7
Suturing Techniques
Mea A. Weinberg1, Stuart L. Segelnick1, and Edgard El Chaar2
1Arthur Ashman Department of Periodontics and Implant Dentistry, New York University, New York, NY, USA
2Department of Periodontics, University of Pennsylvania, Dental Medicine, Philadelphia, PA, USA
Principles of Surgical Wound Closure
Wound stability, the definitive goal of wound management in periodontal surgery, is achieved primarily by wound closure without tension on the edges of the wound. There are two types of periodontal wound closure healing: primary and secondary intention. Primary wound healing occurs when there is close approximation of the wound edges with minimal formation of a blood clot or hematoma and no loss of tissue (Christgau 2004). On the contrary, during secondary wound healing the wound edges do not approximate each other delaying the healing process (Meyle 2006). Extraction sites and apically positioned flaps heal by secondary intention (Pippi 2017). There is a greater risk for infection than in primary intention healing.
Sutures stabilize the wound allowing for optimal healing and is the key to maintaining adequate postoperative wound stability (Burkhard and Lang 2000; Zuhr and Hürzeler 2017). Additionally, one of the most important aspects in achieving maximum wound stability during suturing is having less tension on the wound edges (Zuhr and Hürzeler 2017).
Periodontal surgery using magnification with a microscope has been gaining interest recently primarily because of many advantages including improved visibility to surgical site, rapid healing, and increased patient acceptance (Yadav et al. 2018). Suturing during periodontal microsurgery involves the suture needle to penetrate perpendicular to the tissues and exit the tissues at equal distance. In order to allow for appropriate wound approximation, the suture bite is about 1.5 times the tissue thickness.
Properties of Suture Materials
Basically, there are four features of suturing that should be reviewed when making a decision on surgical wound closure. These features including suture materials, suturing needles, suturing techniques, and suture thread size (refers to the diameter of the material and it ranges from the biggest, 1.0 to the smallest, 10.0) (Table 7.1). The ideal suture material should have the following properties: Christgau (2004), Koshak (2017), and Modi (2009).
- (1) good tissue reaction;
- (2) absent wicking effect;
- (3) high tensile strength (weight required to break a suture) to hold the wound edges together during healing time;
- (4) not cause tissue damage;
- (5) good knotting property and security;
- (6) good memory (after using the suture material it returns to its initial shape) and;
- (7) good elasticity (after the suture is stretched, it should recover its original form and length).
Table 7.1 Features of the sutures.
| Non Resorbable | Thread size | Resorbable | Thread size |
|---|---|---|---|
| silk | 3‐0,4‐0,5‐0 | Gut | 4‐0 |
| Nylon | 4‐0,5‐0,6‐0 | Chromic Gut | 4‐0,5‐0 |
| Polypropylene | 5‐0,6‐0 | PGA | 3‐0,4‐0,5‐0 |
| e‐PTFE | 4‐0,5‐0,6‐0 | PGA‐dyed | 3‐0,4‐0,5‐0 |
Table 7.2 Properties of suturing materials.
Source: Modi (2009)/Springer Nature.
| Suture | Material | Resorption | Properties |
|---|---|---|---|
| Absorbable | |||
| Plain surgical (cat) gut | Submucosa of sheep intestine or serosa of beef intestine. Oldest suture material | Tensile strength is maintained for 3–5 d and absorption complete within 70 d | Not flexible (difficult to be tied and knotted); weak |
| Chromic gut | Submucosa of sheep intestine or serosa of beef intestine; treated with a chromium salt solution to resist body enzymes | Tensile strength is maintained for 7–10 d. Prolong absorption time over 90 d | Poor knotting property; some tissue reactivity since it is natural; weak |
| Polyglycolic acid (PGA) (Dexon) | Braided | Via hydrolysis 28–45 d | Resists muscle pull; not for extended time; may have wicking effect |
| Polyglactin 910 (VICRYL) | Copolymer of glycolide and lactide with polyglactin | About 28 d; some components will have extended time to resorb | Good knotting property; strong; synthetic so less tissue reaction |
| Poliglecaprone 25 (MONOCRYL) | Monofilament (one strand) | High tensile strength which decreases overs 2 wk; Hydrolysis 91–119 d | Easy to handle; Slight tissue reaction; approximate without tension for extended time |
| Nonabsorbable | |||
| Silk | Natural; braided; raw silk spun by silkworm and coated with wax to reduce capillary action | Has reactivity when buried in the tissue; may have a wicking effect; not strong 7 d |
|
| Polytetrafluoroethylene (PTFE) | Synthetic; monofilament, rod shaped, and are neither expanded or dense. |
No wicking effect. High tensile strength. Ideal for bone grafting, soft tissue grafting and implants. Less secure knotting. 2–4 wk |
|
| Nylon (ETHILON) | Synthetic; polymer of polyethylene terephthalate | Better tissue reactivity than silk; poor knotting | |
| Polyester | Synthetic; braided | Some wicking effect because it is braided. Better tissue reactivity than silk; superior knotting | |
Suture materials are classified as being absorbable or non‐absorbable. Sutures are further classified based on the type: plain, chromic, braided monofilament, monofilament, or braided. Several properties of suture materials are reviewed in Table 7.2
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