SUTURING AND TECHNIQUE GENERAL SURGERY 3210303
LEARNING OBJECTIVES • Discuss examples of absorbable and nonabsorbable suture material. • Discuss various types of suture needles, thread material, and knots. • Explain the criteria for selecting suture needles, materials, and technique. • Describe the principle of suturing
OBJECTIVE OF SUTURING • The primary objective of dental suturing is to position and secure surgical flaps to promote optimal healing : Primary intention healing • Surgical sutures should hold flap edges in apposition until the wound has healed enough to withstand normal functional stresses
OBTAINING OPTIMAL WOUND HEALING • • • • •
Thread type Thread diameter Surgical needle The appropriate suturing technique Use of the proper surgical knot
SUTURE MATERIALS • Linen, horse hair, hemp, flax, silkworm gut, kangaroo tendon, umbilical tape, ligament, cotton, iron wire, bark fibers, stainless steel, gold, and silver • 1940s : Synthetic fibers such as nylon and polyester • 1970s: Polyglycolic acid (Dexon) and polyglactin 910 (Vicryl) • 1980s: Polydioxanone (PDS)
CLASSIFIED BY • Performance, size, and physical configuration • Performance: absorbable or nonabsorbable • Size or diameter :The United States Pharmacopeia (USP) and the European Pharmacopeia (EP) • Physical configuration: a monofilament, multifilament (braided,twist)
Question I
SDL: • Question I-II
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SIZE OR DIAMETER
Large
Small
More Strength
Less Strength
More Obvious
Less Obvious
BRAIDED MULTIFILAMENT
SDL
SDL: • Question III-IV
• Braided multifilament มีประโยชน์ในการเพิม$ คุณสมบัตใิ ดของไหมเย็บ • Braided multifilament มีผลอย่างใดต่อแผลเย็บ
BRAIDED MULTIFILAMENT Braided Multifilament
Plaque-Bacterial accumulation
Inflamation
Retard wound healing
Infection
Decrease tensile strength
Good Knot Security
SDL: • Question V-VI
• absorbable property มีผลใดต่อแผลเย็บ • ไหมละลายได้เพราะกลไกใดบ้าง
SDL- ABSORBABLE VS NONABSORBABLE • Question I • What do you think are the main objectives of absorbable suture material? • Question II • What do you think are the outcomes of using absorbable suture material? • Question III • Which name of absorbable suture do you know?
SUTURE MATERIALS Absorbable
• Plain gut and Chromic • Synthetic absorbable • Polyglycolic acid (PGA) • Polyglactin • Polydiaxone (PDS)
Nonabsorbable
• Silk • Synthetic nonabsorbable • • • •
Nylon Polypropylene Polyester Expanded polytetrafluoroethylene (e-PTFE)
ABSORBABLE SUTURES Absorbable
Decrease tensile strength
Proteolysis, Hydrolysis Prolonged Retained material
Inflamation
Retard wound healing
Infection
TWO MECHANISMS OF ABSORPTION • Sutures of biological origin : enzymatic and macrophage activity, hydrolysis • Intraoral PH : A decrease in intraoral pH such as metabolic disorders (epigastric reflux), chemotherapy, radiation and some medications
PLAIN GUT AND CHROMIC Absorbable sutures First, sutures of biological origin Made from an animal protein Loses most of its tensile strength in 24-48 hrs. unless it is coated with a chromic compound: absorption up to 7-10 days and loss of tensile strength for up to 5 days • High tissue reaction : Induce and antigenic reaction • • • •
POLYGLYCOLIC ACID (PGA) Trade name : Dexon The first synthetic absorbable suture Multifilament Retains long-term strength for up to 14 days Resorbs in 21 to 28 days (Increasing rate if there is lower pH) • handling characteristics similar to silk • • • • •
POLYGLACTIN Polyglycolic acid + lactic acid Trade name : Vicryl Absorbable Multifilament Retains long-term strength for up to 20-30 days (3 weeks) • Resorbs in 60 to 90 days • • • • •
POLYDIAXONE (PDS) • Monofilament • With enhanced flexibility and significantly greater tensile strength than both polyglycolic acid and polyglacin
NONABSORBABLE SUTURE
SILK • Trade name : Mersilk, Sofsilk, NC-silk • Non absorbable : histologic analysis of silk in vivo after 2 years’ time revealed no evidence of remaining suture • The most universally used material in dentistry • Multifilament : Promote bacterial retention and growth • Easy handling and tying and is relatively inexpensive
SYNTHETIC NONABSORBABLE • Nylon
: a polyamide polymer, Either monofilament or
braided • Ethilon, Dermalon : monofilament • Nurolon, Surgilon : multifilament
• Polypropylene : Monofilament • Prolene • have very low immunogenicity when compared to most other nonabsorbable sutures and very high breaking strength.
• Low tissue reaction • Memory : Knot security
SUTURE MATERIALS
SDL:SUTURE SELECTION • Question VII
• ท่านจะเลือกไหมทีม$ คี ุณลักษณะอย่างไรเพือ$ เย็บใบหน้าลูกสาวสุดทีร$ กั ของท่าน
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SUTURE SELECTION • The thickness of the tissues to be sutured • Whether there it the presence or absence of tension-free mobile tissues • The duration the suture must remain • The smallest suture that couples the least immunogenicity with highest tensile strength is preferable • The practitioner must ensure that a suture will retain its strength until the tissues of the surgical flaps regain sufficient strength to keep the wound edges together
SUTURE SELECTION • The desired qualities of a suture thread include the tensile strength that is appropriate for its respective use, tissue biocompatibility, ease of tying, and that it allows minimal knot slippage.
THE DURATION THE SUTURE MUST REMAIN
PATHOPYSIOLOGY WOUND HEALING
•
Phase of healing Inflammatory phase 1-7 days
Fibroblastic (Proliferative) phase 4-21 days
Maturation (Remodeling) phase 3 m.- 2 y.
CRITICAL WOUND HEALING PERIOD Tissue Skin
5-7 days
Mucosa
5-7 days
Subcutaneous
7-14 days
Peritoneum
7-14 days
Fascia
14-28 days 0
5
7
14
Tissue Healing Time/Days
21
28
THE DURATION THE SUTURE MUST REMAIN • The minimum coaptation time for tissue flaps is approximately 5 days • Should be removed no later than 7 to 10 days • Selvig et al found bacterial plaque migration extending more than 100 µm into suture channels at 14 days regardless of the suture material tested. • Sutures that remain in intraoral wounds, such as silk, will cause epithelial tracts, thereby increasing the propensity for bacterial migration.
THE TENSILE STRENGTH • persist and retain adequate tensile strength after surgery, until healing has reached a stage at which wound separation is unlikely to occur. • Absorbable sutures VS Nonabsorbable sutures
TISSUE BIOCOMPATIBILITY • should not impede healing or elicit and inflammatory response or toxic effect • nonconducive to bacterial growth • Absorbable sutures VS Nonabsorbable sutures • Monofilament sutures VS Multifilament sutures
BIOLOGIC RESPONSE TO SUTURE MATERIALS • All sutures implanted in the human body act as foreign bodies • Confounding factors in the oral cavity include humidity and an indigenous flora • Natural absorbable sutures are generally digested by enzymatic and macrophage activity; a greater degree of tissue reaction than the breakdown of synthetic absorbable sutures, which occur by hydrolysis
SOME GENERALITIES EXIST REGARDING SUTURE TISSUE REACTIVITY • Multifilament sutures elicit a greater inflammatory response than monofilament sutures • Polypropylene and steel elicit the least inflammatory response, while nylon, polyester, cotton, and silk all cause an increased tissue response, respectively
EASE OF TYING/ MINIMAL KNOT SLIPPAGE • easy handling qualities and excellent knot security. • Memory property • Breaking strength/ Tensile strength
Material
Structure Surgical Tis. Rxn Handlin g (Ease of tying)
Gut (Plain)
Natural Fair
Tensile Strength (Strength remaining)
Knot sec Absorptio n time
++++
1-2 days
++
1 weeks
Chromic Gut Natural Fair
+++
5-7 days
++
1-2 weeks
Dexon
Braided Good
++
14 days
+++
21-28 days
Vicryl
Braided Good
++
20-30 days
+++
60-90 days
Silk
Braided Excellent +++
0% at 1 year
++++
-
Nylon
FairMonofil Good
Prolene
FairMonofil Good
++ +
20% at 1 year Permanent
++ +
-
THREAD DIAMETER • Intraoral : usually 3-0 and 4-0, 5-0 in periodontal plastic surgery • Extraoral : Face 5-0 to 6-0
SURGICAL NEEDLE • Comprised of 3 parts • The needle point • The needle body • The eye • Closed • Split (French) • Swaged : the junction of the needle and suture is uniform and permanent
THE NEEDLE POINT • Wide variety with different company’s naming systems • 2 basic configurations for curved needles – Cutting: cutting edge can cut through tough tissue, such as skin – Tapered: no cutting edge. For softer tissue inside the body
THE NEEDLE POINT • Conventional cutting needle • Reverse cutting needle
• Taper or round needle
SDL:NEEDLE SELECTION • Question VIII • ท่านจะเลือกใช้เข็มแบบใดในการเย็บเหงือกในช่องปากพร้อมเหตุผล
THE NEEDLE BODY • Curved • 16-19 mm. in length • More curve with shorter length needle : More difficult to suture in the interdental papilla area
THE EYE • Traumatic needle • Closed • Split (French)
• Atraumatic needle • Swaged, Eyeless
GENERALLY IN DENTISTRY • the 3/8 reverse cutting needle with a 3-0 or 4-0 thread diameter • the ½ reverse cutting needle with the thinner and more delicate 5-0 or 6-0 thread diameter
INSTRUMENTATION • The needle holder (driver) • The needle driver most commonly used is the 6-inch version of the Hegar-Mayo type.
• The single-toothed 3-inch Adson forcep • The suture scissors
TIE THE KNOT • By • Hand • Instrument
• Type • Square knot • Surgical knot
SQUARE KNOT
SURGICAL KNOT
WHAT’S DIFFERENT?
SUTURE TECHNIQUES • Interrupted technique • The additional stability and control of wound edges
• Continuous technique • The ease and rapidity
SUTURE TECHNIQUES • Interrupted technique • • • •
Simple interrupted Horizontal mattress Vertical mattress Sling
• Continuous technique • Simple/Running • Locking • Continuous sling
SIMPLE INTERRUPTED SUTURE • The most universal technique in practice today • Used for small wounds • Placed correctly, the suture should slightly evert the wound edges
EVERT?
VERTICAL MATTRESS SUTURE
VERTICAL MATTRESS SUTURE
VERTICAL MATTRESS SUTURE • Primarily used extraorally • Excellent eversion and precise skin edge approximation • Two bite technique: provides wound support at two levels, deep and superficial • First bite : approximate • Second bite : reduced tension from wound edge
• Great resisitance to wound separation • Difficult to place a vertical mattress suture in intraoral tissue
HORIZONTAL MATTRESS SUTURE
HORIZONTAL MATTRESS SUTURE • Good tissue evert • Ideal for closure of soft tissue wounds across small bony defects • Take tension of the wound edge horizontally ; provides a broader area of support • Spreads the forces along a horizontal band of tissue instead of at a single point • Considerable wound tension can be created using the horizontal mattress technique • Frequently used during closure of an oroantral opening
HORIZONTAL HALF BURRIES
FIGURE-EIGHT • Used effectively to close the tissue of an extraction site • Not frequently used to gain primary wound closure • Provide a barrier to dislodgement of a clot after tooth extraction and may help stabilize materials placed into an extraction socket, such as gel foam or other packing material
SLING LIGATION
SLING LIGATION • Ideally used in surgery where a flap is elevated only on one side of the alveolus • Allows repositioning of the flap without entering the opposing intact soft tissue
SIMPLE CONTINUOUS SUTURES
CONTINUOUS LOCKED SUTURE
CONTINUOUS SUTURES • Commonly used in dentoalveolar surgery when longer wounds result • Offers quicker closure because fewer knots • A major disadvantage in this type of suturing is the fact that if one knot fails, the entire closure is compromised • This simple technique has the potential to obliquely apply pressure along the length of the wound, while the locked technique decreases this tendency
CONTINUOUS SUTURES
CONTINUOUS SLING • Used when both buccal and ligual flaps have been reflected • Allows both flaps to be repositioned independently of one another
PRINCIPLES OF SUTURING • To ensure proper healing, there must be proper positioning of the soft tissues closest to their original position in a stable fashion, with the least amount of tension. • Closure in this fashion decreases fibrous scarring, decreases the risk for infection, provides enhanced cosmesis, and facilitates hemostasis.
PRINCIPLES OF SUTURING: GENERAL GUIDELINES • Hemostasis and debridement before suture • Least amount of tension • Do not grab the needle at the junction of the needle and suture swaged • Suture layer by layer • Key stitch suture be made at the interdental papilla or distal of tooth • Sutures are usually placed distal to the last tooth and in each interproximal space • Tissue handling by tissue forcep • Sutures should always be inserted through the more mobile tissue flap first
PRINCIPLES OF SUTURING: GENERAL GUIDELINES • the suture needle should be inserted and pulled through the issue in line with the circle • Sutures should be placed no closer than 2 mm to 3 mm from the edge of the flap to prevent tearing through the flap during postoperative swelling • When penetrating through tissues, the needle should enter at right angles to the tissue • Pull the suture just tight enough to secure the flap in place without restricting the flap’s blood supply • Leave the knot on the buccal side
GENERAL GUIDELINES
Larcerated Impaction Partial Torectomy: Torectomy: facial wound mandibulect Torus palatinus Torus omy madibularis suture.xlsx Type Silk Nylon Prolene Chromic Dexon Vicryl Size
3-0 4-0 5-0 6-0
Needle Atraumatic Traumatic Technique Simple interrupted Vertical mattress Horizontal mattress Sling Simple continuous continuous lock continuous sling