Goals

A surgical suture is one that approximates theadjacent cut surfaces or compresses blood vesselsto stop bleeding. Suturing is performed to

1. Provide an adequate tension of wound clo-sure without dead space but loose enough toobviate tissue ischemia and necrosis

2. Maintain hemostasis3. Permit primary-intention healing4. Provide support for tissue margins until they

have healed and the support is no longerneeded

5. Reduce postoperative pain6. Prevent bone exposure resulting in delayed

healing and unnecessary resorption7. Permit proper flap position

Suture Material

Surgical sutures have been used to close woundssince prehistoric times (50,000–30,000 BC) gaveus the first written description of their use datingback as early as 4,000 BC (Macht and Krizek,1978). Many materials have been used through-out the centuries, such as gold, silver, hemp, fas-cia, hair, linen, and bark. Yet none have providedall of the desired characteristics.

Qualities of the Ideal Suture MaterialThe following qualities of the ideal suture mater-ial are compiled from Postlethwait (1971), Varmaand colleagues (1974), and Ethicon (1985):

1. Pliability, for ease of handling2. Knot security3. Sterilizability4. Appropriate elasticity5. Nonreactivity6. Adequate tensile strength for wound healing7. Chemical biodegradability as opposed to

foreign body breakdown

With the possible exception of coated Vicryl(Ethicon, Somerville, New Jersey), none of thesutures available today meet these criteria. Table3-1 lists the various materials—natural, synthet-ic, absorbable (digested by body enzymes orhydrolyzed), and nonabsorbable—available forperiodontal use.

Use

1. Silk and synthetic sutures are employed mostoften.

2. Gut sutures are used only when retrieval isdifficult when securing grafts and in youngerpatients. The limited physical characteris-tics of gut sutures do not warrant their rou-tine use.

3. When using gut (plain or chromic) sutures,it is often advantageous to soak the packagein warm water for a half-hour and to pullgently but firmly on the suture whenopened. This will remove the kinks andstraighten the suture. Finally, lubricating thesuture lightly with petrolatum or sterile bonewax will prevent brittleness. Note: This is notnecessary with Ethicon sutures.

4. Monofilament sutures are recommendedfor bone augmentation procedures to pre-vent “wicking,” reduce the inflammatoryresponse, and permit longer retention(10–14 days).

5. Gore-Tex (Flagstaff, Arizona) and coatedVicryl sutures are recommended for guidedtissue regeneration procedures.

Material Choice

The choice of materials depends on the following:

1. Surgical Procedurea. Plastic procedures

Suture Site 4-0 to 6-0Needle Size P-3*Material Chromic gut, silk,

monofilamentb. Regeneration

Suture Site 3-0 to 5-0Needle Size P-3; RT-16†

Material Gore-Tex, Vicrylc. Apically positioned flaps

Suture Site 4-0Needle Size J-1; FS2; P-3Material silk

d. Periosteal suturingSuture Site 4-0 or 5-0Needle Size J-1; P-3Material silk

e. ExtractionsSuture Site 3-0 or 4-0Needle Size FS-2; X-1Material silk

2. Biocompatibility‡

3. Clinical experience and preference4. Quality and thickness of tissue5. Rate of absorption versus time for tissue

healing

Table 3-2 outlines the charateristics and applica-tions of resorbable and nonresorbable sutures.

Note: Because silk is a multifilament material that“wicks,” it is not the material of choice when anysterile materials are used (eg, implants, bonegrafts, guided tissue regeneration, or guided boneregeneration) or in the presence of infection (Sil-verstein and Kurtzman, 2005). The ideal materialfor these procedures is expanded polytetrafluo-roethylene (ePTFE).

Knots and Knot Tying

“Suture security is the ability of the knot andmaterial to maintain tissue approximation duringthe healing process” (Thacker and colleagues,1975). Failure is generally the result of untyingowing to knot slippage or breakage. Since the knotstrength is always less than the tensile strength ofthe material, when force is applied, the site of dis-ruption is always the knot (Worsfield, 1961;Thacker and colleagues, 1975). This is becauseshear forces produced in the knot lead to breakage.

Knot slippage or security is a function of thecoefficient of friction within the knot (Price,1948; Hermann, 1971). This is determined by thenature of the material, suture diameter, and typeof knot. Monofilament and coated sutures(Teflon, silicon) have a low coefficient of frictionand a high degree of slippage; braided and twist-ed sutures such as uncoated Dacron and catgut

3

Sutures and Suturing

*Small needles (P-3) are more difficult to negotiate the

posterior interproximal areas.†Gore-Tex.

‡These recommendations are not for microsurgical

procedures.

Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 15

16 Basics

Tabl

e 3-

1Su

ture

s an

d Su

turi

ng

Sutu

re T

ensi

le

Tis

sue

Kn

ot T

ensi

le

Sutu

reTy

pes

Raw

Mat

eria

lA

bsor

ptio

nSt

ren

gth

Rea

ctio

nSt

ren

gth

Indi

cati

ons

Eas

e of

Han

dlin

g

Surg

ical

gu

tP

lain

Col

lage

n f

rom

hea

lthy

D

iges

ted

by b

ody

+

Mod

erat

e +

++

Rap

idly

hea

ling

Abs

orba

ble;

shou

ld n

ot b

e u

sed

mam

mal

sen

zym

es w

ith

in

(lea

st)

++

++

mu

cosa

wh

ere

exte

nde

d ap

prox

imat

ion

70 d

Avo

id s

utu

re

ofti

ssu

es u

nde

r st

ress

is r

equ

ired

rem

oval

Sh

ould

not

be

use

d in

pat

ien

ts

wit

h k

now

n s

ensi

tivi

ties

or

alle

rgie

s to

col

lage

n o

r ch

rom

ium

Surg

ical

gu

tC

hro

mic

Col

lage

n f

rom

hea

lthy

D

iges

ted

by b

ody

+M

oder

ate

but

less

++

+A

s ab

ove;

slow

er

mam

mal

s tr

eate

den

zym

es w

ith

in

than

pla

in g

ut

abso

rpti

onw

ith

ch

rom

ic s

alts

90 d

++

++

Coa

ted

Vic

ryl

Bra

ided

C

opol

ymer

of

lact

ide

Hyd

roly

sis

++

+M

ild

++

Sube

pith

elia

l +

++

(pol

ygla

ctin

910

)C

oate

dan

d gl

ycol

ide

coat

ed

56–7

0 d

++

mu

cosa

l su

rfac

esw

ith

pol

ygla

ctin

370

V

esse

l lig

atio

n

and

calc

ium

ste

arat

eA

ll ty

pes

ofge

ner

al c

losu

reD

exon

B

raid

edH

omop

olym

er o

fSl

ow h

ydro

lysi

s af

ter

++

+M

ild+

+Su

bepi

thel

ial

++

++

(pol

ygly

colic

aci

d)C

oate

dgl

ycol

ic a

cid

coat

ed

60–9

0 d

++

sutu

res

wit

h p

olax

amer

188

Mu

cosa

l su

rfac

esV

esse

l lig

atio

nP

DS

(pol

ydio

xan

one)

Mon

ofila

men

tPo

lyes

ter

Slow

hyd

roly

sis

++

++

Slig

ht

++

Abs

orba

ble

sutu

re

++

Bra

ided

poly

mer

180–

210

d+

wit

h e

xten

ded

wou

nd

supp

ort

Surg

ical

silk

Mon

ofila

men

tN

atu

ral p

rote

in f

iber

U

sual

ly c

ann

ot b

e +

+M

oder

ate

+M

uco

sal s

urf

aces

++

++

Bra

ided

ofra

w s

ilk t

reat

ed

fou

nd

afte

r 2

yr+

++

+(l

east

)Sh

ould

not

be

use

d in

pat

ien

tsw

ith

sili

con

pro

tein

w

ith

kn

own

sen

siti

viti

es o

ror

wax

alle

rgie

s to

silk

Nyl

on D

ura

lon

Eth

ilon

Mon

ofila

men

tLo

ng-

chai

n a

liph

atic

D

egra

des

at a

rat

e +

++

Ext

rem

ely

++

Skin

clo

sure

++

poly

mer

sof

15–2

0%/y

rlo

w 0

- +

Nyl

on 6

or

nylo

n 6

.6N

ylon

Du

ralo

n

Bra

ided

Poly

amid

e po

lym

erD

egra

des

at a

rat

e +

++

Ext

rem

ely

++

Skin

clo

sure

++

++

Sueg

ilon

of15

–20%

/yr

low

0-

+M

uco

sal s

urf

aces

Poly

este

r M

ersi

len

e B

raid

edPo

lyes

ter,

Poly

ethy

len

e,N

onab

sorb

able

++

+M

inim

al +

++

+C

ardi

ovas

cula

r,+

++

Dac

ron

Eth

ibon

dTe

reph

thal

ate

coat

ed

plas

tic,

gen

eral

N

one

know

nw

ith

pol

ybu

tila

tesu

rger

yPe

olen

e M

onof

ilam

ent

Poly

mer

of

prop

ylen

eN

onab

sorb

able

++

+M

inim

al+

+

+G

ener

al,p

last

ic,

++

(pol

ypro

pyle

ne)

tran

sien

t ac

ute

ca

rdio

vasc

ula

r,re

acti

onsk

in s

urg

ery

Gor

e-Te

xM

onof

ilam

ent

Exp

ande

d N

onab

sorb

able

++

+E

xtre

mel

y +

+A

ll ty

pes

ofso

ft

++

++

poly

tetr

aflu

oroe

thyl

ene

low

tiss

ue

appr

oxi-

Not

kn

own

(eP

TFE

)m

atio

n a

nd

card

iova

scu

lar

surg

ery

Mon

ocry

l M

onof

ilam

ent

Polig

leca

pron

e 25

Hyd

roly

sis

90–1

20 d

++

++

Min

imal

++

++

Soft

tis

sue

++

+(p

olig

leca

pron

e 25

)C

opol

ymer

of

glyc

olid

e cl

osu

reA

bsor

babl

e;sh

ould

not

be

use

d an

d ca

prol

acto

ne

wh

ere

exte

nde

d ap

prox

imat

ion

of

tiss

ues

un

der

stre

ss is

req

uir

ed

Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 16

Sutures and Suturing 17

Tabl

e 3-

2C

hara

cter

isti

cs a

nd

App

licat

ion

s of

Res

orba

ble

and

Non

reso

rbab

le S

utu

res

Sutu

re

Dis

cipl

ine

Ten

sile

Str

engt

h Ty

pe o

fNee

dle

Dia

met

er o

fM

ater

ial

Type

ofM

ater

ial

Rec

omm

ende

d G

ener

al a

nd

Spec

ific

Te

chn

iqu

eU

sed

Req

uir

emen

tsR

ecom

men

ded

Rec

omm

ende

dR

ecom

men

ded

Kn

otSi

tuat

ion

s U

sed

Inte

rru

pted

Pe

riod

onto

logy

,den

tal

Min

imal

to

3 / 8re

vers

e cu

ttin

g,4-

0C

hro

mic

gu

t,si

lk

Slip

kn

otIn

terp

roxi

mal

su

turi

ng

sutu

reim

plan

t an

d or

al s

urg

ery

mod

erat

eta

pere

dpo

lyte

traf

luor

oeth

ylen

e (P

TFE

)1 / 2

or 5 / 8

reve

rse

4-0

Poly

este

r “c

olor

”br

aide

d,Su

rgeo

n’s

knot

cutt

ing,

tap

ered

poly

prop

ylen

e,m

onof

ilam

ent

nylo

n5-

0C

hro

mic

gu

t,gu

tSl

ip k

not

*Fl

aps

not

un

der

ten

sion

Tape

r-cu

t5-

0Po

lyes

ter

“col

or”

brai

ded,

Surg

eon’

s kn

otpo

lypr

opyl

ene,

mon

ofila

men

t ny

lon

Figu

re e

igh

t Pe

riod

onto

logy

an

d de

nta

l M

inim

al t

o 3 / 8

reve

rse

cutt

ing,

4-0

Ch

rom

ic g

ut,

gut,

silk

,Sl

ip k

not

Pri

mar

y lin

gual

of

man

dibu

lar

mol

ar

sutu

reim

plan

t su

rger

y,m

oder

ate

tape

r-cu

tP

TFE

regi

onex

trac

tion

sit

esSl

ing

sutu

rePe

riod

onto

logy

,den

tal

Mod

erat

e3 / 8

reve

rse

cutt

ing,

4-0

Ch

rom

ic g

ut,

silk

,PT

FESl

ip k

not

Use

d w

hen

a f

lap

has

bee

n e

leva

ted

on

impl

ant

and

oral

su

rger

yta

per-

cut

only

on

e si

deH

oriz

onta

l D

enta

l im

plan

t an

d or

al

Hig

h3 / 8

reve

rse

cutt

ing,

3-0

Poly

glyc

olic

aci

d (P

GA

)Su

rgeo

n’s

knot

Use

d in

an

teri

or m

andi

ble

or p

oste

rior

m

attr

ess

surg

ery

tape

r-cu

tre

gion

to

resi

st m

usc

le p

ull

sutu

reV

erti

cal

4-0

Ch

rom

ic,g

ut,

silk

Slip

kn

otU

sed

to r

esis

t m

usc

le p

ull,

clos

ely

adap

t m

attr

ess

flap

s to

bon

e an

d ei

ther

tee

th o

r su

ture

den

tal i

mpl

ants

Can

als

o be

use

d to

api

cally

or

coro

nal

ly

posi

tion

fla

ps3-

0P

GA

Surg

eon’

s kn

otU

sed

to r

esis

t m

usc

le p

ull,

clos

ely

adap

t fl

aps

to b

one

and

eith

er t

eeth

or

den

tal i

mpl

ants

Can

als

o be

use

d to

api

cally

or

coro

nal

ly

posi

tion

fla

ps3-

0Si

lkSl

ip k

not

Use

d to

res

ist

mu

scle

pu

ll,cl

osel

y ad

apt

flap

s to

bon

e an

d ei

ther

tee

th o

r de

nta

l im

plan

tsC

an a

lso

be u

sed

to a

pica

lly o

r co

ron

ally

po

siti

on f

laps

Ver

tica

l slin

g Pe

riod

onto

logy

,den

tal

Hig

h3 / 8

reve

rse

cutt

ing,

3-0

PG

ASu

rgeo

n’s

knot

Use

d to

res

ist

mu

scle

pu

ll,cl

osel

y ad

apt

mat

tres

s im

plan

t an

d or

al s

urg

ery,

tape

r-cu

tfl

aps

to b

one,

rege

ner

ativ

e ba

rrie

rs,

sutu

rees

peci

ally

wh

en

and

den

tal i

mpl

ants

,alo

ng

wit

h

perf

orm

ing

guid

ed t

issu

e m

ain

tain

ing

appr

oxim

atio

n o

ffl

ap

and

bon

e re

gen

erat

ive

edge

ste

chn

iqu

es4-

0Si

lkSl

ip k

not

Use

d to

res

ist

mu

scle

pu

ll,cl

osel

y ad

apt

flap

s to

bon

e,re

gen

erat

ive

barr

iers

,an

d de

nta

l im

plan

ts,a

lon

g w

ith

mai

n-

tain

ing

appr

oxim

atio

n o

ffl

ap e

dges

Con

tin

uou

s Pe

riod

onto

logy

,den

tal

Hig

h3 / 8

reve

rse

cutt

ing,

3-0

PG

ASu

rgeo

n’s

knot

Use

d pr

imar

ily in

ede

ntu

lou

s ar

eas

such

in

depe

nde

nt

impl

ant

and

oral

su

rger

yta

per-

cut

as m

andi

bula

r an

teri

or o

r po

ster

ior

slin

g su

ture

regi

on t

o re

sist

mu

scle

pu

ll4-

0Si

lkSl

ip k

not

Use

d of

ten

in d

enta

l im

plan

t an

d bo

ne

augm

enta

tion

pro

cedu

res

and

in

hype

rpla

stic

/fib

rou

s ri

dge

redu

ctio

n

for

den

ture

sta

bilit

y

*Res

tric

ted

area

s su

ch a

s bu

ccal

ves

tibu

le m

axill

ary

mol

ars

or m

uco

gin

giva

l su

rger

y (e

g,so

ft t

issu

e gr

afts

).(S

ilver

stei

n L

,199

9)

Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 17

have greater knot security because of their highcoefficient of friction (Taylor, 1938).

It is interesting to note that basic suture silk,although extremely user friendly, is distinctlyinferior in terms of strength and knot securitycompared with other materials (Hermann, 1971).It also shows a high degree of tissue reaction(Postlethwait, 1968; Taylor, 1978), and the addi-tion of wax or silicon to reduce the tissue reactionand prevent wicking further diminishes knotsecurity (Hermann, 1971).

Knot selection is the last of the variables andthe one over which surgeons have the most influ-ence. Knot security has been found to vary great-ly among clinicians, and even the security ofknots tied by the same clinician varies at differenttimes (Hermann, 1971).

A sutured knot has three components (Fig-ure 3-1) (Thacker and colleagues, 1975):

1. The loop created by the knot (Figure 3-1A)2. The knot itself, which is composed of a num-

ber of tight “throws” (Figure 3-1B;); eachthrow represents a weave of the two strands

3. The ears, which are the cut ends of the suture

In Figure 3-2, we see the four knots mostcommonly used in periodontal surgery. In astudy, Thacker (1975) found that the granny knotwas the least secure, always requiring morethrows or ties to achieve the same knot strengthas the square or surgical knot. For materials witha high degree of slippage (monofilament or coat-ed sutures), flat and square throws were recom-mended, with all additional throws being squared.Cutting the ears of the suture too short is con-traindicated when slippage is great because theknot will come untied if the slippage exceeds thelength of the ears. Loosely tied knots were shownto have the highest degree of slippage, whereas intight knots, slippage was not a significant factor.

Principles of Suturing

Ethicon (1985) recommends the following prin-ciples for knot tying:

1. The completed knot must be tight, firm, andtied so that slippage will not occur.

2. To avoid wicking of bacteria, knots shouldnot be placed in incision lines.

3. Knots should be small and the ends cut short(2–3 mm).

4. Avoid excessive tension to finer-gauge mate-rials because breakage may occur.

5. Avoid using a jerking motion, which maybreak the suture.

6. Avoid crushing or crimping of suture mate-rials by not using hemostats or needle hold-ers on them except on the free end for tying.

7. Do not tie the suture too tightly because tis-sue necrosis may occur. Knot tension shouldnot produce tissue blanching.

8. Maintain adequate traction on one endwhile tying to avoid loosening the first loop.

9. The surgeons knot and square knot strength,although generally not needing more thantwo throws, will have increased strength withan additional throw.

10. Granny knots and coated and monofilamentsutures require additional throws for knotsecurity and to prevent slippage. CoatedVicryl will hold with four throws—two fullsquare knots.

Sutures should be removed as atraumatical-ly and cleanly as possible. Ethicon (1985) recom-

mends the following principles for sutureremoval:

1. The area should be swabbed with hydrogenperoxide for removal of encrusted necroticdebris, blood, and serum from about thesutures.

2. A sharp suture scissors should be used to cutthe loops of individual or continuous suturesabout the teeth. It is often helpful to use a no.23 explorer to help lift the sutures if they arewithin the sulcus or in close opposition tothe tissue. This will avoid tissue damage andunnecessary pain.

18 Basics

FIGURE 3-1. Knot anatomy. A, Various knot components prior to completion. B, Completed knot anatomy.

FIGURE 3-2. Suturing knots.

Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 18

Sutures and Suturing 19

3. A cotton pliers is now used to remove thesutures. The location of the knots should benoted so that they can be removed first. Thiswill prevent unnecessary entrapment underthe flap.

Note: Sutures should be removed in 7 to 10 days toprevent epithelialization or wicking about the suture.

Surgical NeedlesMost surgical needles are fabricated from heat-treated steel and possess a microsilicon finish todiminish tissue drag and a tip that is extremelysharp and has undergone electropolishing(Ethicon, 1985). The surgical needle has a basicdesign composed of three parts (Figure 3-3):

1. The eye which is press-fitted or swaged (eye-less) permits the suture and needle to act asa single unit to decrease trauma.

2. The body which is the widest point of needleand is also referred to as the grasping area. Thebody comes in a number of shapes (round,oval, rectangular, trapezoid, or side flattened).

3. The point which runs from the tip of themaximum cross-sectional area of the body.The point also comes in a number of differ-ent shapes (conventional cutting, reversecutting, side cutting, taper cut, taper, blunt)(Figure 3-4).

4. The chord length is the straight line distancebetween the point of a curved needle and theswage.

5. The radius is the distance measured from thecenter of the circle to the body of the needleif the curvature of the needle was continuedto make a full circle.

Needle Holder SelectionEthicon (1985) gives the following pointers forselecting a needle holder:

1. Use an approximate size for the given needle.The smaller the needle, the smaller the nee-dle holder required.

2. The needle should be grasped one-quarter tohalf the distance from the swaged area to thepoint, as shown in Figure 3-5.

3. The tips of the jaws of the needle holdershould meet before the remaining portionsof the jaws.

4. The needle should be placed securely in the tipsof the jaws and should not rock, twist, or turn.

5. Do not overclose the needle holder. Itshould close only to the first or secondrachet. This will avoid damaging or notch-ing the needle.

6. Pass the needle holder so that it is alwaysdirected by the surgeon’s thumb.

7. Do not use digital pressure on the tissue; thismay puncture a glove.

Placement of Needle in TissueEthicon (1985) gives the following principles forplacing the needle in tissue:

1. Force should always be applied in the direc-tion that follows the curvature of the needle.

2. Suturing should always be from movable tononmovable tissue.

3. Avoid excessive tissue bites with small needlesbecause it will be difficult to retrieve them.

4. Use only sharp needles with minimal force.Replace dull needles.

5. Grasp the needle in the body one-quarter tohalf the length from the swaged area. Do nothold the swaged area; this may bend or breakthe needle. Do not grasp the point areabecause damage or notching may result (seeFigure 3-5).a. Prior to suturing, the needle holder is

repositioned to the forward half of theneedle with a few millimeters of the tip,as shown in Figure 3-5.

6. The needle should always penetrate the tis-sue at right angles.a. Never force the needle through the tissue.

7. Avoid retrieving the needle from the tissueby the tip. This will damage or dull the nee-dle. Attempt to grasp the body as far back as possible.

9. An adequate tissue bite (≥ 2–3 mm) isrequired to prevent the flap from tearing.

Suturing Techniques

Different suturing techniques may employ eitherperiosteal or nonperiosteal suture placement:

1. Interrupteda. Figure eightb. Circumferential director loopc. Mattress—vertical or horizontald. Intrapapillary

2. Continuousa. Papillary slingb. Vertical mattressc. Locking

The choice of technique is generally made onthe basis of a combination of the individual oper-ator’s preference, educational background, andskill level, as well as surgical requirements.

Periosteal Suturing

Periosteal suturing generally requires a highdegree of dexterity in both flap management andsuture placement. Small needles (P-3), finesutures (4-0 to 6-0), and proper needle holdersare a basic requirement. Periosteal suturing per-mits precise flap placement and stabilization.

TechniqueThe five steps here are used in periosteal suturing(Chaiken, 1977) and are seen in Figure 3-6:

FIGURE 3-3. Needle anatomy. Needles are described by their arc. Most periodontal surgical needles are ofthree-eighths or one-half curvature. Different components of the needle are described.

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20 Basics

FIGURE 3-4. Cutting needles. Both outline and cross-sectional views of the various forms of cutting needle are shown. Conventionalcutting and reverse cutting are also shown.

FIGURE 3-5. Correct handling of suture needles. A, Needle holder holding a suture needle just anterior tothe curvature; correct position; A', suture needle undamaged. B, Suture needle held incorrectly at tip; B', tipof suture needle damaged. C, Suture needle held incorrectly behind curvature; C', needle bent as a result.

A A'

B B'

C C'

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Sutures and Suturing 21

1. Penetration: The needle point is positionedperpendicular (90°) to the tissue surface andunderlying bone. It is then inserted com-pletely through the tissue until the bone isengaged. This is as opposed to the usual 30°needle insertion angle (see Figure 3-6A).

2. Rotation: The body of the needle is nowrotated about the needle point in the direc-tion opposite to that in which the needle isintended to travel. The needle point is held

tightly against the bone so as not to damageor dull the needle point (see Figure 3-6B).

3. Glide: The needle point is now permitted toglide against the bone for only a short dis-tance. Care must be taken not to lift or dam-age the periosteum (see Figure 3-6C).

4. Rotation: As the needle glides against thebone, it is rotated about the body, followingits circumferenced outline. In this way, theneedle will not be pushed through the tissue,

resulting in lifting or tearing of the perios-teum (see Figure 3-6, D and E).

5. Exit: The final stage of gliding and rotation isneedle exit. The needle is made to exit thetissue through the gentle application of pres-sure from above, thus allowing the tip topierce the tissue. If digital pressure is to beused, care must be used to avoid personalinjury (see Figure 3-6F).

1

2

FIGURE 3-6. Periosteal suturing. A, Needle penetration; needle point is perpendicular to bone. B, Rotation of needle body about point.C,D, The needle is moved along the bone below the periostum. E, Rotation about needle body permitting point to exit periosteum andtissue. F, Completed periosteal suture.

A

D E F

B C

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Interrupted Sutures

IndicationsInterrupted sutures are most often used for thefollowing:

1. Vertical incision2. Tuberosity and retromolar areas3. Bone regeneration procedures with or with-

out guided tissue regeneration4. Widman flaps, open flap curettage, unreposi-

tioned flaps, or apically positioned flaps wheremaximum interproximal coverage is required

5. Edentulous areas6. Partial- or split-thickness flaps7. Osseointegrated implants

TypesIn Figure 3-7, we see the four most commonlyused interrupted sutures:

1. Circumferential, direct, or loop (see Figure3-7A)

2. Figure eight (see Figure 3-7B)3. Vertical or horizontal mattress (see Figure

3-7C)4. Intrapapillary placement (see Figure 3-7D)

Technique

Figure Eight and Circumferential Sutures.Suturing is begun on the buccal surface 3 to 4 mmfrom the tip of the papilla to prevent tearing of thethinned papilla. The needle is first inserted intothe outer surface of the buccal flap and then eitherthrough the outer epithelialized surface (figureeight) (Figure 3-8) or the connective tissue underthe surface (circumferential) (see Figure 3-8A) ofthe lingual flap. The needle is then returned throughthe embrasure and tied buccally.

When interproximal closure is critical, thecircumferential suture will permit greater coapta-tion and tucking down of the papilla because ofthe lack of intervening suture material betweenthe tips of the papilla.

Mattress Sutures. Mattress sutures are used forgreater flap security and control; they permitmore precise flap placement, especially whencombined with periosteal stabilization. They alsoallow for good papillary stabilization and place-ment. The vertical mattress (nonperiosteal) sutureis recommended for use with bone regenerationprocedures because it permits maximum tissue clo-

sure while avoiding suture contact with the implantmaterial, thus preventing wicking. They are left for14 to 21 days (Mejias, 1983) and therefore requirea suitable material (eg, nylon, e-PTFE) that isbiologically inert and does not rapidly “wick.”

Vertical Mattress Technique. The flap is stabi-lized and a P-3 needle is inserted 7 to 10 mm api-cal to the tip of the papilla. It is passed through theperiosteum (if periosteal sutures are being used),emerging again from the epithelialized surface ofthe flap 2 to 3 mm from the tip of the papilla. Theneedle is brought through the embrasure, wherethe technique is again repeated lingually or palatal-ly. The suture is then tied buccally (Figure 3-9A).

Horizontal Mattress Technique. A P-3 needle isinserted 7 to 8 mm apical to and to one side of themidline of the papilla, emerging again 4 to 5 mmthrough the epithelialized surface on the oppos-ing side of the midline (Figure 3-9B). The suturemay or may not be brought through the perios-teum. The needle is then passed through theembrasure, and the suture, after being repeatedlingually or palatally, is tied buccally. For greaterpapillary stability and control, the double parallel

A B

FIGURE 3–7. Four interrupted sutures. A, Circumferential. B, Figure-eight. C, Vertical mattress. D, Intrapapillary.

C D

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Sutures and Suturing 23

A B

FIGURE 3-8. A, Circumferential suture. B, Figure-eight suture.

A B

FIGURE 3-9. A, Horizontal mattress suture. B, Vertical mattress suture.

A B C

FIGURE 3-10. Sling suture about adjacent tooth.

D E F

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24 Basics

FIGURE 3-11. Sling suture about single tooth.

A

E FD

B C

strands of this suture can be made to cross overthe three tops of the papillae. This is the doublecrossed-over suture.

Intrapapillary Placement. This technique is rec-ommended for use only with modified Widmanflaps and regeneration procedures in which there isadequate thickness of the papillary tissue.

A P-3 needle is inserted buccally 4 to 5 mmfrom the tip of the papilla and passed through thetissue, emerging from the very tip of the papilla.This is repeated lingually and tied buccally, thuspermitting exact tip-to-tip placement of the flaps(see Figure 3-7D).

Sling Suture. The sling suture is primarily usedfor a flap that has been raised on only one side ofa tooth, involving only one or two adjacent papil-lae. It is most often used in coronally and lateral-ly positioned flaps. The technique involves use ofone of the interrupted sutures, which is eitheranchored about the adjacent tooth (Figure 3-10)or slung around the tooth to hold both papillae(Figure 3-11).

Specialized Interrupted Suturing Techniques forBone Regeneration and Retromolar and Tuberos-ity Areas. Laurell Modification. Laurell modi-fied mattress suture (1993) (Figure 3-12) for coro-nal flap positioning and primary flap coverage is atechnique which, although capable of beingemployed for all regenerative techniques, is used

sion and above the first suture (Figure 3-13A2).The suture is passed through the interproximalpapilla and returned as a horizontal mattresssuture on the buccal surface and tied off.

Retromolar Suture Modification for Primary Cov-erage. This technique (Hutchenson 2005) (Fig-ure 3-14) is specially designed for gaining inti-mate tissue-tooth contact where regeneration isbeing attempted. It is employed when there is anintrabony defect distal to the last tooth on thelower teeth. It not only permits primary flap clo-sure but close approximation of the tissue on thedistal aspect of the tooth. Figure 3-14A shows adefect distal to the last tooth. The arrows on Fig-ure 3-14B indicates desired movement of flap anddotted lines indicate ideal flap position. Flap ide-ally should be positioned against distal surface oftooth with primary closure. Suture is begun onthe mesiobuccal of the terminal tooth (Figure3-14C1). The suture is passed through interprox-imal to the distal and inserted through only theundersurface of the buccal flap. The suture isbrought almost 360° around the tooth startinglingually and continuing bucally until againreaching the distal surface (Figure 3-14C2). Theneedle is passed through the undersurface of thelingual flap and tied on the buccal surface (Figure3-14C3). Figure 13-14D shows suturing havingbeen completed and primary coverage attained.

predominantly when standard interproximal inci-sions are used. Start bucally below the papilla (2–4mm) and insert the needle to and then throughthe undersurface of the lingual flap (Figure 3-12A1). The suture needle is then reinserted lin-gually 2–4 mm above the initial suture and contin-ued to and then through the buccal flap (Figure3-12A2). The suture is then brought lingually overthe coronal aspect of the flap and through the loop(Figure 3-12A3). The suture is afterwards returnedbucally and sutured (Figure 3-12A4). Figure 3-12Bshows the completed suture.

Modified Flap Suturing Technique. This tech-nique (Cortellini et al 1995) was introducedspecifically for achieving maximum interproxi-mal coverage and primary closure over intrabonydefect is treated by GTR. The modified flap tech-nique (Figure 3-13) requires the initial incisionbe made at the buccal line angles in the area ofthe interproximal defect. It is a papillary preser-vation technique. The suturing permits coronalpositioning, flap stabilization, and primary inter-proximal closure. The first suture is begun buc-cally 5–6 mm below the initial incision (Fig-ure 3-13A1). The suture is passed through thebuccal and palatal flaps. It is then reinsertedpalatally and allowed to exit the buccal flap 2 mmabove the initial placements. This is tied off andshould stabilize the body of the flap. The secondsuture is now begun 3–4 mm below the initial inci-

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Sutures and Suturing 25

FIGURE 3-12. Laurell modified mattress suture (see text). FIGURE 3-13. Modified flap suturing technique (see text).

Continuous Sutures Sling

When multiple teeth are involved, the continuoussuture is preferred.

Advantages1. Can include as many teeth as required2. Minimizes the need for multiple knots3. Simplicity4. The teeth are used to anchor the flap5. Permits precise flap placement6. Avoids the need for periosteal sutures7. Allows independent placement and tension

of buccal and lingual or palatal flaps. Buccalflaps can be positioned loosely, whereas lin-gual and palatal flaps are pulled more tightlyabout the teeth.

8. Greater distribution of forces on the flaps

DisadvantagesThe main disadvantage of continuous sutures isthat if the suture breaks, the flap may become

loose or the suture may come untied from multi-ple teeth.

TypesThe choice of continuous suture depends on theoperator’s preference. These, too, can be periostealor nonperiosteal:

1. Independent sling suture2. Mattress sutures

a. Verticalb. Horizontal

3. Continuous locking

Technique

Independent Sling SutureThe continuous sling suture (Figure 3-15),although most often begun as a continuation oftuberosity or retromolar suturing (see Figure3-15A), can also be started with a looped sutureabout the terminal papilla (buccal, lingual, orpalatal). It is then continued through the next

interproximal embrasure (see Figure 3-15B) insuch a manner that the suture is made to encirclethe neck of the tooth (see Figure 3-15C). Theneedle is then passed either over the papilla andthrough the outer epithelialized surface or under-neath and through the connective tissue under-surface of the papilla. The needle is passed againthrough the embrasure and continued anteriorly(Figure 3-15D). This procedure is repeatedthrough each successive embrasure until allpapillae have been engaged.

Note: For maximum flap control, it is best to passthe needle through the connective tissue under-surface of the papilla.

A terminal end loop (Figure 3-15E) is thenused if a single flap has been reflected or if theflaps are to be sutured independently. In thismanner, the flaps are tied against the teeth asopposed to each other.

FIGURE 3-14. Retromolar area modified suture technique (see text).

A B

C D

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Terminal End Loop. On completion of suturing,the suture is tied off against the tooth as opposedto the other flap. This is accomplished by leaving aloose loop of approximately 1 cm length of suturematerial before the last embrasure. When the lastpapilla is sutured and the needle is returnedthrough the embrasure, the terminal end loop isused to tie the final knot (Figure 3-15F–I).

Modification. When two flaps have beenreflected and after the first flap has been sutured(Figure 3-16A), it is often desirable to continueabout the distal surface of the last tooth (Figure3-16B), repeating the procedure on the opposingflap (Figure 3-16C) and then tying off in a termi-nal end loop (Figure 3-16D and E).

Alternative Procedure. This technique simulta-neously slings together both the buccal and lin-gual or palatal flaps.

INDICATIONS.1. When flap position is not critical2. When buccal periosteal sutures are used for

buccal flap position and stabilization3. When maximum closure is desired (unrepo-

sition or Widman flaps or bone regeneration)

FIGURE 3-15. Continuous sling suture with terminal end loop.

1 23

4

A

G H

E

B

I

F

C

D

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Sutures and Suturing 27

TechniqueAfter the initial buccal and lingual tie, the suture ispassed buccally about the neck of the tooth inter-dentally and through the lingual flap. It is thenagain brought interdentally through the buccalpapilla and back interdentally about the lingualsurface of the tooth to the buccal papilla. Then it isbrought about the lingual papilla and then thebuccal surface of the tooth. This alternating buc-cal-lingual suturing is continued until the suture istied off with a terminal end loop (Figure 3-17).

Vertical and Horizontal Mattress Suture. Whengreater papillary control and stability and moreprecise placement are required or to prevent flapmovement, vertical or horizontal mattress suturesare used. This is most often the case on the palate,where additional tension is often required, orwhen the papillary tissue is thin and friable.

through the remaining loop of the suture, and thesuture is pulled tightly, thus locking it. This proce-dure is continued until the final suture is tied off atthe terminal end (Figure 3-18).

Suture Removal

Sutures are used for wound stabilization andshould be removed when sufficient tissue strengthhas been achieved. This is usually between 5 and10 days, and in most instances, these sutures areremoved in 7 days.

Materials1. Scissors2. Cotton pliers3. Double-ended scaler4. Hydrogen peroxide5. Topical anesthetic6. Cotton swabs

Technique. The procedure is identical to thatpreviously described for the independent papil-lary sling suture (see Figure 3-15), except thatvertical or horizontal mattress sutures are substi-tuted for the simple papillary sling. The tech-nique is similar to that previously described forthe interrupted mattress sutures.

Locking. The continuous locking suture is indi-cated primarily for long edentulous areas,tuberosities, or retromolar areas. It has the advan-tage of avoiding the multiple knots of interruptedsutures. If the suture is broken, however, it maycompletely untie.

Technique. The procedure is simple and repeti-tive. A single interrupted suture is used to make theinitial tie. The needle is next inserted through theouter surface of the buccal flap and the underlyingsurface of the lingual flap. The needle is then passed

A

E

B C

D FIGURE 3-16. Continuous independent sling suture of indi-vidual flaps.

1

23

4

5 8

8 7 65

4

321

7 65

67

8

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FIGURE 3-17. Modification of continuous slingsuture. This technique permits simultaneous sutur-ing of both flaps.

ED

BA C

1

2

3

4

5

6

7

8

9

1

2

3

4

5

6

7

89

1

2

3

4

5

6

7

8

9

10

11

1

3

5

7

9

11

12

13

14

2

4

6

8

10

12

Method1. The scaler is used to remove the dressing.

The dressing should be loosened first in anapicocoronal direction. This will place thetension against the teeth and not the tissue.

2. The area is then gently swabbed with hydro-gen peroxide to move clotted blood, serum,and debris and is rinsed with warm water.

3. Topical anesthetic may be optionally applied

for reduction of patient sensitivity prior tosuture removal.

4. A sharp scissors should be used to cut theloops of the individual or continuoussutures. Note: It is often helpful to use the tipof an explorer to gently lift the suture off thetissue prior to cutting. This will avoid tissuedamage and unnecessary pain.

5. Interrupted sutures need be cut only on thefacial aspect close to the tissue.

6. Continuous sutures will require cutting bothbuccally and lingually.

7. Once the sutures are removed, the areashould again be swabbed with hydrogen per-oxide or chlorhexidine gluconate to removeany residual debris.

8. The teeth should be polished for completeremoval of debris and stain.

9. Plaque control should again be reviewed.

FIGURE 3-18. Continuous locking sutureused primarily for edentulous areas.

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