Suturing

Suturing and periodontal dressing

Suturing

The purpose of suturing is to maintain the flap in the desired position until healing has progressed to the point at which sutures are no longer needed.
Many types of sutures, suture needles, and materials are available

Sutures for Periodontal Flaps

Nonabsorbable (nonresorbable)
1. Silk: braided
2. Nylon: monofilament (Ethilon)
3. ePTFE: monofilament (Gore-Tex)
4. Polyester: braided (Ethibond)
Absorbable (resorbable)
1. Surgical: gut
2. Plain gut: monofilament (30 days)
3. Chromic gut: monofilament (45 to 60 days)
Synthetic
1. Polyglycolic: braided (16 to 20 days)
2. Vicryl (Ethicon)
3. D Dexon (Davis & Geck)
4. Polyglycaprone: monofilament (90 to 120 days)
5. Monocryl (Ethicon)
6. Polyglyconate: monofilament (Maxon)


Suturing Technique
The needle is held with the needle holder, and it should enter the tissues at right angles and be no less than 2 to 3 mm from the incision.
The needle is then carried through the tissue, where it follows the needle’s curvature.
The knot should not be placed over the incision.

Ligation

Interdental Ligation
Two types of interdental ligation can be used:
• the direct loop suture.
• the figure-eight suture.
Sling Ligation

1.Simple loop suture is used to approximate the buccal and lingual flaps. (A) The needle penetrates the outer surface of the first flap. (B) The undersurface of the opposite flap is engaged, and (C) the suture is brought back to the initial side, where (D) the knot is tied.







2.Interrupted figure-eight suture is used to approximate the buccal and lingual flaps. The needle penetrates the (A) outer surface of the first flap and (B) the outer surface of the opposite flap. (C) The suture is brought back to the first flap, and (D) the knot is tied.





Single, interrupted sling suture is used to adapt the flap around the tooth. (A) The needle engages the outer surface of the flap and (B) encircles the tooth. (C) The outer surface of the same flap of the adjacent interdental area is engaged. (D) The suture is returned to the initial site, and the knot is tied.

Types of Sutures

Horizontal Mattress Suture.
Continuous, Independent Sling Suture.
Anchor Suture.
Closed-Anchor Suture.
Periosteal Suture.







1(A) Continuous, independent sling suture with the use of a horizontal mattress suture around (B) diastemata or (C) wide interdental areas. This mattress suture is used on both the (D) buccal and the (E) and (F) lingual surfaces. (G) to (I) Continuation of suture on the lingual surfaces. (J) Completed suture.








2(A) and (B) Continuous, independent sling suture is used to adapt the buccal and lingual flaps without tying the buccal flap to the lingual flap. The teeth are used to suspend each flap against the bone. It is important to anchor the suture on the two teeth at the beginning and end of the flap so that the suture will not pull the buccal flap to the lingual flap.




3 Distal wedge suture. This anchor suture is also used to close flaps that are mesial or distal to a lone-standing tooth.




4 The closed-anchor suture, which is another technique that can be used to suture distal wedges.




Periosteal sutures for an apically displaced flap. Holding sutures, which are shown at the bottom, are placed first. This is followed by the closing sutures, which are shown at the coronal edge of the flap.


Periodontal Dressings
In general, dressings have no curative properties but assist healing by protecting the tissue rather than providing “healing factors.”

Periodontal Dressings

Purpose of dressings
The dressing minimizes the likelihood of postoperative infection.
facilitates healing by preventing surface trauma during mastication,
and protects the patient from pain induced by contact of the wound with food or with the tongue during mastication.

Periodontal Dressings

Types of dressings
Zinc Oxide–Eugenol Dressing
Supplied as a liquid and a powder that are mixed before use and may induce allergic reaction.
Noneugenol Dressing
(Coe-Pak). The reaction between a metallic oxide and fatty acids. Most common in use.
Cyanoacrylates
tissue conditioners (methacrylate gels)

Periodontal Dressings

Antibacterial Properties of Dressing
Improved healing and patient comfort with less odor and taste have been obtained by incorporating antibiotics into the dressing.
Care must be taken when any antibiotic products are used because they may produce hypersensitivity reactions.
The incorporation of tetracycline powder into the Coe-Pak is generally recommended, particularly when long and traumatic surgical procedures are performed.


Periodontal Dressings
Retention of Dressing
Periodontal dressings are usually kept in place mechanically by interlocking the dressing in interdental spaces.
Numerous reinforcements and splints and stents for this purpose have been described.
The placement of dental floss tied loosely around the teeth enhances retention of the dressing.

Periodontal Dressings

Preparation and Application of Dressing




(A) Equal lengths of the two pastes are placed on a paper pad. (B) The pastes are mixed with a wooden tongue depressor for 2 or 3 minutes until (C) the paste loses its tackiness. A capsule of tetracycline powder can be added at this time.(D) The mixed paste is placed in a paper cup of water at room temperature. With lubricated fingers, it is then rolled into cylinders and placed on the surgical wound.

Periodontal Dressings

(A) A strip of pack is hooked around the last molar and pressed into place anteriorly. (B) The lingual pack is joined to the facial strip at the distal surface of the last molar and fitted into place anteriorly. (C) Gentle pressure on the facial and lingual surfaces joins the pack interproximally.
Inserting the periodontal pack

Periodontal Dressings

Removal of the Dressing and Return Visit
the periodontal dressing is removed by inserting a curette along the margin and exerting gentle lateral pressure.
Pieces of the dressing retained interproximally and particles adhering to the tooth surfaces are also removed with curettes.
The entire area is irrigated with peroxide to remove the superficial debris.

Periodontal Dressings

Redressing
After the dressing is removed, it is usually not necessary to replace it. However, redressing for an additional week is advised for the following types of patients:
• those with a low pain threshold who are particularly uncomfortable when the dressing is removed;
• those with unusually sensitive root surfaces postsurgically; or
• those with an open wound where the flap edges have necrosed.