Suturing techniques involved in dental surgery

This was my presentation during Oral Surgery rotation at the University of Detroit Mercy School of Dentistry (UDMSD)

1. Suturing in Dental Surgery Hasanain Alani, 18’ July 21, 2016

2. Overview Objectives Review of suturing materials Techniques used in Oral Surgery

3. What is Suturing? The primary objective is to position and secure surgical flaps to promote optimal healing. When performed properly, healing by primary intention occurs. Performed intra- and extra-orally A chieve functional and esthetic results Decreasing the potential for postoperative infections occurance

4. Suture Armamentarium Needle Holder Suture scissors Adson forceps Suture Needle

5. Suture Materials: Needle A surgical needle has 3 parts: the needle point, the needle body, and the swaged (press-fit) end  The most commonly used are the 3/8 and ½ circle needles. The common shapes: ROUND Less traumatic than the other two, requires more force REVERSE CUTTING: The sharp TIP is DOWNWARD. More safe when working in delicate tissue. Cutting Sharp TIP is UPWARD. Extra sharp tip in is more likely to tear the tissue.

6. Suture Materials: Thread Properties Tensile strength Biocompatibility Ease of tying Least tissue irritation and reaction Diameter and size Coefficient of friction Classification Origin Structure Duration

7. Durability Resorbable Natural Plain gut Chromic gut Synthetic Polyglycolic acid (PGA) Poliglecaprone 25 How do sutures resorb? Antigeni c Reaction Acidic Environment Nonresorbable Silk Polyester Monofilament type ‘nylon’ Polytetrafluoroethylene (PTFE)

8. Silk Sutures This is the most universally used material in dentistry Advantages: Inexpensive Easy to handle and tie Disadvantages: It must be removed It is multifilament When Should we avoid using silk? And what are the alternatives?

9. Example Patient diagnosed with bulimia presented to OS clinic for #30 extraction, and it was determined that the flap edges need to be positioned by sutures. What is the minimum coaptation time for tissue flaps? Synthetic vs Organic thread? F ast A bsorbing Polyglycolic A cid (PGA-FA)

10. Diameter Thread materials range in diameter from 1 to 10, and the higher number corresponds to the thinner, more delicate thread . periodontal plastic surgery: 5–0 for soft tissue grafts, 4-0 mucoperiosteal grafts and implants surgery.

11. Knots Art of suturing! An appropriate type of know should be used for the specific suture material Slip knot: used with silk, chromic or plain gut suture Surgeon’s knot: used with synthetic resorbable and other nonresorbable synthetic suture materials to prevent untimely knot untying.

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

13. Interrupted Suture Do the pass technique, two loops around the needle holder, then grab the tail and do the knot. Indications: Single tooth extraction, third molar extraction flap, biopsies, implants, ..etc. Advantages: It is the most commonly used technique, preferred in urgent situations and it is easy to remove. Failure of one is inconsequential of the others. Disadvantages: It does not bring all surfaces into contact and less supportive for healing of the flap margins.

14. Simple Continuous Suture Start it with simple interrupted suture Then you cut the tail off and leave that last piece loose then you can do your loops . Indications: Bone graft, removal of mandibular tori, tuberosity reduction and where esthetics are not important Advantages: It is very easy to produce and offers a more water tight closure Disadvantages: if you cut one part of it, you lost all of it.

15. Horizontal Mattress Suture The strongest type of sutures, very far away (8 mm from the edge) Indications: large distances between tissues, bone grafts and implants, and closure of extraction socket. Advantages: Good for hemostasis, less prominent scarring. Disadvantages: Leave a gap between flaps and it is difficult to remove.

16. Vertical Mattress Suture The far far , near near technique. Indications: where the wound edges tend to evert Advantages: greater closure strength and better distribution of wound tension Disadvantages: Scar formation and the formation of edge necrosis.

17. Figure of 8 sutures Pattern goes 1-2-3-4-1 Indication: Extraction socket closure, adaptation of ginigival papilla around the tooth, and bone graft placement in socket Advantages: Rapid closure Disadvantages: Due to its orientation, it is difficult to remove and it leaves a significant amount of suture threads inside the socket.

18. General Principles 1- Grasp the needle 2/3 front, and 1/3 behind the needle driver. 2- The needle should pass perpendicular to the tissue 3- The needle should pass at an equal depth and distance on both sides of the wound 4- Pass from the thinner to the thicker tissue 5- The suture should never be closed under tension (no blanch). 6- The knot should be placed at 2-3 mm from the incision 7- Suture should pass over the dental papilla, not the empty socket.

19. Conclusion Due to the daily surgical procedures carried by dentists, a greater knowledge of suturing armamentarium and materials and is needed. The success of technique-sensitive surgeries depends on the clinician’s knowledge and skills to close the wound and achieve optimal healing The innovations in suturing materials decrease the potential for postoperative infections.

20. Refrences 1- Silverstein, Lee H., Gregori M. Kurtzman, and Peter C. Shatz . "Suturing for optimal soft-tissue management."  Journal of Oral Implantology  35.2 (2009): 82-90 . 2- Chu, Chih -Chang, J. Anthony Von Fraunhofer , and Howard P. Greisler , eds. Wound closure biomaterials and devices . CRC Press, 1996 . 3- Int J Periodontics Restorative Dent. 1998 Oct;18(5):474-87. Oral tissue reactions to suture materials.Selvig  KA(1), Biagiotti GR, Leknes KN, Wikesjö UM.