Suturing

Techniques

 
Techniques
The easiest and most adaptable suture is the inter­rupted suture. It requires a single entry and exit, and each suture terminates in a surgical knot (Figs 1-1 a to 1-1 c). It can be used with all flap designs and offers the advantage of functioning independently. If one suture breaks or is pulled free, the remaining sutures are not disturbed.
Disadvantage. Because most flap closures require a series of interrupted sutures, placing them is time consuming and the increased number of knots col-lects food and debris.
Continuous sutures
This suture style is used to join the edges of an inci­sion from one end of the wound to the other with a single stitch. It is particularly advantageous when closing long horizontal incisions. A continuous suture is easy to place and, because there are fewer knots, it is easy to keep clean.
Disadvantage. The major concern with any continu­ous suture is when one suture loosens or pulls free, the entire incision line is placed in jeopardy. The patient should be forewarned of this possibility and urged to call the office if it occurs

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Fig 1-1 a                                                                                       Fig 1-1 b


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Fig 1-lc

Figs 1-1a to 1-1 c The interrupted suture is a series of disconnected ties that terminate in either a double loop square knot or a triple loop surgical knot.
Mattress sutures
The mattress suture originates as an interrupted suture. However, contrary to the normal proce¬dure of cutting both threads, the needle-attached thread Is not cut but continues to enter and exit along the incision line in a series of angled loops until it terminates in a three-threaded surgical knot at the end of the wound. This suture style is easy to place and, because it only has one knot at the beginning and one knot at the end, it is easy to remove and keep clean (Figs 1-2a to 1-2e).
Disadvantage. The angle of the weave reposi¬tions the flap In torque with the attached tissues. This invites gaps and overlaps along the incision line

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Fig 1-2a


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Fig 1-2b                                                                   Fig 1-2C



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Fig 1-2d                                                                    Fig 1-2e



Figs 1-2a to 1-2e The mattress suture begins with a two-threaded surgi­cal knot, and after a series of continuously angled loops, ends in a three-threaded knot.
Blanket sutures
A blanket suture is a modified mattress suture, it begins as an interrupted suture, but differs from the mattress as it continues down the incision line. The uncut needle thread is brought through a loop of thread after each tissue entry. As each loop interlocks, it tightens and straightens the previous loop in a preferred untorqued angle until it ends in a three-threaded surgical knot. These perpendicular sutures are better able to hold the edges of the flap in apposition and are easy to place, remove, and keep clean Figs 1-3a to 1-3c).
Slinq sutures
The sling suture is really a modified mattress suture that Is extremely versatile and efficient in closing long intrasulcular flaps. It originates at the junction of the vertical and horizontal incisions with an interrupted suture. The uncut thread is then fed to the lingual by passing the needle between the teeth apical to the height of contour. The thread is woven around the lingual neck of the tooth and returned to the facial side of the arch by feeding the needle above/below the contact points of the next nearest embrasure. Unless the cingula of the anterior teeth or the height of contours of the posterior teeth are destroyed or absent, it is generally unnecessary for the needle to pass through the lingual tissues before it is returned to the facial aspect.
The needle next enters and exits the papillae and is fed beneath the contact points to the lingual. This weaving sequence continues along the full length of the flap, where it ultimately ends in a three-threaded surgical knot (Figs 1-4a to 1-4d


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Fig 1-3a                                                                   Fig 1-3b


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Fig 1-3c


Figs 27-3a lo 27-3c The blanket suture is similar to the mat­tress suture in that it begins with a two-threaded surgical knot, but as it continues down the suture line, the needle loops and locks each entry and exit before ending in a three-threaded knot
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Figs 1-4a to 1-4d The sling suture begins with a single two-threaded surgi­cal knot, and before ending in a three-threaded surgical knot, it weaves down the intrasulcular line, passing from the buccal aspect to the lingual aspect, enter­ing and exiting the facial crestal tissue at each embrasure la and b~. The cin-gula and/or heights of contour are used for lingual retention. The continuous sling technique Is particularly useful when closing posterior flaps (c-. To better secure closure in the absence of sufficient crown structure, the lingual tissue may be entered and exited at each embrasure Id).
Thread breakage is apt to occur when the opera­tor attempts to feed the needle from the labial to the li ngual if the contacts are long and tight, there is extensive caries in the embrasures, crowns are pre­sent and splinted, or the operator tries to floss the suture thread between the crowns as opposed to feeding the needle under the contact points.
if the thread breaks during placement, the seg­ment of the sling that has already been placed should not be removed. Instead, it is best to allow a length of the broken thread to extend out of the embrasure where it broke and begin a new sling suture at the opposite incision junction. The new sling advances along the crest as usual, and when the broken thread is reached, the new end is tied to the broken end at that embrasure (Figs 1-5a to 1-5c


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Fig 1-5a                                                           Fig 1-5b



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Fig 1-5c


Figs 1-5a to 25-5c If a continuous sling suture breaks during placement, a new sling is started at the opposite end of the incision and both slings are tied together at the breaking point with a surgical knot.
Basket sutures
The basket suture is a variation of the sling where only one tooth is involved. The needle is inserted in the flap as in the sling, but approximately 2 inches of the thread is left unfed. The suture loops around the lingual aspect of the tooth apical to the height of contour and returns to the buccal where the needle reengages the flap. The suture material retraces its original path around the lingual, return-ng to its origin, where it is knotted with the 2 inches of unfed suture thread (Figs 1-6a and 1-6b).
A modification of the basket suture is an alter­native technique whereby the papillae can be sutured in place without the thread exiting in the incision line at any time. The initial entry is made approximately 6 mm below the mesiolabial papil-ae. is passed beneath the tissue, and exits 2 mm below the mesiolabial papillae. Approximately 2 nches of thread is left unfed at the entry point. Once it exits the tissue, the thread is passed through the contact to the lingual. Here it is woven around the lingual neck of the tooth to the mesial l ngual line angle, where it is passed through the contact to the distolabial aspect. It then penetrates the distolabial papillae at the 6-mm level (where it passes under the flap), exits at the 2-mm level, and is terminated in a knot with the primary thread at the entry point (Figs 1-a and 1-b).
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Fig 1-6a                                                                         Fig 1-6b


Figs 1-6aand 1-6b The basket suture, which can be used regardless ot the number of teeth involved, is basi­cally a sling that weaves between the embrasures, using the lingual aspect of the tooth twice for retention (A->B—A) as it returns to its origin to dose with a surgical knot
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Fig 1-7a                                                                       Fig 1-7b


Figs 1-7a and 1-7b A simple modi­fication to the basket is designed to pre­vent the suture thread from passing through the incision line. Entrances and exits ~A->B->C->D-A) all occur in the freed flap and the lingual contours are used for retention.
Sutures for vertical incisions
Closing the vertical Incision is easily accomplished with one or more interrupted sutures. These are oosely placed and are only intended to maintain the closure, if these sutures are pulled tight, the tissue may overlap and even tear. The patient will be uncomfortable throughout the postsurgical period, and the sutures will be difficult and painful to remove.
For a long vertical cut, a gentle, easy-to-place, easy-to-remove vertical closure alternative to a series of interrupted sutures is a crisscross continuous suture. The needle enters the unattached tissue at a evel near the vertical-horizontal junction, it crosses the incision line and reenters from the undersurface of the attached tissue at a level a few millimeters below/above the mucobuccal fold. Here it exits and horizontally crosses the incision line where it reen­ters the surface of the unattached tissue at the previ­ously selected fold level. From this level, it recrosses the incision line from underneath and enters the undersurface of the attached tissue at a level equal to that selected for the initial entry, it then crosses horizontally to join the primary free end in a surgical knot at the entry point (Fig 1-8a and 1-8b)


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Fig 1-8a                                                                      Fig 1-8b


Figs 1-8a and 1-8b Vertical incisions should be closed without adding tension to the flap with a simple interrupted suture. When the incision is ong, a crisscross technique IA->B>C-4DI that never allows the thread to pass between the inci­sion edges is test.
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Suggestions
1. The more precise the incision, the better the reapproximation and the better and faster the
healing.
2. To avoid needle tears when closing an Ochsenbein-Luebke flap, 3 to 4 mm of the attached gingival tissue should be elevated before attempting to insert the suture needle (Fig1-9).
3. Suturing begins by inserting the needle through the superficial surface of the unattached tissue before entering the inferior surface of the attached tissue (Fig 1-10).
4. To prevent tearing, the suture needle should enter and exit tissue at least 2 mm from the inci­sion edge and be spaced approximately 2 mm apart (Fig 1-11). The terminating knots should be placed over tissue and not over the incision line.
5. Sutures are only pulled tight enough to bring and keep the incised edges in contact.
6. A sutured flap should be tested by moving the ips and/or cheeks. If gaps become evident, they should be closed by interrupted sutures.
7. A sutured flap should be finger compressed for 3 to 5 minutes. Compressing the tissues for a short period of time after they have been repositioned creates an initial adhesion and prevents blood from pooling between the inner surface of the flap and the bone.
8. A pool of blood may build between palatomu-cosal tissue and bone, causing the flap to sag. The loss of adhesion results in tissue ischemia and slough. If such a possibility exists, an acrylic stent should be prefabricated as a precaution.
9. To ensure that no sutures are inadvertently missed at the time of removal, the number of sutures originally placed should always be recorded.
10. Reanesthetizing the patient with a long-acting anesthetic, such as bupivacaine hydrochloride
Marcaine) with 1:200,000 epinephrine (5%), at the time of dismissal may be helpful in controlling an initial pain response for 2 to 4 hours.
11. A gentle cleansing of the surgical site with a dis­infectant-soaked gauze sponge or cotton swab lets the operator more clearly identify the quality of the sutures.
12. Prior to releasing the patient, the operator should carefully and softly cleanse the face and lips with a nonallergenic soap.
13. Prior to release, the patient's mouth should be examined carefully after he or she has rinsed gently with a small glass of cooled saline solu­tion.
14. An ice pack should be provided immediately after the surgery and the patient should be instructed on how to position it over the surgi­cal site.
15. The patient should be contacted 6 to 12 hours after surgery to evaluate his or her condition and needs.

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Fig 1-9 To provide needle room and prevent tearing prior to closing an Ochsenbein-Luebke flap, at least 2 mm of the attached gingiva should be elevated from bone.




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Fig 1-10 All suturing begins by first inserting the needle through the detached tissue before entering the attached tissue.



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Fig 1-11 To prevent a suture from out­ing through the thin gingival tissues while reducing its potential to pull free over lime a 2-mm bite should be taken on either side of the incision and a 2-mm space should exist between each suture placement.
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