The Suture Book Silverstein Pdf

Establishing nontension primary wound closure of various soft-tissue flaps is paramount for optimal postsurgical wound healing. Surgical procedures that require clinical flap manipulation such as those used with traditional periodontal therapy, periodontal plastic cosmetic surgery, hard- and soft-tissue regeneration, and the excision of pathologic tissue also require excellence in execution and thorough understanding of the various techniques of surgery, suturing, and the materials currently available to ensure the desired clinical results. This article will discuss the rationale of specific suturing techniques and suture materials to aid the clinician in obtaining optimal wound closure.

The Suture Book Silverstein Pdf

DOWNLOAD: https://shurll.com/2wVPmZ

Establishing nontension primary wound closure of various soft tissue flaps is paramount for optimal postsurgical wound healing. Surgical procedures that require clinical flap manipulation, such as those used with traditional periodontal therapy, periodontal plastic cosmetic surgery, hard and soft tissue regeneration, and the excision of pathologic tissue, also require excellence in execution. Also paramount to clinical success is a thorough understanding of the various techniques of surgery, suturing, and the materials currently available to ensure the desired clinical results. This article will discuss the rationale of specific suturing techniques and suture materials to help the clinician obtain optimal wound closure.

The primary objective of dental suturing is to position and secure surgical flaps to promote optimal healing (Table 1). When used properly, surgical sutures should hold flap edges in apposition until the wound has healed enough to withstand normal functional stresses. When the proper suture technique is used with the appropriate thread type and diameter, tension is placed on the wound margins so primary intention healing occurs.1 Accurate apposition of surgical flaps is significant to patient comfort, hemostasis, reduction of the wound size to be repaired, and prevention of unnecessary bone destruction. If surgical wound edges are not properly approximated and are therefore inadequate, hemostasis is present and blood and serum may accumulate under the flap, delaying the healing process by separating the flap from the underlying bone.2

The desired qualities of a suture thread include the tensile strength that is appropriate for its respective use, tissue biocompatibility, ease of tying, and allowance of minimal knot slippage. It is important that the clinician select the specific suture thread and diameter based on the thickness of the tissues to be sutured and whether tension-free mobile tissues are present or absent.4 Therefore, it seems that suture technique and material selection should be based on a knowledge of the desired goals of the respective surgical procedures and the physical and biologic characteristics of the suture thread in relationship to the intraoral in vivo healing process.

Practitioners have an armamentarium of suture materials from which to select for use both intraorally and extraorally (Table 2). Adequate strength of the suture material will prevent suture breakage, and proper suture knots for the material used will prevent untimely untying or knot slippage. Clinicians must also understand the nature of the suture material, the biologic processes of healing, the biologic forces in the healing wound, and the interaction of the suture and tissues. This is vital because practitioners must ensure that a suture will retain its strength until the tissues of the surgical flaps regain sufficient strength to keep the wound edges together. In those circumstances in which the intraoral tissues most likely will never regain their preoperative strength, or the surgical flaps are not tension free, clinicians should consider using a suture material that retains long-term strength for up to 14 days and resorbs in 21 to 28 days, such as conventional polyglycolic acid (PGA) sutures.2,4

Conversely, if a suture is to be placed in a tissue that heals rapidly (eg, intraoral tissue), clinicians should select a resorbable suture that will lose its tensile strength at about the same rate as the tissue gains strength. The suture will also be absorbed by the tissue so that no foreign material remains in the wound once the tissue has healed, such as surgical gut or the newer fast absorbing polyglycolic acid (PGA-FA).1

Two mechanisms of absorption result in the degradation of absorbable sutures. First, sutures of biological origin, such as surgical gut (eg, plain and chromic gut), are gradually digested by intraoral enzymes.2 This suture material is made from an animal protein and can potentially induce an antigenic reaction. When used intraorally, this material loses most of its tensile strength in 24 to 48 hours, unless it is coated with a chromic compound that extends absorption up to 7 to 10 days and extends loss of tensile strength for up to 5 days.5

Second, surgical gut sutures may break too rapidly to maintain flap apposition, particularly if used in patients with a very low intraoral pH. A decrease in intraoral pH may be caused by a plethora of physiological events, such as metabolic disorders (eg, epigastric reflux, hiatal hernia, bulimia). Autoimmunity caused by Sjögren's syndrome, chemotherapy, radiation therapy, and some medications (eg, maximum acid output inhibitors, angiotensin-converting inhibitors, antipsychotics, diuretics, antihypertensive agents, antipsoriasis medications, and steroid inhalers) can also result in dry mouth and a low intraoral pH.2,6

The minimum coaptation time for tissue flaps is approximately 5 days.5 Therefore, clinicians should select a fast-absorbing PGA suture for indications in which there is a low intraoral pH, when surgical gut sutures are contraindicated. The PGA-FA suture material is manufactured from synthetic polymers and is principally broken down by hydrolysis in tissue fluids in approximately 7 to 10 days; it is not affected by a low intraoral pH.1,2 The PGA-FA suture also has a higher tensile strength than surgical gut suture material; however, it absorbs at a rate comparable to that of surgical gut sutures under normal intraoral physiologic conditions.1,2

Polyester sutures are made of multifilaments that are braided into a single strand. This suture is made of a polyethylene polymer, does not weaken when moistened, and has a lot of tensile strength. Polyester sutures are usually coated with a biologically inert nonabsorbable compound, which aids the suture in passing more easily through tissues. This coating, however, does present a problem in that it also makes knot security an issue, because the material will easily untie if not secured with a surgeon's knot.4 The e-PTFE suture material is a nonabsorbable monofilament that has high tensile strength, good handling properties, and good knot security, but it is expensive compared with all the other nonresorbable suture materials.1

Surgical knot tying is an important component to the art of suturing. For knot security and to prevent untimely knot untying, it is essential that the appropriate surgical knot be used for the specific suture material being secured. For instance, when using silk, e-PTFE, chromic gut, or plain gut suture material, a slip (granny) surgical knot should be used. However, with synthetic resorbable and other nonabsorbable synthetic suture materials, a surgeon's knot must be used to prevent untimely knot untying4 (Figures 4a through 4c). The type of knot that is used for each material is determined by the mode in which each type of thread is manufactured.5

(a) Surgeon's knot, step 1: the suture needle is wound around the needle holder twice in the direction of the wound. (b) Surgeon's knot, step 2: the free end of the suture is grabbed with the needle holder and the knot is tightened to the tissue. (c) Surgeon's knot, step 3: the suture needle is wound around the needle holder once away from the wound, and then the free end of the suture is grasped and tightened, completing the knot.

The interrupted suture encompasses 2 suturing techniques: the simple loop and the figure-8. The simple loop (Figures 5 and 6) is the most commonly used technique in dentistry and is routinely used to coapt tension-free, mobile surgical flaps.4 For example, the simple loop is useful in edentulous ridge areas, to coapt vertical releasing incisions, for periosteal suturing, and to coapt flaps in ENAP, modified Widman flap, some periodontal regeneration, and some exploratory flap procedures.

The figure-8 technique (Figure 7) is placed similarly to the simple loop on the buccal aspect; however, on the lingual aspect, the needle penetrates the outer, not inner, surface of the lingual flap. This results in the suture thread being interposed between the surgical flaps. Both interrupted suture techniques achieve similar results when used for wound closure with tension-free flaps. The figure-8 is useful when suturing on the lingual aspect of the lower molars, especially in a patient with an active gag reflex or a large, cumbersome tongue.4

Variations of the mattress suture technique are referred to as the vertical (Figure 8), apically or coronally repositioned vertical mattress (Figure 9), vertical sling (Figures 10 and 11), and horizontal mattress (Figure 12). Unlike the mattress suture technique, interrupted sutures should be used only with tension-free mobile flaps and should have needle penetration 3 mm from the wound edges or at the base of an interdental papilla. In contrast, when performing a mattress suture, the needle penetration through the surgical flap should be about 8 mm away from the flap edge, or just coronal to the mucogingival junction, and always in keratinized tissue. 75035a25d1