Suturing Techniques used in Dentistry

Suturing is an important aspect of any Dental / Surgical procedure where there is either cutting or injury to the soft tissue in the oral cavity. Proper placement of sutures can help in faster and proper healing of the tissues involved. It helps in Primary healing of the wound site and also prevents any secondary infections.

It is very important to note that the selection of the correct type of Suture Needle in Dentistry is as important as the suturing technique as it helps in properly piercing and also maintain the integrity of the Tissue. Along with this make sure that you choose the most acceptable Suture Materials used in Dentistry depending on the case and tissue surface which is being treated.

Principles of Suturing techniques:

1. The needle holder should grasp the needle at approximately 1/3rd of the distance from the end and not in the middle of the curve.
2. The needle should enter the tissue perpendicular to the surface. If the needle pierces the tissue obliquely a tear may develop.
3.  The needle should be passed through the tissue following the curve of the needle
4. The suture should be placed at an equal distance from the incision on both the sides and at an equal depth
5. If one tissue side in thinner than the other the needle should pass from the thinner tissue to the thicker one
6. If one tissue plane is deeper than the other, then the needle should pass from the deeper to the superficial side
7. The distance that the needle is passed into the tissue should be greater than the distance from the tissue edge
8. The tissue should not be closed under tension or too tight as they will tear or necrosis around the suture might occur. Undermine the tissue if you see that the suture or tissue is in tension
9. The edges of the tissue should be everted and tissue merely approximated with the suture
10. The knot should be positioned on top of the incision line
11. Each suture should be placed with a distance of 3-4mm
12. The suture should be placed closer than 3mm only in areas of tension so it helps in holding the suture in place while movements

Various types of Suturing Techniques:

1. Simple loop modification of interrupted suture technique.
2. Continuous non-interlocking suture technique.
3. Continuous locking suture technique.
4. Vertical mattress suture technique.
5. Horizontal mattress suture technique.
6. Continuous horizontal mattress suture technique.
7. Modification of interrupted suture technique.
8. Cross (Crisscross) suture technique.
9. Periosteal Suturing Technique.
10. Coronally repositioned mattress suture technique.
11. Vertical sling mattress suture technique.
12. Single interrupted sling suture technique.
13. Sling suture about a single tooth.
14. Independent sling suture technique

These are the Suture techniques which are used in Medical and Dental surgeries, but let us discuss in detail about the most commonly used Suturing techniques in Dentistry which are 8 –

1. Interrupted simple suture
2. Simple Continuous/running suture
3. Continuous locking/blanket suture
4. Vertical Mattress Suture
5. Horizontal Mattress Suture
6. Sling suture for single tooth
7. Cross (Crisscross) suture
8. Periosteal Suturing technique

Let us discuss in detail about these eight Suturing techniques, by knowing their advantages, disadvantages and how to use them.

Vertical Mattress suture:

It is also called as Internal vertical mattress suture, the needle is passed from one edge to the other and again from latter edge to the first and the knot is tied to close it. It passes at 2 levels one deep to provide support and adduction of wound surfaces at a depth and one superficial to draw the edges together and evert them. When the needle is brought back from the second flap to the first the insertion is more superficial than it was done for the first flap.

This suture gives maximum tissue approximation and adaptation of the wound site thus drastically decreasing the amount of dead tissue/space along with injury line.

Advantages of Vertical Mattress Suture: 

• Does not interfere with the healing as suture runs parallel to the blood supply.
• It reduces the amount of dead space during wound healing and provides increased strength across the wound

Disadvantages of Vertical Mattress Suture:

• Fine wound edges are difficult to approximate using this suturing technique leading to open edges
• Sutures need to be removed early to prevent prominent suture marks on the healing skin surface

Simple continuous or Running Suture:

This type of suture is placed with the needle inserted in a continuous fashion from one end of the tissue to the other such that the suture passes perpendicular to the incision line below and obliquely above it. The knot should be placed on the untightened end of the suture.

Advantages of Simple Continuous:

• Simple and fast, only two knots with tags are required
• Distributes the tension evenly across the incision line
• It is watertight

Disadvantages of Simple Continuous:

• A single cut at one point might open the whole incision wound

Interrupted Simple Suture:

This is the most commonly used suture technique in Dental procedures like Impactions, Tooth extractions etc.  It is called as interrupted stitch because the individual stitches are not connected. Each suture is placed separately and not connected to adjacent ones.

Advantages of Interrupted Simple Suture:

1. Can be used in areas where the tissues are under stress
2. The degree of eversion is produced
3. Sutures are placed 4-8 mm apart and can be used to close large wounds where the tension is shared between each one separately
4. In case of loosening of one suture, others won’t be affected
5. In case of any secondary infection or hematoma, some sutures can be removed and others left in place
6. It is easy to clean as there are no interferences between each suture and they are not connected

There are no disadvantages to this type of suture.

Continuous Locking Suture:

This type of suture is indicated and used mostly in long edentulous areas along with retromolar or tuberosity areas. This type of suture is similar to continuous suture but the locking is done by inserting the suture through its own loop while closing the suture.

Advantages of Continuous Locking Suture:

• Because of the locking, there is only one knot to close it
• Single closing knot helps in distributing tension uniformly across the suture
• You get watertight closure because of which it cannot be used in areas of tension
• It prevents excessive tightening which might lead to the tearing of tissues

Vertical Mattress suture: 

Similar to simple sutures but comes with a insertion into the wound edge to ensure edge eversion. The Needle for the suture is first inserted into the wound edge and is crossed through the tissue to an equal distance on opposite side of the wound. Now the needle needs to be reversed and returned which a very small bite at the epidermal or dermal edge, this helps in approximating the wound edges.

Horizontal Mattress Suture:

Most commonly used in cases where Bone grafting is required, it involves volatile closure with continuity. To place a Horizontal mattress suture, the needle has to pass through one edge of the incision to the other and it is again brought back and inserted into the first edge. This process is continued along with incision line to the other end edge of the incision and a knot is given.

Care should be taken in choosing the case for this suture as it tends to obstruct Blood supply to the tissue which might result in necrosis and dehiscence.

The other not commonly used suture methods are Sling suture for a single tooth, Cross (Crisscross) suture, Periosteal Suturing technique. These suture techniques are used in selective cases when the need arises. Knowing how and when to place your Suture is very important to attain proper healing of the surgical site or to get proper closure and help in the healing of any injury in the oral cavity.

References:

Click to access GJO.MS.ID.555833.pdf