Clinical Advances in Periodontics — Vol. 1, No. 3, November 2011
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Basic Suture Techniques For Oral Mucosa
Terrence J. Griffin, Yong Hur, Jing Bu

Focused Clinical Question: What is the preferred suture method for maintaining wound closure?

Summary: Optimal wound healing after surgical procedures requires good soft-tissue management. The final key step for a refined surgical technique is adequate closure by suturing. This article reviews the most common suturing methods used in dentistry, and their applications in various periodontal surgeries are discussed. The nine most common periodontal suture techniques and six different periodontal surgical categories were selected by the periodontal faculty at Tufts University School of Dental Medicine. A survey was distributed to periodontists in the United States, each of whom selected their choice of suture technique for each of the periodontal surgical procedures. The results of this survey show that simple interrupted sutures were used in the majority for each surgical procedure.

Conclusion: Although suture selection and application is complex because of multiple variables, an effort was made to establish a general consensus and current trends regarding suturing techniques. Clin Adv Periodontics 2011;1:221-232.

Key Words: Hemostasis, surgical; humans; surgical flaps; sutures; suture techniques.

Soft-tissue healing in dental surgery depends on good surgical technique and soft-tissue management.1,2 Gentle flap manipulation, ideal incision placement, and appropriate suture techniques are required for optimal healing.3-7 Proper technique and material for suturing will promote wound healing through close approximation of the flap edges, minimized dead space, reduced postoperative bleeding, resistance to tension on the flap margins, and the prevention of infection.8-14

There are various suturing techniques used in dental applications. 15,16 Each technique has advantages and disadvantages. The choice of suture technique comes with the understanding of the wound anatomy and the surgeon’s preference.17,18With the proper technique, the dentist will be able to overcome challenges, such as variations of the anatomy of the wound, tension of the flaps, thickness of the gingiva, and esthetic needs of the patient.

The purpose of this article is to review the basic suturing techniques, their advantages and disadvantages, as well as their applications in various periodontal surgeries. The nine most common suturing techniques and six different periodontal surgical categories were selected by 25 periodontal faculty members at Tufts University School of Dental Medicine. An informal survey was sent out to periodontists in the United States to gauge the usage of each suture technique with various periodontal surgical procedures. Frequently, more than one suture technique is used in a surgery. These survey results were tabulated, and the general consensus for the applications of each suture technique will be discussed.

Principles of Suturing

Avoid Excessive Tension on Sutures

Excessive tension on wounds will result in the blanching of the flaps and wound edges. This may result in necrosis at the wound edge as a result of interference of the blood supply (Fig. 1). Another complication is tearing of the flap by the suture, resulting in ‘‘tracks,’’which are small cuts left by the suture as it dissects through the tissue. These tracks often contribute to flap retraction, graft exposure, and postoperative pain.

Suture Whenever Possible From Movable to Immovable Tissue

This allows for more precise positioning of tissue edges and better wound closure. It is easier to control the suture needle and manage the flap if the moveable tissue (i.e., the flap) is approximated to a steady base.

Always Try to Keep Knots Away From Wound Edges

Knots are both the most irritating and weakest part of any suture technique. For this reason, place the knots so that they are away from the wound edges whenever possible.

Use as Few Knots as Possible

This is a corollary to the previous principle for much the same reasons. Avoid knots whenever possible because they represent the weakest part of any wound closure and at the same time can be the greatest irritant.

Use the Smallest Suture Possible to Close the Wound

It is generally better to use several small sutures rather than a lesser number of large-gauge ones. A number of smaller sutures are less irritating to the tissues than a larger one, especially if it is a multifilament material. In addition, smaller sutures result in smaller perforations than larger sutures and heal much more quickly. Several smaller sutures are better able to secure the wound and less likely to result in tissue tears because they do not weaken the integrity of the tissue as much.

Use the Least Amount of Sutures That Will Secure the Wound

Do not over-suture. Excess suturing causes needless perforation of the tissues bordering the wound and interferes with the blood supply. This will, in turn, affect the integrity of the wound and its healing.

Advantages and Disadvantages of Continuous Sutures

Many surgeons prefer continuous suture techniques over interrupted sutures. Both techniques have advantages and disadvantages.19

Continuous Sutures: Advantages

The advantages of continuous sutures include: 1) involving as many teeth as required; 2) minimizing the use of knots; 3) using teeth to anchor the flap; 4) eliminating the need for periosteal sutures; 5) enabling independent placement of buccal, lingual, or palatal flaps; and 6) requiring less time for both placement and removal.

Continuous Sutures: Disadvantages

If breakage or resorption occurs anywhere along its length, a portion of or the entire flap may loosen, exposing bone, implants, grafts, etc.The entire suture is only as secure as its weakest knot.

Primary and Secondary Suture Line

Secondary Suture Line

The secondary suture line (Fig. 2a) is used to give strength to wound closure and compensate for muscle and soft-tissue pull. The suture line is usually away from the wound edges. It is used as an adjunct to the primary suture line by taking stress away from the edges of the wound. After using a secondary suture line, a primary suture line is usually used to close the edges of the wound and complete closure.

Primary Suture Line

The primary suture line (Fig. 2b) is themost common type of suture line used in surgery. This suture line is used to close the incision. It is usually the only type of suture used except in largewounds inwhich resistance tomuscle and soft-tissue pull and wound security are of paramount importance.

Handling the Needle

The needle consists of the needle point, the body, and the swaged end (Fig. 3). The needle point is sharp and is designed to pierce through tissues.Designs of the body include reverse cutting edge, tapered point, tapered cut, or conventional cutting edge. For the most part, the reverse cutting edge is used because it prevents the needle from tearing through the tissue as the needle cuts through the tissue. The swaged end is pressed fitted around the suture line to provide smooth passage of the needle through the tissue.

The needle holders have a cross-hatching pattern of teeth for its beak. This prevents the needle from being damaged as well as gripping the needle adequately. Maximal control of the needle is achieved when the needle is held approximately two thirds the length of the needle from the needle point and z3 mm from the tip of the beak of the needle holder (Fig. 4). Gripping the needle point or swaged end should be avoided to prevent damage to the cutting edge or damage to the swaged end. When suturing, the needle tip should pierce perpendicular to the soft tissue. Small circular twists of the forearm should be used to pass the needle through the soft tissue.

Periodontal Suture Techniques

Interrupted Suture Techniques Simple-Loop (Interrupted) Suture Technique

This is the most commonly used suture technique in dentistry. It can be applied in most periodontal procedures to close elevated flaps and vertical and horizontal incisions and tostabilize soft tissues.

The technique is as follows (Fig. 5) (Video 1):

Pierce the outer surface of the buccal flap with the suture needle.

Thread the needle under the interproximal contact and pierce the inner aspect of the lingual flap with the suture needle.

Pass the suture needle under the interproximal contact toward the buccal aspect.

Tie off the free ends of the suture. Cut off the suture, leaving 2 to 3 mm of suture material.

Figure-Eight (Interrupted) Suture Technique

This is another very commonly used suture technique in dental surgery and is frequently confused with the simple loop. The indications for its use are similar to simple-loop interrupted sutures. The main advantage is easier access between the teeth. A disadvantage is that there will be interposed suture material between the flaps that may prevent ideal approximation of the flap edges compared to the simple-loop interrupted suture technique.

The technique is as follows (Fig. 6) (Video 2):

Pierce the outer surface of the buccal flap with the suture needle.

Thread the needle under the interproximal contact and pierce the outer aspect of the lingual flap with the suture needle.

Pass the suture needle through the interproximal contact and tie and cut off the remaining suture, leaving 2 to 3 mm.

Vertical-Mattress (Interrupted) Suture Technique

The vertical-mattress suture technique allows for precise flap and papillaplacement. It is often used in conjunction with periosteal sutures. It is frequently used inperiodontal resective therapy and guided tissue regeneration (GTR) procedures.

The technique is as follows (Fig. 7) (Video 3):

Pierce the buccal flap just above the mucogingival junction, anchoring the flap to the underlying periosteum.

Note that the underlying periosteum has not been reflected to engage.

The needle should emerge from the center of the papilla 2 to 3 mm from the flap edge.

Pass the needle through the contact area and anchor the lingual flap the same way, starting from the center of the lingual papilla 2 to 3 mm from the flap edges.

Thread the needle through the interproximal contact and tie and cut the suture on the buccal side, leaving 2 to 3 mm of suture material.

Horizontal-Mattress (Interrupted) Suture Technique (Including ``X`` Modification)

The design of the horizontal-mattress suture technique resists flap tension causedby musclepullandsoft-tissue contraction. However, additional sutures are necessary to approximate thewound edges. The reason for this is that the horizontal-mattress suture is a secondary suture line.Theplacement of the suture is away from the wound edges and does not provide complete closure of the wound edges. Primary suture lines are then placed to hold the wound edges together so that healing can occur by primary intention. This suture can be left for an extended time such as in augmentation procedures.

The technique is as follows (Fig. 8) (Video 4):

Pierce the external side of the buccal flap 3 to 4 mm from the flap margin.

Pierce the internal side of the lingual flap 3 to 4 mm from the lingual flap margin.

Penetrate the external side of the lingual flap 5 mm laterally from the second piercing.

Pass the needle through the internal side of the buccal flap and tie the free ends.

Sling (Interrupted) Suture Technique

The indication for the sling suture is the need for repositioning flaps in a coronal direction with additional anchorage the teeth. The ability to vary the tension and vertical position of the flap to a tooth or implant allows the surgeon good control of the extra forces of the flap.

The technique is as follows (Fig. 9) (Video 5):

Pierce the outer aspect of the flap at its distal end and pass the needle under the interproximal contact.

Wrap the suture mesially around the tooth and pass the needle through the interproximal contact and pierce the inner aspect of the flap.

Thread the suture needle through the mesial interproximal contact andwrap the suture around the tooth, going distally.

Pass the suture needle through the distal interproximal contact and tie and cut the suture, leaving 2 to 3 mm of suture material.

Continuous Suture Techniques Continuous Interlocking Suture Technique

This is used for long edentulous spans, such as implant placements, ridge augmentations, or reductions. It is a quick and efficientway of closing long horizontal or vertical incisions.

The technique is as follows (Fig. 10) (Video 6): n From the distal end, tie a simple loop and cut off only the free end.

Pierce both flap margins 5mmlaterally from the simple loop.

Thread the needle under the last horizontal span.

In increments of 5 mm from the last lockingsegment,piercebothflapmargins until the entire span is closed.

Leave a small loop of suture on the final segment after piercing both flap margins.

Use the loop of suture to tie off the suture. Cut off all excess ends, leaving 2 to 3 mm of material.

Continuous Horizontal-Mattress Suture Technique

The continuous horizontal-mattress suture technique includes:

Initial suture placement of simple-loop interrupted

Horizontal extension of the suture

Locking of the suture

Final loop

Tying the suture

Clinical application

The continuous horizontal-mattress suture is an efficient way of obtaining secure adaptation of opposing flaps in edentulous areas. It will resist tension on the flaps from muscle pull and will evert the flap edges and cause dehiscence. Applications for the continuous horizontal-mattress technique are implants and regenerative procedures. Like with the simple interrupted horizontal-mattress technique, it is used as a secondary suture line and will require another suture to maintain the approximation of the flap edges.

The technique is as follows (Fig. 11) (Video 7):

Tie a simple loop on the distal aspect and cut the free end.

Pierce both flaps 5 mm from the initial simple loop.

Continue the piercings in increments of 5 mm, alternating between buccal and lingual flaps.

Onthe final segment, leave a small loop of suture material after piercing both flaps.

Use the loop of suture to tie the suture. Cut off all excess ends, leaving 2 to 3 mm of excess.

Continuous Vertical-Mattress Sling-Suture Technique

Continuous vertical-mattress sutures can be used for resective procedures to position the flap apically and to prevent the recurrence of periodontal pockets. It is frequently used for flaps in osseous and crown-lengthening procedures.

The technique is as follows (Fig. 12) (Video 8):

Starting from the mesial aspect, tie an interrupted vertical-mattress suture and cut off the free end.

Wrap the suture distally around the tooth on the buccal aspect and perform a vertical mattress on the lingual aspect.

Pass the needle through the contact area and perform a vertical mattress on the buccal aspect.

Alternate the side of the placement of the vertical mattress and the sling through the entire span.

Leave a small loop of suture on the final segment.

Use the loop of suture to tie off the suture.

Continuous Independent Sling- Suture Technique/Continuous Dependent Sling-Suture Technique Continuous independent sling sutures are indicated when a flap with multiple papillae are elevated on a single side. This is an extension of the sling-suture technique.

The technique canbeapplied for theother side if both sides are elevated. The continuous dependent sling-suture technique can be used aswell if the surgery involves a periodontal flap for both sides. Surgeries that may require a muco-periosteal flap for both sides include osseous surgeries, crownlengthening procedures, and open-flap debridement. The continuous dependent sling-suture technique has a better ability to vary flap tension than the continuous independent sling-suture technique.

For continuous independent sling sutures, the technique is as follows (Fig. 13) (Video 9):

Tie a simple loop and cut off the free end.

Sling around the tooth on the lingual side.

Pass the needle through the contact area and anchor the buccal flap by piercing the center of the papilla z2 to 3 mm from the flap margins.

Continue the sling on the lingual side until the span is closed.

On the final segment, leave a loop of suture. Tie off the free ends of the suture using the loop of suture.

For continuous dependent sling sutures, the technique is as follows (Fig. 14):

Enter the outer aspect of the buccal flap from the mesial aspect and leave a free end.

Pass the needle through the contact area, first pierce the opposite side flap from the inner aspect, and then return the needle to the buccal aspect where you tie off to the remaining free end. The papillae should be anchored bypiercing 2 to 3mmfrom the flap margins.

Continue the sling around the lingual aspect and pierce the buccal flap from the outer aspect.

Pass the needle under the contact area and pierce the lingual flap from its inner aspect.

Return theneedle to the buccal aspect and then wrap around the tooth to enter the contact area of the next distal tooth.

Pierce the underside of the lingual flap and return to the buccal aspect where the inner side of the buccal flap is pierced.

Now, return through the contact area where a sling is formed distally and then the inner aspect of the buccal flap is engaged.

Continue distally by anchoring the flaps by alternating between the buccal and lingual sides until the entire span is secured.

On the final segment, leave a large loop to tie off the free ends of the suture.

National Survey of Current Periodontal Suture Techniques

The nine most common suturing techniques and six different periodontal surgical categories were selected by 25 periodontal faculty members at Tufts University School of Dental Medicine. The protocol was approved by the Tufts Medical Center Institutional Review Board. A survey was sent out to periodontists in the United States to gauge the usage of each suture technique with various periodontal surgical procedures. These survey results reflect the general consensus for the applications of each suture technique.

The nine suturing techniques included: 1) simple-loop (interrupted); 2) figure-eight (interrupted); 3) vertical-mattress (interrupted); 4) horizontal-mattress (interrupted); 5) sling (interrupted); 6) continuous interlocking; 7) continuous horizontalmattress; 8) continuous vertical-sling; and 9) continuous independent sling/ continuous dependent sling.

The six categories of periodontal surgeries were: 1) crown lengthening or periodontal resective procedure without pocketing; 2) flap surgery with osseous recontouring or other resective procedures; 3) GTR; 4) soft-tissue grafting, such as free gingival graft or subepithelial connective tissue graft; 5) implant therapy without guidedbone regeneration (GBR) procedures; and 6) GBR procedures or maxillary sinus augmentation.

Results

For crown lengthening and periodontal resective procedures without periodontal pockets, the interrupted simple-loop suture was used by 41.5% of the periodontists surveyed. The interrupted vertical-mattress suture was used by 21%, whereas the continuous sling was used by 17% of the polled periodontists. The continuous vertical mattress sling was used by 9.2% of the respondents. The other techniques each attained a usage of <6% (Fig. 15).

Flap surgery with osseous recontouring and other resective periodontal procedures again had interrupted simple-loop sutures as the majority, coming in at 36.3%usage. Continuous sling sutures came in at a close second at 26.2% use, whereas both continuous and interrupted vertical-mattress sling sutures gained the vote of 13.6% from the respondents. Other techniques each were used <7% of the time (Fig. 16).

With GTR, interrupted simple-loop sutures were used by 35.4% of the dentists. Interrupted vertical-mattress sutures were used for GTR by 28.7%. Interrupted horizontal-mattress sutures were used by 10.9% and interrupted sling sutures were used by 8. 4%. The other techniques were each used <5% by the polled periodontists (Fig. 17).

The interrupted simple-loop suture once again was used most frequently (46.1%) with soft tissue grafts such as the free-gingival, or subepithelial connective tissue grafts. Interrupted sling sutures were used 23.9% and continuous sling sutures was used 13.2% of the time. The other techniques were each used £5% of the time (Fig. 18).

Implant therapy without GBR was predominantly done with interrupted simple-loop sutures. Interrupted simple-loop sutures were overwhelmingly used in 74.2% of the cases. Other techniques each were used <8% of the time (Fig. 19).

GBR was generally sutured using simple interrupted sutures at 42.9% from the responding periodontists. Continuous sutures were frequently used at 18.6%, interrupted horizontal-mattress sutures at 15.8%, interrupted vertical-mattress sutures at 9.5%, and all other techniques each came in at <5% (Fig. 20).

Discussion

The goal of this survey was to determine the indications of each suturing technique for various periodontal surgical procedures for ideal conditions. Themethodology is simpledpollpracticing periodontists in what suturing technique they preferred to use for each surgery type and then tabulate the results. The suturing technique with the most number of votes clearly supports that technique while techniques with the least number of votes would mean that the technique is not widely used.

The survey results show that for each of the various periodontal procedures the interrupted simple-loop suture was the most prevalent technique. However there were other techniques were used significantly aswell. In crown lengthening, interrupted vertical-mattress and continuous sling sutures were used frequently. With flap osseous surgery, continuous sling and interrupted vertical-mattress sutures were used frequently. Implants without GBR were sutured primarily with only simple interrupted sutures.

In GTR, interrupted vertical-mattress, interrupted horizontal- mattress, and interrupted sling sutures were used with themajority of periodontists.Comments left by the surveyed periodontists about this procedure stated that they used multiple suture techniques for this type of surgery. Interrupted sling sutures were frequently used to stabilize the membranes, whereas vertical- or horizontal-mattress sutures were used to secure the flaps.

Soft-tissue grafts predominantly were sutured using either continuous or interrupted sling sutures. The choice of whether to use a continuous or interrupted sling is dependent on the size of the site. A combination of sutures can be used for soft-tissue grafts, such as sling sutures on the recipient site and horizontal-mattress sutures on the donor site. Another combination is with simple-loop interrupted sutures on the recipient site and sling sutures on the donor site. The choice in the various combinations is left up to operator preference.

The results revealed that the continuous interlocking suture was frequently used for GBR. However, the combination of horizontal-mattress and simple-loop interrupted sutures was the most commonly used technique for this procedure.

The survey was simplified by allowing only a single choice per surgical procedure. However, multiple suture techniques are often requiredbecause of the complexity of the periodontal surgery, adjacent anatomy, and the operator’s preference. This survey did not have the depth to address this concern. We tried to overcome this shortcoming by addressing the comments from the periodontists surveyed and integrating them into a streamlined decision tree.

Suturing is empirical, so there is limited evidence to choose superior techniques. We propose a decision tree to aid the dentist in selecting the optimal suture technique based on surgical goals and their experience (Fig. 21). In general, interrupted sutures enable precise flap placement and better control compared to continuous sutures. In comparison, continuous sutures involve more efficient flap management for wide areas with less knotting.

The simple-loop technique is easy to place and can be used in diverse applications.

The figure-eight technique can be applied in interproximal papillae with limited access to approach under the flap.

The horizontal-mattress technique is indicated when muscle pull will place tension on the flap.

The vertical-mattress technique can be combined with periosteal suture for apically positioned flap when the periosteum is not reflected from the bone.

Sling sutures can be used when additional coronal anchorage is needed.

Continuous interlocking sutures can be used to close a long-spanning edentulous ridge.

The continuous horizontal-mattress technique has the same indications as the interrupted horizontal-mattress technique for wide soft- and hard-tissue augmentation as a secondary suture line.

The continuous vertical-mattress technique is indicated for resective surgeries for multiple teeth requiring apically positioned flap.

The continuous sling-suture technique can be used for wide periodontal procedures with need of additional anchorage.

Conclusions

Knowledge of the various suture techniques is required for the optimal surgical wound healing in dentistry. There is no single technique that is the best choice because of the sophisticated characteristics of periodontal procedures. In this article, the most common suture techniques in periodontal procedures are reviewed. The survey tried to show the current trend of the selection of suturing techniques based on the type of surgery. It is very important for the dentist to know the current techniques and their clinical applications to promote optimal healing of surgical wounds.

Acknowledgment

The authors report no conflicts of interest related to this study.

CORRESPONDENCE:

Dr. Terrence J. Griffin, Department of Periodontology, Tufts University School of Dental Medicine, 1 Kneeland St., Boston, MA 02111. E-mail: Terrence.Griffin@tufts.edu.

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