What are the key aspects of oral surgery suturing. How do different suture materials and needles affect wound closure. Why is proper suturing technique crucial for optimal healing in oral surgeries. What are the main objectives of surgical wound closure in the oral cavity.

The Fundamentals of Oral Surgery Suturing

Oral surgery suturing is a critical skill in dental practice, essential for promoting proper healing after various procedures. This ancient technique, refined over centuries, remains a cornerstone of modern oral surgery. The primary goals of suturing in oral surgery include:

• Re-approximating wound edges with minimal tension
• Facilitating hemostasis (stopping bleeding)
• Promoting healing by primary intention
• Minimizing bone loss at surgical sites

Proper suturing technique is crucial for achieving these objectives and ensuring optimal patient outcomes. By understanding the principles of oral surgery suturing, dental professionals can enhance their surgical skills and improve patient care.

Essential Instruments for Oral Surgery Suturing

Successful oral surgery suturing relies on the use of appropriate instruments. The classic suturing kit for oral procedures typically includes:

• Needle holders: Used to grasp and manipulate suture needles
• Tissue forceps: For handling soft tissues during suturing
• Scissors: To cut suture material
• Suture needles: Various shapes and sizes for different applications
• Suture materials: Both resorbable and non-resorbable options

Each instrument plays a specific role in the suturing process. Familiarity with these tools and their proper use is essential for efficient and effective wound closure in oral surgery.

Types of Suture Materials in Oral Surgery

Selecting the appropriate suture material is crucial for successful wound closure in oral surgery. Suture materials are broadly categorized into two main types:

Resorbable Sutures

Resorbable sutures are designed to break down and be absorbed by the body over time. They are often preferred in oral surgery due to their convenience and reduced need for suture removal. Common resorbable suture materials include:

• Polyglycolic acid (PGA)
• Polyglactin 910
• Poliglecaprone 25
• Chromic gut

These materials vary in their absorption rates and tensile strength, allowing surgeons to choose the most appropriate option for each specific procedure.

Non-resorbable Sutures

Non-resorbable sutures maintain their strength indefinitely and require removal after the wound has healed. They are often used in situations where extended wound support is necessary. Common non-resorbable suture materials in oral surgery include:

• Silk
• Nylon
• Polypropylene
• Polyester

Non-resorbable sutures offer excellent tensile strength and are often preferred for certain types of oral surgeries or when precise control over suture removal timing is desired.

Suture Needle Selection in Oral Surgery

Choosing the right suture needle is crucial for effective wound closure in oral surgery. Needles vary in shape, size, and curvature, each designed for specific applications. The most common types of needles used in oral surgery include:

Curved Needles

Curved needles are the most frequently used in oral surgery due to their versatility and ease of use in confined spaces. They come in various curvatures, including:

• 1/4 circle
• 3/8 circle
• 1/2 circle

The choice of curvature depends on the specific surgical site and the surgeon’s preference.

Reverse Cutting Needles

These needles have a triangular cross-section with the cutting edge on the outside curve. They are ideal for suturing tough tissues, such as gingiva or palatal mucosa.

Taper Point Needles

Taper point needles have a round cross-section and are designed to pass through delicate tissues with minimal trauma. They are often used in areas where tissue damage must be minimized, such as in periodontal surgery.

Selecting the appropriate needle type and size is essential for achieving optimal wound closure while minimizing tissue trauma.

Fundamental Suturing Techniques in Oral Surgery

Mastering various suturing techniques is crucial for oral surgeons to effectively close different types of wounds. Some of the most common suturing techniques used in oral surgery include:

Simple Interrupted Suture

This is the most basic and widely used suturing technique. It involves placing individual sutures at regular intervals along the wound edge. Simple interrupted sutures are versatile and allow for easy adjustment of tension along the wound.

Continuous Suture

Also known as running suture, this technique involves a single strand of suture material placed in a continuous line along the wound edge. It is faster to place than interrupted sutures but may be less adjustable.

Mattress Sutures

Mattress sutures come in vertical and horizontal variations. They are useful for reducing tension on wound edges and everting tissue margins. Mattress sutures are particularly helpful in areas with thick tissue or where there is a need to reduce dead space.

Figure-of-Eight Suture

This technique is often used to ligate blood vessels or secure drains. It provides excellent stability and is less likely to slip compared to simple interrupted sutures.

Proficiency in these techniques allows oral surgeons to adapt their approach based on the specific requirements of each surgical site and procedure.

Factors Influencing Suture Selection in Oral Surgery

Choosing the appropriate suture material and technique for oral surgery depends on various factors. Consider the following when selecting sutures:

• Location of the surgical site
• Type of tissue being sutured
• Expected healing time
• Patient factors (e.g., age, overall health)
• Risk of infection
• Aesthetic considerations

For example, sutures in highly mobile areas of the mouth may require stronger materials, while those in cosmetically sensitive regions might benefit from finer, less visible sutures. Understanding these factors helps surgeons make informed decisions to optimize wound healing and patient comfort.

Postoperative Care and Suture Management

Proper postoperative care is essential for ensuring optimal healing after oral surgery. Patients should be educated on the following aspects of suture care:

• Maintaining oral hygiene without disturbing the surgical site
• Avoiding foods that may interfere with healing or damage sutures
• Recognizing signs of infection or complications
• Following prescribed medication regimens
• Attending follow-up appointments for suture removal (if applicable)

For non-resorbable sutures, timely removal is crucial to prevent tissue irritation and promote proper healing. The timing of suture removal depends on the location and type of procedure but typically ranges from 5 to 14 days post-surgery.

Complications and Challenges in Oral Surgery Suturing

While suturing is generally a safe and effective technique, oral surgeons must be aware of potential complications and challenges. Some common issues include:

Wound Dehiscence

Wound dehiscence occurs when the sutured edges of a wound separate before healing is complete. This can be caused by excessive tension, poor tissue quality, or premature suture removal. To prevent dehiscence, surgeons should ensure proper wound edge approximation and use appropriate suturing techniques to distribute tension evenly.

Infection

Surgical site infections can compromise healing and lead to serious complications. To minimize infection risk, oral surgeons should maintain strict aseptic technique, use appropriate antimicrobial prophylaxis when indicated, and educate patients on proper postoperative care.

Suture Reactions

Some patients may experience allergic reactions or tissue irritation from certain suture materials. Surgeons should be aware of patient allergies and consider using hypoallergenic materials when necessary.

Difficult Access

The oral cavity’s confined space can make suturing challenging, particularly in posterior regions. Surgeons may need to employ specialized instruments or techniques to overcome these access limitations.

By anticipating and addressing these potential complications, oral surgeons can improve patient outcomes and minimize postoperative issues.

Advances in Oral Surgery Suturing Techniques

The field of oral surgery continues to evolve, with new technologies and techniques emerging to enhance suturing outcomes. Some recent advancements include:

Barbed Sutures

These self-anchoring sutures feature tiny barbs along their length, eliminating the need for knots and potentially reducing suturing time. Barbed sutures may offer improved wound closure strength and more even distribution of tension along the wound.

Tissue Adhesives

In some cases, tissue adhesives can be used as an alternative or adjunct to traditional sutures. These adhesives can provide rapid wound closure and may be particularly useful in pediatric patients or for small, superficial wounds.

Absorbable Staples

Absorbable staples offer a quick and efficient method for wound closure in certain oral surgery procedures. They may be particularly useful in areas where traditional suturing is challenging or time-consuming.

Computer-Assisted Suturing Devices

Emerging technologies are exploring the use of robotic or computer-assisted devices to aid in suturing. While still in developmental stages for oral surgery applications, these technologies may offer increased precision and consistency in wound closure.

As these and other innovations continue to develop, oral surgeons must stay informed about new techniques and technologies to provide the best possible care for their patients.

Training and Skill Development in Oral Surgery Suturing

Becoming proficient in oral surgery suturing requires dedicated training and practice. Dental professionals can enhance their suturing skills through various methods:

Hands-On Workshops

Participating in hands-on suturing workshops allows practitioners to practice techniques under expert guidance. These workshops often use simulated tissues or animal models to provide realistic suturing experience.

Continuing Education Courses

Many dental associations and educational institutions offer continuing education courses focused on advanced suturing techniques. These courses can help practitioners stay updated on the latest developments in oral surgery suturing.

Mentorship Programs

Working alongside experienced oral surgeons through mentorship programs provides valuable opportunities to observe and practice suturing techniques in real clinical scenarios.

Virtual Reality Training

Emerging virtual reality technologies are being developed to provide immersive suturing training experiences. These platforms allow practitioners to practice techniques in a risk-free environment and receive immediate feedback on their performance.

Investing time and effort in developing strong suturing skills is essential for any dental professional involved in oral surgery. Continuous practice and education help ensure optimal patient outcomes and professional growth.

Ethical Considerations in Oral Surgery Suturing

While technical proficiency is crucial in oral surgery suturing, ethical considerations also play a vital role in ensuring patient welfare. Some key ethical aspects to consider include:

Informed Consent

Patients should be fully informed about the suturing process, including the type of sutures used, potential risks, and postoperative care requirements. Obtaining proper informed consent is essential for maintaining ethical practice.

Material Selection

Choosing suture materials that align with patients’ personal or religious beliefs (e.g., avoiding animal-derived products for certain patients) demonstrates respect for individual values and promotes patient-centered care.

Minimizing Discomfort

Ethical practitioners strive to minimize patient discomfort during suturing and the postoperative period. This may involve using appropriate anesthesia, selecting less irritating suture materials, or employing techniques that reduce tissue trauma.

Avoiding Unnecessary Procedures

Surgeons should only perform suturing when clinically necessary and avoid unnecessary or excessive suturing for cosmetic or financial reasons.

By maintaining a strong ethical foundation in their suturing practices, oral surgeons can ensure they provide the highest quality care while respecting patient autonomy and well-being.

Future Directions in Oral Surgery Suturing

The field of oral surgery suturing continues to evolve, with several exciting areas of research and development on the horizon:

Smart Sutures

Researchers are exploring the development of “smart” sutures that can monitor wound healing, detect infections, or even deliver medications directly to the surgical site. These advanced sutures could revolutionize postoperative care and complication prevention.

Nanomaterial-Enhanced Sutures

The incorporation of nanomaterials into suture design may lead to sutures with enhanced antimicrobial properties, improved tensile strength, or better tissue integration.

Bioactive Sutures

Future sutures may be designed to actively promote healing by releasing growth factors or other bioactive compounds that stimulate tissue regeneration and reduce scarring.

3D-Printed Suture Guides

Advancements in 3D printing technology may allow for the creation of patient-specific suture guides, improving precision in complex oral surgeries and potentially reducing procedure times.

As these technologies develop, oral surgeons will need to stay informed about new advancements and critically evaluate their potential benefits and limitations in clinical practice.

Conclusion

Oral surgery suturing is a fundamental skill that combines technical proficiency, material science, and patient-centered care. By understanding the principles of suture selection, mastering various techniques, and staying informed about advancements in the field, oral surgeons can optimize wound healing and improve patient outcomes. As the field continues to evolve, practitioners must balance traditional techniques with emerging technologies to provide the highest standard of care in oral surgery.

Laceration – sutures or staples

A laceration is a cut that goes all the way through the skin. A small cut can be cared for at home. A large cut needs medical attention right away.

If the cut is large, it may need stitches or staples to close the wound and stop the bleeding.

It is important to take care of the injury site after the doctor or health care provider applies the stitches. This helps prevent infection and allows the wound to heal properly.

Stitches are special threads that are sewn through the skin at an injury site to bring a wound together. Care for your stitches and wound as follows:

• Keep the area clean and dry for the first 24 to 48 hours after stitches have been placed.
• Then, you can start to gently wash around the site 1 to 2 times daily. Wash with cool water and soap. Clean as close to the stitches as you can. Do not wash or rub the stitches directly.
• Dab the site dry with a clean paper towel. Do not rub the area. Avoid using the towel directly on the stitches.
• If there was a bandage over the stitches, replace it with a new clean bandage and antibiotic treatment, if instructed to do so.
• Your provider should also tell you when you need to have a wound checked and the stitches removed. If not, contact your provider for an appointment.

Medical staples are made of special metal and are not the same as office staples. Care for your staples and wound as follows:

• Keep the area completely dry for 24 to 48 hours after staples are placed.
• Then, you can start to gently wash around the staple site 1 to 2 times daily. Wash with cool water and soap. Clean as close to the staples as you can. Do not wash or rub the staples directly.
• Dab the site dry with a clean paper towel. Do not rub the area. Avoid using the towel directly on the staples.
• If there was a bandage over the staples, replace it with a new clean bandage and antibiotic treatment as directed by your provider. Your provider should also tell you when you need to have a wound check and the staples removed. If not, contact your provider for an appointment.

Keep the following in mind:

• Prevent the wound from reopening by keeping activity to a minimum.
• Make sure your hands are clean when you care for the wound.
• If the laceration is on your scalp, it is OK to shampoo and wash. Be gentle and avoid excessive exposure to water.
• Take proper care of your wound to help reduce scarring.
• Call your provider if you have questions or concerns about how to care for stitches or staples at home.
• You can take pain medicine, such as acetaminophen, as directed for pain at the wound site.
• Follow-up with your provider to make sure the wound is healing properly.

Call your provider right away if:

• There is any redness, pain, or yellow pus around the injury. This could mean there is an infection.
• There is bleeding at the injury site that will not stop after 10 minutes of direct pressure.
• You have new numbness or tingling around the wound area or beyond it.
• You have a fever of 100°F (38.3°C) or higher.
• There is pain at the site that will not go away, even after taking pain medicine.
• The wound has split open.
• Your stitches or staples have come out too soon.

Skin cut – caring for stitches; Skin cut – suture care; Skin cut – caring for staples

• Incision closures

Beard JM, Osborn J. Common office procedures. In: Rakel RE, Rakel DP, eds. Textbook of Family Medicine. 9th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 28.

Lammers RL, Scrimshaw LE. Methods of wound closure: In: Roberts JR, Custalow CB, Thomsen TW, eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Philadelphia, PA: Elsevier; 2019:chap 35.

Simon BC, Hern HG. Wound management principles. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018:chap 52.

Updated by: Jesse Borke, MD, CPE, FAAEM, FACEP, Attending Physician at Kaiser Permanente, Orange County, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Browse the Encyclopedia

Oral Surgery Suturing – StatPearls

Continuing Education Activity

Surgical closure of wounds is a process that has been performed with needles and thread since prehistoric times. The goal then and now is to re-approximate wound edges under minimal tension. This enables hemostasis and healing by primary intention to minimize bone loss at surgical sites. This activity outlines the various suture materials and needles while highlighting the techniques utilized by the oral surgery healthcare team when managing the closure of surgical wounds within the oral cavity.

Objectives:

• Review the classic suturing instruments utilized for oral surgery.

• Summarize the characteristics of typical resorbable and non-resorbable suture materials used in oral surgery.

• Review the most common needles used and their indications for use.

• Describe common surgical knots, suturing techniques, and indications for each.

Access free multiple choice questions on this topic.

Introduction

Strings and animal tendons have been used to suture for thousands of years. Over time, innovations in suture materials and improved techniques decreased the complications associated with wound closure. The primary goal when suturing is to re-approximate wound edges under minimal tension enabling hemostasis and healing. This article outlines the various suture materials and needles while highlighting the techniques utilized by the oral surgeon when managing the closure of surgical wounds within the oral cavity.[1]

Anatomy and Physiology

The ideal outcomes in any surgical setting are good closure and stabilization of re-approximated wound edges. However, dental surgeons are exposed to a unique challenge since they have to reapproximate and stabilize various types of soft tissue (delicate unattached mucosa vs. more substantial attached mucosa with keratinized tissue) onto varying types of hard tissue (compact and medullary bone, cementum, and titanium implant surfaces). Additional challenges include bacterial colonization, the tension created from the tongue, swallowing pattern, and masticatory function.[2]

Wound healing is a multifaceted process consisting of four sequential and overlapping phases: the hemostatic phase, inflammatory phase, proliferative phase, and maturation phase. The hemostatic phase is rapidly occurring, usually within minutes of wound closure. Exposed collagen and tissue factor initiate the hemostatic phase constricting vessels and formating the platelet plug. The platelets degranulate, releasing cytokines and growth factors originating the fibrin clot formation via the coagulation cascade. Simultaneously, the acute inflammatory phase drives the healing process, which usually lasts 72 hours. This phase is characterized by heat, pain, swelling, and redness. Increased vascularity facilitates the accumulation of cells consisting of macrophages, leukocytes, growth factors, and enzymes that rid the site of toxins, damaged cells, and bacteria.[3][4]

The proliferative phase varies in duration but generally continues for days to weeks, replacing the fibrin clot with granulation tissue and immature type III collagen. The granulation tissue comes from the extracellular matrix (ECM), consisting of collagen, elastin, hyaluronic acid, and proteoglycans. Cell types present in this phase are fibroblasts, keratinocytes, and endothelial cells. Growth factors and cytokines (TGF beta 1, 2, and 3; vascular epidermal growth factor and the interleukin family) are actively involved during this phase.[4]

The maturation and remodeling phase is the last step in wound healing. This phase consists of replacing the extracellular matrix and type III collagen with type I collagen (better organized), which can take months to years.[4]

Wounds heal by first, second, and third intention. Ideally, a wound heals by first intention whereby the wound edges are reapproximated, and the sutured is closed. The site will heal through the process mentioned above with minimal scar formation. Second intention healing is when the wound is too wide, deep, or jagged to re-approximate the tissue edges. These wounds are not closed, and the healing process begins at the wound base, migrating superficially to the epidermis. Finally, third intension healing is when a wound is infected or necrotic; therefore, it must be cleaned or drained until the infection has resolved to be definitively closed.[4][3]

Equipment

To provide consistent and repeatable wound closure, it is critical for the dental surgeon to understand the suturing armamentarium, including suture materials, needle types, and suturing instruments.[1]

A variety of suturing materials are available for use at the discretion of the dental surgeon. A key consideration when choosing the most appropriate material is tensile strength. Sutures vary in how they distribute tension across the wound after re-approximation. Tensile strength is directly related to the size of the thread material. Therefore, dental surgeons should select the smallest thread that achieves appropriate tension to minimize tissue damage. The suture material also needs to be easy to handle and provide secure knots. Thread materials utilized for suturing consist of resorbable materials and non-resorbable materials.[1]

Resorbable suture materials are most often the surgeon’s primary choice in modern dentoalveolar surgery. They eliminate the need for post-operative suture removal, reducing patient anxiety and usually result in less tissue inflammation. Resorbable suture materials consist of natural (gut and chromic gut) and synthetic materials (polyglycolic acid and polydioxanone). 

Natural suture materials are composed of highly purified collagen derived from animals such as sheep and beef intestines. Surgical gut sutures are absorbed rapidly by enzymatic degradation. For this reason, surgical gut sutures are reserved for scenarios where the surgical flap is under minimal tension. The plain gut suture thread loses 50% of its tensile strength within 24 hours of exposure to the intraoral environment and completely resorbs in 3 to 5 days. 

Chromic gut sutures are treated with chromium salts to extend their absorption time to approximately 7 to 10 days. These sutures maintain tensile strength for up to 5 days. As discussed before, surgical gut sutures are the most common suture material utilized in dentoalveolar surgery. Still, they are contraindicated in scenarios where the intraoral pH is decreased—for example, gastroesophageal reflux disease (GERD), antipsychotic drug therapy, and Sjogren’s Syndrome. If the surgical gut suture is used in these scenarios, it may rapidly dissolve, resulting in surgical flap dehiscence.[5][6][7][1]

The most common synthetic resorbable suture material used is made from polyglycolic acid (PGA). PGA is digested by hydrolysis, which takes 21 to 28 days in the intraoral environment. In addition to the extended absorption profile that PGA suture materials possess, it also maintains high tensile strength for approximately three weeks. PGA is the resorbable suture material of choice when placing mattress sutures to keep tension against the muscles of mastication. Its braided structure tends to improve handling characteristics and maintain knot integrity. This suture also comes coated with an antimicrobial agent. Another synthetic resorbable material commonly used to close the dermis is polydioxanone. This is a monofilament that holds 70% of its tensile strength for two weeks.[5][6][7][1]

Silk and polyester are the primary non-resorbable materials used today. Silk is inexpensive and readily available, primarily manufactured with fibers in a braided configuration. The braid allows for elasticity and the material to adhere to itself, maintaining tension within the knot allowing for secure knots. However, silk sutures are more likely to cause infection, and removal is recommended one week after placement. The braided arrangement of fibers increases surface area, which wicks fluid and bacteria into the composition of the thread. As a result, the bacteria distributes into the wound, increasing the likelihood of infection. Silk is contraindicated when used at sites where permanent structures are present such as implants or particulate grafts.[5][6]

Polyester sutures are another widely used non-resorbable material. Polypropylene, black monofilament, and polytetrafluoroethylene are the primary polyester sutures used in dentoalveolar surgery. It is critical to use a surgeon’s knot versus a slipknot when closing with a polyester suture because of the material memory. The surgeon’s knot will prevent the knot from coming untied. The non-absorbent polyester fibers decrease the likelihood of facilitating bacterial growth.[5]

A myriad of surgical suture needles exists on the market today. Reverse-cutting suture needles are the primary choice for dentoalveolar surgeons. The reverse-cutting needle is triangular in cross-section, where the triangle’s base faces the inner part of the circle created by the needle. This shape prevents tearing oral mucosa as tension is applied during the knot tying. The 3/8-circle needle is most often used in dentoalveolar settings. However, the 1/2-circle needle is sometimes preferred where working space is restricted, such as the maxillary posterior region.[8][9]

Technique or Treatment

Equally important as the selection of suturing materials is the appropriately selected knot and technique. Two primary knots are utilized in dentoalveolar circumstances: the slip knot (Figure 1) and the surgeon’s knot (Figure 2).

The primary factor when selecting one or the other is the suture material utilized. A surgeon’s knot must be selected when using synthetic suture materials to prevent loosening of the knot. Synthetic sutures like polyester maintain memory (they will unravel to return to a straight position). First, a surgeon’s knot is done by tying a double overhand throw; then, an additional single overhand throw is placed in the opposite direction to lock the knot. The granny or surgical slip knot enables the surgeon to tighten the suture toward the tissue and pull the flap edges together. The slip knot may be used with gut and chromic gut suture materials. This knot is not recommended when using resorbable or non-resorbable synthetic materials. The surgical slip knot is executed by making two separate overhand knots in the same direction, pulling taught and re-approximating the wound edges without blanching the tissue, then place an additional overhand throw in the opposite direction to lock the knot.[10][5]

Suturing techniques consist of interrupted and continuous suturing methods. The simple interrupted and crisscross (Figure 3) are two interrupted techniques frequently utilized in dentoalveolar settings to approximate tension-free wounds and flaps.

The simple interrupted technique is accomplished by first penetrating the buccal gingiva, crossing the wound, and exiting the lingual tissue with the needle oriented medially throughout this movement. A loop is created, and the suture thread is tied off at the original entry point. This technique may be utilized for closing small wounds or placed in multiples to close larger wounds.[10][5]

The crisscross technique is an ideal choice for extraction sites, maintaining both the blood clot and materials packed into the socket, such as gel foam, collagen plugs, and graft material. The crisscross technique can be performed in two manners. The first is where the needle is inserted into the mesial/buccal gingiva and exits the distal/buccal gingiva. The needle crosses over the alveolar arch or extraction site, enters the mesial/lingual gingiva, and exits the distal/lingual tissue. The suture is then tied off to the non-working end of the suture thread at the original entry point on the buccal/mesial of the extraction site. The crisscross technique can also be performed where the needle enters the mesial/buccal gingiva, crosses the extraction site, and exits the mesial/lingual tissue. The suture thread is brought across the extraction site, enters the distal/buccal gingiva, and exits the distal/lingual gingiva. The suture thread is then tied off at the original entry point at the mesial/buccal non-working end. The crisscross and interrupted techniques are not recommended for flaps or wounds that are under tension.[5][10][11]

The horizontal mattress technique (Figure 4) is an interrupted suturing technique recommended for flaps under tension where the flap is released beyond the mucogingival junction. This technique is performed by first entering the mesial/buccal gingiva and exiting the mesial/lingual gingiva. The suture thread enters the distal/lingual tissue, crosses the wound, penetrates the distal/lingual tissue, and is then tied off at the original entry point at the mesial/buccal non-working end. Since prolonged tension is expected when using this technique, it’s prudent to use a longer-lasting resorbable or permanent suture.[5][10][11]

The continuous suture (Figure 5) is used when longer wounds are present, such as full mouth extractions. The continuous suture can be locking and non-locking. The advantage of the locking variation is that some security will remain if either knot unties. With the non-locking variation, if either knot comes untied, the flap is compromised, and the wound will likely dehisce. The advantage to the continuous suture is that it applies evenly distributed pressure across the entirety of the wound. Continuous sutures under tension can be reinforced with separate, simple horizontal mattress sutures.[11]

Clinical Significance

Successful outcomes when performing procedures such as dental implant placement, soft tissue grafting, bone harvesting, and grafting are dependent on the clinician’s knowledge and familiarity with the basic suturing materials and techniques discussed in this paper. Post-surgical complications and infections have dramatically reduced with the innovations in suturing materials. Our responsibility as clinicians is to remain knowledgeable regarding suture innovation to continue providing the highest quality of care.[10]

Enhancing Healthcare Team Outcomes

Suturing is a foundational surgical skill that must be mastered to provide optimal outcomes for our patients. Unfortunately, there often is a lack of suturing guidance within the dental field. We can learn from our medical colleagues who frequently use silicone suturing molds in medical school and residency before suturing real human tissue. As dentoalveolar surgeons, we can utilize silicone training models to hone our skills and practice the basic knots and suturing methods previously discussed in the article. This enables us as clinicians to develop competency before suturing within a patient’s mouth. In addition, many suturing materials and instructions are available to those pursuing a surgical specialty or general practitioners desiring to perform more dentoalveolar surgery. [12]

A study where 38 medical students completed surveys regarding confidence before and after completing a suturing lab with silicone models unsurprisingly revealed that all students felt more comfortable with their suturing capabilities after performing the suturing labs. The study’s goal was to perform a quantitative measure of the competence and confidence gained by the students.[12]

Practice on silicone models before live patients is not only optimal, but ethical. There are numerous resources to improve suturing competency. It is our responsibility as dental professionals to utilize the resources available and take the initiative to hone our suturing skills before performing dentoalveolar surgery on patients.[12]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

Basic Suturing Knots and Technique. Contributed by Barron N. Davis, DMD

References

1.

Byrne M, Aly A. The Surgical Suture. Aesthet Surg J. 2019 Mar 14;39(Suppl_2):S67-S72. [PubMed: 30869751]

2.

Burkhardt R, Lang NP. Influence of suturing on wound healing. Periodontol 2000. 2015 Jun;68(1):270-81. [PubMed: 25867989]

3.

Minozzi F, Bollero P, Unfer V, Dolci A, Galli M. The sutures in dentistry. Eur Rev Med Pharmacol Sci. 2009 May-Jun;13(3):217-26. [PubMed: 19673173]

4.

Wang PH, Huang BS, Horng HC, Yeh CC, Chen YJ. Wound healing. J Chin Med Assoc. 2018 Feb;81(2):94-101. [PubMed: 29169897]

5.

Kurtzman GM, Silverstein LH, Shatz PC, Kurtzman D. Suturing for surgical success. Dent Today. 2005 Oct;24(10):96-102; quiz 103. [PubMed: 16277068]

6.

O’Neal RB, Alleyn CD. Suture materials and techniques. Curr Opin Periodontol. 1997;4:89-95. [PubMed: 9655027]

7.

Regula CG, Yag-Howard C. Suture Products and Techniques: What to Use, Where, and Why. Dermatol Surg. 2015 Oct;41 Suppl 10:S187-200. [PubMed: 26418685]

8.

Koyuncuoglu CZ, Yaman D, Kasnak G, Demirel K. Preference of Suture Specifications in a Selected Periodontal and Implant Surgeries in Turkey. Eur J Dent. 2019 Feb;13(1):108-113. [PMC free article: PMC6635974] [PubMed: 31170760]

9.

Torres-Lagares D, Barranco-Piedra S, Rodríguez-Caballero A, Serrera-Figallo MA, Segura-Egea JJ, Gutiérrez-Pérez JL. Suture needles in oral surgery: alterations depending on the type and number of sutures. Med Oral Patol Oral Cir Bucal. 2012 Jan 01;17(1):e129-34. [PMC free article: PMC3448183] [PubMed: 22157669]

10.

Silverstein LH, Kurtzman GM, Shatz PC. Suturing for optimal soft-tissue management. J Oral Implantol. 2009;35(2):82-90. [PubMed: 19400063]

11.

Brandt MT, Jenkins WS. Suturing principles for the dentoalveolar surgeon. Dent Clin North Am. 2012 Jan;56(1):281-303, xi. [PubMed: 22117956]

12.

Gallagher PO, Bishop N, Dubrowski A. Investigating the Perceived Efficacy of a Silicone Suturing Task Trainer Using Input from Novice Medical Trainees. Cureus. 2020 Jan 09;12(1):e6612. [PMC free article: PMC7008766] [PubMed: 32064192]

Disclosure: Barron Davis declares no relevant financial relationships with ineligible companies.

Disclosure: Kevin Smith declares no relevant financial relationships with ineligible companies.

Stitches after childbirth: materials and technologies

Childbirth is a complex physiological process that affects many groups of muscles, tissues, and organs. For a woman, labor activity is associated with significant physical exertion and, unfortunately, does not always pass without undesirable consequences. Most often, obstetricians encounter tissue ruptures that require immediate and effective suturing.

Two types of materials are used for suturing:

• self-absorbable and represented by catgut of animal origin or semi-synthetic threads;
• non-absorbable threads based on silk or nylon.

The suture can be continuous, fixed only at the beginning and end of the incision, or consist of separate parts, each of which is secured with a knot.

Cervical and vaginal sutures

After delivery, the woman is examined immediately. If it has injuries, the tears are immediately sutured with natural or semi-synthetic threads, which dissolve on their own a few days after the operation.

As a rule, during the procedure on the cervix, the doctor does not need to perform additional anesthesia – the sensitivity of the tissues of the uterus is extremely low, and the patient does not experience pain. When treating vaginal tissue ruptures, local anesthesia is used or, in extreme cases, an injection is given for short-term general anesthesia.

During the recovery period, the stitches on the cervix do not cause concern, if the vagina is damaged, the woman experiences some soreness, which disappears after a few days. Special care for the seams and the area of ​​​​their application is not required.

Perineal sutures

Perineal sutures are required if the perineum is damaged or artificially incised during labor. Violations of tissue integrity in this case may have varying degrees of severity and affect:

• only the skin of the posterior commissure of the vagina;
• not only the skin, but also the muscle tissue of the pelvic floor;
• muscles and walls of the rectum.

If the rupture is large, the specialist performs an incision in the perineum, which subsequently facilitates tissue fusion and rehabilitation, as well as simplifies suturing. There are two methods for restoring the perineum after childbirth.

• According to the first, the work is carried out in layers. First, the wall of the rectum is restored, then the muscles are sutured. Both stages are carried out using absorbable materials. Lastly, by means of synthetic threads impregnated with an anesthetic, the skin is connected.
• In the second case, both skin and muscle tissue are sutured with one absorbable thread. A well-made suture is less painful during healing.

Perineal injury is more difficult and takes longer to heal than cervical or vaginal rupture. To alleviate the woman’s condition and speed up the process, it is necessary to provide at least relative peace and effective protection against pathogenic microflora.

To do this, a woman must adhere to a sparing motor regimen and strictly observe the rules of hygiene. For 10 days, a woman in labor cannot sit, there are dietary restrictions. The sutures are removed 6-7 days after application in a maternity hospital or in a consultation.

Stitches after caesarean section

If a woman has a caesarean section, not only the uterus is damaged, but also many layers of soft tissues, which must be restored after the operation.

Depending on the caesarean section technique used, the incision on the label may be longitudinal or transverse. The tissues are connected using semi-synthetic threads, which disappear 70-120 days after the operation. This time is enough to restore the integrity of the uterus. For tissue splicing, a single-row or double-row continuous suture is used, or several separate sutures are applied.

Today, dissection of the uterus is more often accompanied by the imposition of special, absorbable brackets on the edges of the incision. This technique reduces the risks during surgery and simplifies the subsequent treatment of the wound. After suturing the uterus, they proceed to the restoration of muscles, tendons, abdominal cover and subcutaneous fatty tissue. The procedure is performed with absorbable material.

The choice of skin restoration method depends on which of the three methods of caesarean section is used in practice. Today physicians use:

• lower median laparotomy, accompanied by a vertical incision from 12 to 15 cm long along the midline;
• Joel-Cohen laparotomy with a transverse incision between the womb and umbilicus;
• Pfannenstiel laparotomy with a transverse arcuate incision along the suprapubic skin fold.

The first days after the operation, the patient can and should move, while she must receive the necessary anesthesia. It is useful to wear a bandage, which will not allow the seams to disperse, and the tissues to change their position. The care of the sutures consists in their treatment with antiseptic agents and the wearing of a sterile, tight-fitting bandage to the skin. After 6-7 days, as a rule, the stitches are taken out, and the woman in labor is discharged. At home, she needs to observe hygiene and protect the seam from pressure and rough mechanical influences.

See also:
facelift massage
facial lipolytics
ultrasound of kidney vessels
ultrasound of the cervix during pregnancy

Return →

Secrets of the invisible seam – Plastic surgeon Kudinova

Creating the thinnest, most invisible seam is an extremely important task when performing facial plastic surgery. Agree, scars can nullify the best plastic surgery. Therefore, the “invisible seam” is my credo and one of the most important goals of my daily work. If you happen to meet my patient, you will hardly notice the slightest traces of a facelift done.

Photo: stitch after SMAS lift, on the day of surgery and 8 weeks after.

I was certainly pleased to know that my esteemed colleagues and many informed patients consider the vanishing suture one of my professional know-how. The effect of a “seamless” facelift “according to the method of the plastic surgeon Kudinova” actually consists of many components. The first one is a cut.

The art of the perfect cut

In facial plastic surgery, not only a thorough knowledge of anatomy is important (understanding how this whole complex complex of muscles, ligaments, bones, fat and skin works). It is very good to have an innate “sense of tissue” – an intuitive flair, which (as I see from the example of my students) is not inherent in every plastic surgeon.

The location of the incision, its size must be accurately verified. Accuracy is especially important when creating an incision in front of the tragus of the ear – in this area, the relatively thick skin of the cheek passes into the thin, delicate skin of the anterior region. An error of just a couple of millimeters – and the magical effect of the “invisibility” of the work of a plastic surgeon will inevitably be lost! If you have ever done needlework, you will understand what I am talking about.

Invisible seam is my biggest secret

To prevent the seam from deforming, not only threads of different thickness and properties are used for each section of the incision, but also different technologies for fixing tissues. And for the correct distribution of tension, special invisible technologies of “unloading” fixation are used. This eliminates the deformation of the cut line.

Naturally, we want to hide the seams better. Wherever possible, the incisions are neatly hidden – behind the ears, in the scalp, under the chin. And finally, special attention is required to be paid not only to the application of the sutures themselves, but also to competent work with them after the operation.

A little magic and care for a flawless result

Don’t think that the work of a plastic surgeon ends with the application of a bandage. The seam will become completely indistinguishable if you “conjure” it well in the first week or two after the operation.

Gradually remove the threads and replace them with special glues. We start from the most noticeable place – in front of the tragus of the ear.

A few brand secrets, gentle care and as a result – in a week we will get a thin pink mark without the slightest sign of skin tightening and microdecubitus, which usually leave threads. So gradually, as it heals, we get rid of the threads and other areas of the skin. Each of them has its own term, its own tricks and secrets.

In the photo you can see what the stitch looks like 3 weeks after the SMAS facelift.

As a result, in a couple of months, only the hairdresser who cuts your hair will be able to find my stitch. I want the patient not to have to think about hiding the traces of plastic surgery.