held 2/3 from the tip

single pass if attainable

perpendicular to the surface

2-3mm from the edge

3-4mm from the next suture

no blanching, no tension

not along incision line

ends of suture no longer than 1cm

passed from free to fixed tissue

needle is held 2/3 from the tip

facial tissue first needle is regrasped with needle holder passed thru the lingual papilla

when two margins of the wound are close together, needle may insert through both sides of the wound in a single pass

needle penetrates perpendicularly to tissue surface

when passing needle thru tissue, needle enters surface at right angle, to make the smallest possible hole in the mucosal flap

if oblique or acute → flap tearing and wound edges not properly align and needle is pushed thru rather than turned

(to prevent needle or suture from pulling thru soft tissue flap)

suture for an envelope flap

sutures are placed at the papillae only, not placed at empty tooth socket

suture for a three-cornered flap

vertical end of the incision must be closed separately with 2 sutures for the vertical end

#9 periosteal elevator → to elevate the non-flap side of the incision, facilitate passage of the needle

when it is repositioned, the first suture is placed at the occlusal end of the vertical-releasing incision (1). the papillae are then sutured sequentially (2, 3), and finally, the superior aspect of the releasing incision is sutured (4)

types of suturing techniques

simple interrupted suture

simple continuous suture

continuous locking suture

horizontal mattress suture

vertical mattress suture

figure-of-eight suture

instrument tie

most intraoral sutures are tied with an instrument tie

the suture is pulied through tissue until the short tail of the suture (approx 1-2cm long) remains

the needle holder is held horizontally by the right hand in preparation for the knot-tying procedure

the left hand then wraps the long end of the suture around the needle holder twice in the clockwise direction to make two loops of suture around the needle hoider

the surgeon then opens the needle holder and grasps the short end of the suture very near its end

the ends of the suture are then pulled to tighten the knot

the needle holder should not pull the suture it is holding at all until the knot is neary tied to avoid lengthening that portion of the suture

simple interrupted suture

most commonly used

suture goes through one side, comes up through the other side and tied in a knot at the top

• advantages:

  • can be placed quickly

  • tension adjusted individually

  • if one suture is lost, remaining sutures stay in position

simple continuous suture

done if the incision is long

needle is reinserted in a continuous fashion

• advantages:

  • quick and has fewer knots

• disadvantages:

  • not possible to free a few sutures at a time

  • even when one breaks, entire closure is affected

continuous locking suture

similar to the simple continuous type, but the locking is provided by withdrawing the suture through its own loop

• advantages:

  • reduced number of knots

  • uniform distribution of tension

  • prevents excessive tightening

• disadvantages:

  • prevents the adjustment of tension over the wound if tissue swelling occurs

horizontal mattress suture

helps in eversion of wound margins

the easiest way to fix two papillae with a single knot

• advantages:

  • prevents flap inversion into the cavity

  • helps control post-op bleeding by tensing mucoperiosteum

• disadvantages:

  • may restrict blood supply (necrosis)

  • technique involves repeated needle passes and knot tying

vertical mattress suture

used in areas prone to inversion

• uses 2 stitches:

  • deep, wide stitch to bring the deeper tissues together

  • shallow, close stitch to turn the skin edges slightly outward

• advantages:

  • provides increased strength

  • does not interfere with healing as suture runs parallel to blood supply

• disadvantages:

  • fine wound edge approximation is difficult

figure-of-eight suture

a modification of the horizontal mattress suture technique

used to close open sockets and prevent clot displacement

provides good adaptation of gingival papilla along the adjacent teeth

scalpel blade handling

• scalpel blade insertion:

  • holds the noncutting portion of the blade in the needle

  • grip ribbed edge with needle holder

  • male portion of the fitting pointing upward

  • slide onto handle until it clicks

  • use pen grasp when making incisions

• scalpel blade removal:

  • lift up the back end with needle holder

  • slide blade off away from body

  • discard in sharps container

type of scalped blades used in oral surgery

No.10 – extraoral incision

No.11 – stab incision

No.12 – distal to last molars

No.15 – intraoral incision → most commonly used

scalpel holder