Suturando para sucesso cirúrgico.pdf

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Suturing for Surgical Success

Written by Gregori M. Kurtzman, DDS Saturday, 01 October 2005 00:00

Surgery involves the creation of a wound, and proper closure of this wound is usually

necessary to promote optimal healing. Suturing a wound positions and secures the

surgical flaps to promote healing. Surgical sutures should hold the edges of a flap in

apposition until the wound has healed sufficiently to withstand normal functional

stresses and resist reopening.

Table 1. General Guidelines for Suturing.

Sutures are usually first placed distal to the last tooth,

in each interproximal space, with suturing continued in

a mesial direction.

First insert sutures through the more mobile tissue flap.

When space is restricted, use a one-half circle needle.

Only needle holders should be used to grasp suture

needles, and the suture needle should be inserted and

pulled through the issue in line with the curve of the

needle.

Grab the suture needle in the center of the needle,

never at its tip or near where the thread is swage to the

needle.

When suturing multiple tissue levels, the goal is to

suture periosteum to periosteum and gingival tissue togingival tissue. (Note: The connective tissue and

epithelial layers are together being referred to as

gingival tissue.)

The needle should enter tissue at right angles to the

tissue.

Do not place sutures closer than 2 mm to 3 mm from

the flap edges to prevent tearing through the flap

during suturing, or if postoperative swelling occurs.
http://www.dentistrytoday.com/periodontics/359-suturing-for-surgical-successhttp://www.dentistrytoday.com/periodontics/359-suturing-for-surgical-successhttp://www.dentistrytoday.com/periodontics/359-suturing-for-surgical-success


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When suturing, flaps should be approximated without

blanching of the tissue. Pull the suture just tight

enough to secure the flap in place without restricting

the flap's blood supply.

In addition to proper technique, it is critical to select the appropriate type and size(diameter) of suture material to ensure that wound margins are free of tension, allowing

healing by primary intention.1 Accurate apposition of surgical flaps contributes to

patient comfort, hemostasis, reduction of wound size, and prevention of unnecessary

bone resorption. If surgical wound edges are not properly approximated, hemostasis can

be compromised and blood/serum may accumulate under the flap. This could result in a

space between the underlying soft tissue and bone, thus delaying the healing process.2 In

addition, when this occurs, healing will be by secondary intention, which can lead to

irregular soft-tissue contours and the formation of scar tissue (Table 1).

Conventional intraoral surgical treatment concludes with closure of the soft tissue.

Proper suturing precisely positions the mucosal and/or mucoperiosteal flaps as required

by the surgical procedure being performed. Certain periodontal surgical procedures (eg,

excisional new attachment procedure [ENAP] and modified Widman flap procedure)

require the surgical flap margins to be positioned in their original location, whereas

other periodontal procedures may require that the surgical flaps be placed apically,

coronally, or laterally to their original position in order to achieve the surgical

objectives.3

Suturing technique, the type and diameter of suture material (thread), the type of

surgical needle, and the design of the surgical knot are essential factors in achieving

optimal wound healing. Wound closure variables are different when suturing over hardversus soft tissue, or suturing over various types of materials placed into the surgical

site to promote periodontal regeneration (eg, bone graft material or a membrane). The

suture material and needle design will change accordingly.

This article will discuss suturing materials and certain useful suture knot designs, with a

focus on periodontal surgical procedures.

MATERIAL COMPONENTS

Needles

Figure 1. Comparison of a

one-half circle needle (top)

and three-eighths circle needle


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The surgical needle is composed of the point, the body, and the swaged (press-fit) end.

Classification of suture needles is usually based on their curvature, radius, and shape.

For intraoral use, three-eighths and one-half circle needles are most commonly used3,4

(Figure 1).

When using the three-eighths needle to close tissue in the oral cavity, the clinicianrotates the needle on a central axis to pass it from the buccal surface to the lingual

surface in one motion, whereas the one-half circle needle is traditionally used in more

restricted areas (eg, buccal surface of maxillary molars and facial surface of maxillary

and mandibular incisors). The one-half circle needle is routinely used for periosteal and

mucogingival surgery.1-4

Figure 2. Conventional needle

(left) and reverse-cutting

needle

Suture needles may also be classified as either conventional cutting or reverse cutting.5

In the oral cavity, reverse-cutting sutures should be used to prevent the suture material

from tearing through the papillae or edges of the surgical flap (referred to as "cut out" ).

Conventional su-ture needles are generally associated with cut out because the inside

concave (inner) curvature is sharpened; as the needle is pulled through the tissue, it cuts

the tissue. This is detrimental in dental surgery because the tears that are created willcomplicate healing. In contrast, the inner curvature of a reverse-cutting needle is

smooth, with a third cutting edge located on the convex (outer) edge.4 Figure 2

illustrates the inner curvature of a reverse-cutting needle compared to a conventional

needle. For suturing of mucoperiosteal flaps in the oral cavity, the three-eighths reverse-

cutting needle with 3-0 or 4-0 thread diameters and the one-half reverse-cutting needle

with thinner 5-0 or 6-0 thread diameters are commonly used combinations.

Suture Material

Tensile strength is an important quality when determining which suture material is

appropriate for specific situations. Tissue biocompatibility and ease of handling, with afocus on minimal knot slippage, also influence which thread should be selected. The

clinician should select the suture material and diameter based on the thickness of the

tissue to be sutured and whether there is a need for flap tension. 4

Therefore, selection of the suturing technique and material should be based on the goals

of the surgical procedure and the physical/biologic characteristics of the suture material

in relationship to the healing process. Adequate strength of the suture material will

prevent breakage during suturing, and proper tying of the knot in consideration of the

material being used will prevent untying or knot slippage. The clinician must also

understand the nature of the suture material, the wound healing process, the biologic

forces exerted on the healing wound (eg, muscle pulls and swelling), and the interaction

of the suture and tissue. The suture must retain its strength until the tissues of the flaps


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regain sufficient strength to keep the wound edges together. In clinical situations where

the tissues will not regain their preoperative strength, or tension is exerted on the

surgical flaps, consideration should be given to using a suture material that retains long-

term strength (up to 14 days) and resorbs in 21 to 28 days, such as conventional

polyglycolic acid (PGA) suture material.2,4 A clinical example would be a resorbed

anterior mandible that has muscle attachments close to the crestal ridge; when the flapmargins are reapproximated there will be tension on the margins. Should a resorbable

suture material be used that loses its tensile strength after a few days, the re-adhesion of

the periosteum to the underlying bone will not have gained enough strength to

overcome the muscle pull. Therefore, a longer-lasting suture material should be utilized

until the flap has achieved sufficient reattachment to the bone.

Resorbable sutures lose tensile strength over a period of time from several days to

several weeks, and the breakdown of the resorbable material should equal the healing

rate of the tissue being coapted by the material. If a suture is to be placed in tissue that

heals rapidly, a resorbable suture should be used that will lose its tensile strength at

approximately the same rate as the tissue gains strength. The suture will be absorbed bythe tissue, leaving no foreign material in the wound after healing. Examples are surgical

gut or the rapidly resorbable PGA sutures (PGA-FA).1

Resorbable sutures re-sorb due to 2 mechanisms. Sutures of biological origin (eg,

surgical gut, plain and chromic gut) are gradually digested by enzymes in the tissue,

whereas resorbable sutures fabricated from synthetic materials such as polygycolic acid

are hydrolyzed via the Kreb's cycle.2 Surgical gut suture material is made from animal

protein (ie, gut), thus it can potentially induce an antigenic reaction.6 When used

intraorally, this material loses most of its tensile strength in 24 to 48 hours; coating the

material with a chromic compound extends resorption to 7 to 10 days, and extends

significant tensile strength to 5 days.5

An additional consideration with regard to gut su-tures is that breakage of the material

during the resorption process may occur too rapidly to maintain flap apposition,

particularly if used in patients with a very low intraoral pH.4 Many physiological events

can cause a decrease in intraoral pH, including disorders such as epigastric reflux, hiatal

hernia, and bulimia. Sjogren's syndrome, chemotherapy, radiation therapy, and certain

medications (eg, angiotensin-converting inhibitors, anti-psychotics, diuretics,

antihypertensive agents, antipsoriasis medications, and steroid inhalers) can cause

xerostomia and a low intraoral pH.2,7

Coaptation of tissue flaps requires a minimum of 5 days.5 Selection of a fast-absorbing

PGA suture is indicated in clinical situations where there is a low intraoral pH (and

surgical gut sutures are contraindicated). PGA-FA suture material is not affected by low

intraoral pH; it is manufactured from synthetic polymers and is mainly degraded by

hydrolysis in tissue fluids (via enzymes involved in the Kreb's cycle). This requires 7 to

10 days.1,2 This material has a higher tensile strength than surgical gut suture material,

but its resorption rate is comparable to that of surgical gut sutures under normal

intraoral physiologic conditions.1,2

Nonresorbable sutures are fabricated either from natural or synthetic materials. Silk has

been the most widely used material for dental and many other types of surgery.8

Silk iseasy to handle, is tied with a slipknot, and costs less than many other nonresorbable


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suture materials. However, silk sutures have certain disadvantages. Being nonresor-

bable, silk sutures must be removed by the clinician, usually 1 week following surgery.

The patient generally is not anesthetized for this suture removal. Further, being a

multifilament thread, silk demonstrates a "wick effect," which pulls bacteria and fluids

into the wound site.9 Therefore, silk is not the suture material of choice when foreign

materials such as dental implants, bone grafts, or regenerative barriers are placed undera mucoperiosteal flap, or when infection of the surgical site is present at the time of

surgery (ie, removal of a septic tooth).

Nonresorbable sutures that can be used in situations where silk is contraindicated

include nylon, polyester, polyethylene, polypropylene, or expanded

polytetrafluoroethylene (e-PTFE). Polyester sutures comprise multiple filaments of

polyester polymer, which are braided into a single strand that possesses high tensile

strength and does not weaken when moistened. A biologically inert, nonresorbable

compound of proprietary composition4 is often used to coat these sutures to aid the

suture in passing more easily through tissues. However, this coating allows the material

to untie easily unless the suture is secured with a surgeon's knot. 4 Nonresorbable e-PTFE suture material is a monofilament with high tensile strength, good handling

properties, and good knot security. It is, however, expensive compared with other

nonresorbable suture materials.1

Table 2. Suture Thread Types Used in Dentistry.

(A) Nonresorbable

Type Commonly used thread size

silk 3-0, 4-0, 5-0

nylon 4-0, 5-0, 6-0

polypropylene 5-0, 6,0

e-PTFE 4-0, 5-0

(B) Resorbable

Type Commonly used thread

size

Resorption time

(days)

gut 4-0 3 to 5

chromic gut 4-0, 5-0 7 to 10

PGA 3-0, 4-0, 5-0 21 to 28

PGA-dyed 3-0, 4-0, 5-0 21 to 28

In addition to material composition, surgical threads are also classified by numbering

from 1 to 10; higher numbers indicate thinner, more delicate thread.10 For example, in

implant dentistry a 3-0 thread diameter is generally used to secure flaps when a mattress

suturing technique is used, and a 4-0 thread is used closer to the flap edges to coapt

tension-free flap edges. A 4-0 thread also is used to secure implant surgical flaps when

interrupted sutures, horizontal or vertical mattress sutures (depending on where the

tissue is positioned), and most continuous suture techniques are utilized. In periodontal

plastic surgery procedures a 5-0 thread diameter is most often used to secure soft-tissue


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grafts and transpositional/sliding pedicle flaps. When securing most other periodontal

mucoperiosteal flaps, 4-0 thread is used (Table 2).

SURGICAL KNOTS

Figures 3a to 3c. Slipknot

being tied.

3b.

3c. Figures 4a to 4c. Surgeon's

knot being tied.

4b. 4c.

Tying surgical knots is a critical aspect of suturing. The appropriate surgical knot

should be used for the specific suture material in order to ensure knot security. For

example, a slip (granny) surgical knot, which allows the surgeon to tighten the suturetoward the tissue without loosening or opening, could be used for e-PTFE, chromic gut,

or plain gut suture material (Figures 3a to 3c). However, a surgeon's knot, which will

remain where positioned, must be used with synthetic resorbable and nonresorbable

suture materials to prevent untying of the knot4 (Figures 4a to 4c). The mode of

manufacture of each specific suture thread determines the type of knot that is used. 5


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EXAMPLES OF USEFUL SUTURING TECHNIQUES

Figure 5. A simple loop suture

used to coapt flap margins.

Figure 6. The simple loop

suture being tied to coapt the

edges of the incision.

Two suturing techniques can be used for the interrupted suture: the simple loop and thecriss-cross (which is a modification of the horizontal mattress suture technique). In

dental surgery, the simple loop (Figure 5) is used most commonly to coapt tension-free,

mobile surgical flaps.4 Procedures where the simple loop is useful include surgery of

edentulous ridge areas, to coapt vertical releasing incisions, for periosteal suturing, and

to coapt flaps as part of certain periodontal surgical procedures (ie, modified Wid-man

flap, some periodontal regeneration surgery, and some exploratory flap procedures). A

simple loop is created by entering the buccal flap from the epithelial surface (position 1)

and crossing under the periosteum to exit the epithelial surface of the lingual flap

(position 2); a knot is tied toward the buccal (Figure 6). (Note: This example assumes a

simple flap where all the soft tissue has been elevated off the bone, including the

periosteum.)

Figure 7. A criss-cross suture

placed at an extraction site toclose the margins and aid in

retention of graft material

placed in the socket.

The criss-cross is similar to the simple loop on the buccal aspect; however, on the

lingual aspect, the needle penetrates first through the epithelial surface of the lingual

flap, thus interposing additional suture thread between the surgical flaps. The criss-cross

technique is useful when suturing on the lingual aspect of the man-dibular molars,especially in a patient with an active gag reflex or a large tongue. 4 A criss-cross suture is

tied by entering the mesial buccal aspect (position 1) and exiting the distal buccal aspect

(position 2); the suture is then crossed over the socket, enters the mesial lingual aspect(position 3), and exits the distal lingual aspect (position 4). The suture at the distal


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References

1. Silverstein LH. Essential principles of dental suturing for the implant surgeon.Dent

Implantol Update. 2005;16:1-7.

2. Silverstein LH. Suture selection for optimal flap closure and tissue healing. Perio-implant showcase.Pract Periodontics Aesthet Dent. 2005;16:2-3.

3. Cohen ES. Sutures and suturing. In:Atlas of Cosmetic Reconstructive Periodontal

Surgery. 2nd ed. Philadelphia, Pa: Lea & Febiger; 1994:9-30.

4. Silverstein LH.Principles of Dental Suturing: The Complete Guide to Surgical

Closure. Mahwah, NJ: Montage Media; 2000.

5. Wound Closure Manual. Somerville, NJ: Ethicon Inc; 1985:1-101.

6. Knot Tying Manual. Somerville, NJ: Ethicon, Inc; 1968.

7. Lilly GE, Salem JE, Armstrong JH, et al. Reaction of oral tissues to suture materials.

Oral Surg Oral Med Oral Pathol. 1969;28:432-438.

8. Macht SD, Krizek TJ. Sutures and suturingcurrent concepts.J Oral Surg.

1978;36:710-712.

9. Manor A, Kaffe I. Unusual foreign body reaction to a braided silk suture: a case

report.J Periodontol. 1982;53:86-88.

10. Meyer RD, Antonini CJ. A review of suture materials, part I. Compendium.

1989;10:260-265.

11. Mejias JE, Griffin TJ. The absorbable synthetic sutures. Compend Contin Educ

Dent. 1983;4:567-572.

12. Hutchens LH. Periodontal suturing: a review of needles, materials and techniques.

Postgrad Dent. 1995;2(4):1-15.

13. Silverstein LH, Kurtzman GM. A review of dental suturing for optimal soft-tissue

management. Compend Contin Educ Dent. 2005;26:163-171.

Acknowledgment

Illustrations by David Kurtzman, DDS.


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Dr. Gregori Kurtzman is assistant clinical professor, University of Maryland,

Baltimore College of Dental Surgery, Department of Endodontics, Prosthetics, and

Operative Dentistry, and is in private practice in Silver Spring, Md. He can be reached

at (301) 598-3500 [email protected].

Dr. Silverstein is associate clinical professor of periodontics at the Medical College ofGeorgia in Augusta, Ga, and is author of the text Principles of Dental Suturing: A

Complete Guide to Surgical Closure. He is in private practice in Mari-etta, Ga, and can

be reached at (770) 952-5432.

Dr. Shatz is assistant clinical professor of periodontics at the Medical College of

Georgia in Augusta, Ga, and is in private practice in Marietta, Ga. He can be reached at

(770) 952-5432.

Dr. David Kurtzman is in private practice in Marietta, Ga. He can be reached at (770)

980-6336
mailto:[email protected]:[email protected]:[email protected]:[email protected]

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