Overview of Oral Surgery Suturing
Stitches, or sutures, have been used to close wounds for thousands of years. In the past, materials like strings and animal tendons were used. Nowadays, thanks to improvements in technology and techniques, the process has become much safer and less likely to cause complications.
When a doctor stitches up a wound, their main goal is to bring the edges back together. Doing this reduces tension on the wound, helps to stop bleeding and encourages healing. This document discusses the different types of stitches and needles used, and the methods used by oral surgeons when they need to stitch up wounds in the mouth.
Anatomy and Physiology of Oral Surgery Suturing
The ultimate goal in any type of surgery is to properly close the wound and make sure the edges of the wound stay secured together. However, those who perform dental surgery face a unique challenge. They have to bring together different types of soft tissue (like the softer, unattached tissue in our mouths versus the firmer, attached tissue with skin-like features) against a mix of different hard surfaces (different types of bones, tooth roots, and titanium implants used in dental procedures). Other challenges they face can include bacteria buildup and forces from tongue movement, swallowing, and chewing.
Healing a wound is a complex process made up of four stages that happen one after the other: the stage that stops bleeding, the stage that fights infection, the stage that fills in the wound, and the final stage, where the wound fully matures and finishes healing.
The first stage happens right after the wound is closed, usually within minutes. It starts when the body reacts to things like exposed collagen (a protein found in skin and bones) that trigger blood vessels to constrict, or narrow, and form a plug made up of platelets (tiny blood cells that help your body form clots to stop bleeding). Platelets then break down, releasing chemicals and growth factors that start the creation of a clot made of fibrin—a protein that helps stop bleeding–through a process known as the coagulation cascade. At the same time, the following stage starts up, called the inflammation stage, which is part of the healing process and typically lasts around 72 hours. This stage is when you might experience heat, pain, swelling, and redness. Blood flow is increased to bring more cells to the site to help clear out toxins, damaged cells, and bacteria.
The following stage, known as the proliferation stage, is when new tissue starts to form to fill in the wound, and can last from several days to weeks. The fibrin clot gets replaced with granulation tissue, which is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. This tissue comes from the extracellular matrix (ECM), a collection of molecules produced by cells that gives structure and support to cells and tissues, and contains collagen, elastin (a protein in connective tissue that allows many tissues in the body to resume their shape after stretching or contracting), hyaluronic acid (a substance that is naturally present in the human body and is found in the highest concentrations in fluids in the eyes and joints), and proteoglycans (proteins essential for tissue regeneration). Several types of cells are present in this stage, including fibroblasts (cells that produce collagen and other fibers), keratinocytes (the main type of cell found in the skin), and endothelial cells (cells that line the interior surface of blood vessels). Various chemicals and growth factors play an active role during this stage.
The final stage of wound healing, the maturation and remodeling stage, involves the replacement of the extracellular matrix and type III collagen (a type of collagen that is found in extensible tissues such as skin, lung, and the vascular system, among others) with type I collagen (the most abundant collagen type that provides structure to skin, tendons, fibrous cartilage, connective tissue, and bones), which is better organized. This final stage can take several months or even years to complete.
Wounds can heal in three ways. Ideally, a wound heals through ‘first intention’ healing where the wound edges are brought close together again and sutured, or stitched, closed. The wound would heal through the above-mentioned process with minimal scarring. ‘Second intention’ healing is when a wound is too wide, deep, or rough to bring the tissue edges back together. These wounds are left open and the healing process starts at the base of the wound and works its way up to the surface of the skin. Lastly, ‘third intention’ healing is when a wound is infected or dies; therefore, it needs to be cleaned or drained until the infection has been treated before it can be fully closed.
Equipment used for Oral Surgery Suturing
In simple terms, the dentist has to understand the types of materials used to sew a wound after a dental procedure. This will ensure that the healing process is not interrupted and is as comfortable as possible for the patient. The right material ensures that the wound remains closed as it heals, thus preventing complications.
The materials used for this purpose, also known as sutures, vary among dentists. A significant factor they consider when choosing the right suture is how much pressure it can withstand before breaking. To minimize harm to the tissue, the dentist will usually go for the smallest size of suture that still can keep the wound closed under pressure. The sutures also need to be easy to handle and make secure knots.
Sutures are often made of materials that the body can break down, so there is no need to remove them after the wound has healed. These are called resorbable materials. Many modern dentists prefer to use them because they make after-care easier for the patient, usually resulting in less swelling. Natural resorbable materials are made from animals’ body parts, while synthetic ones are man-made.
One type of natural resorbable suture is made from sheep and cow intestines. The body can easily break this down, but it loses its strength quickly and is usually used when the wound is not under a lot of strain. It typically loses half its strength within a day of surgery and is completely broken down in 3-5 days.
Another type of natural resorbable sutures made from gut but are treated with chromium salts so they break down slower. They usually take about 7-10 days to be completely resorbed by the body and maintain their strength for up to 5 days. These types of sutures are popular among dentists, but they are not suitable for use in certain patients, like those with decreased pH in their mouth, which can be caused by conditions like acid reflux, specific drug therapies, and Sjogren’s Syndrome.
Most dentists use a synthetic suture made from polyglycolic acid (PGA). The body takes about three weeks to break this down. The special thing about PGA sutures is that they remain strong for approximately three weeks. Their structure gives the dentist better control while handling them and ensures that knots stay secure. They also come with a coating of antimicrobial agents to prevent infection. Another synthetic resorbable suture often used by dentists is polydioxanone, which the body takes two weeks to absorb. During this time, it maintains 70% of its original strength.
Non-resorbable sutures are also used. These types of sutures don’t break down in the body, so they need to be removed by the dentist after the wound has healed. Silk is one of the common non-resorbable materials. It is inexpensive and readily available, but there is a higher risk of infection because of its thread. It typically needs to be removed a week after surgery. Polyester is another non-resorbable material often used by dentists. Different types of polyester sutures, like polypropylene and polytetrafluoroethylene, are common in dental surgeries. When using these materials, the dentist ties a special type of knot called a surgeon’s knot to prevent it from coming loose. These sutures are less likely to cause infection because bacteria cannot grow on them.
The needles used to sew the sutures also come in various types. Generally, dentists prefer to use reverse-cutting suture needles. These needles have a triangular shape that reduces the chances of tearing the oral tissue when the dentist makes the knot. They come in different sizes, the choice of which depends on how much space the dentist has to work with.
How is Oral Surgery Suturing performed
When it comes to repairing wounds or injuries in the mouth from dental procedures, the materials used for stitching and the type of knot tied are really important. In dental situations, the two main types of knots used are ‘the slip knot’ and ‘the surgeon’s knot’. They hold the stitches in place to allow the damaged area to heal.
The right knot to use depends on the material used for the stitching. If synthetic materials are used, like polyester, then a surgeon’s knot is needed because it prevents the knot from coming undone. Synthetic stitches tend to straighten out over time, causing the knot to loosen. The surgeon’s knot is created by tying a knot twice, followed by an additional knot in the opposite direction to lock it in place.
On the other hand, a slip knot can be used when natural materials, like gut or chromic gut staples, are used for stitches. This type of knot allows the surgeon to adjust the tightness of the stitch against the tissue, which pulls the wound edges together for faster healing. The stitch is tied twice in the same direction, and then an additional knot is added in the opposite direction to lock it.
When it comes to stitching, there are two main methods: interrupted and continuous. ‘Interrupted’ means each stitch is tied off individually. One type of interrupted stitch commonly used in dental procedures is called a ‘simple interrupted.’ This technique places the stitch across the wound and ties it off at its starting point. This can be used for small wounds, or several times for larger wounds. ‘Crisscross’ is another interrupted stitch, and it’s great for extraction sites, as it helps hold in place things like blood clots, gel-foam, or bone graft material.
‘Continuous’ stitching is when a single stitch line is used along the whole length of the wound. This is used when longer wounds are present. The ‘horizontal mattress’ stitch is one type of continuous stitch. It’s often used for deep wounds where the skin has been pulled back beyond the gum line. Because it heals under tension, it’s best to use a stitch that will last longer or doesn’t dissolve.
Both interrupted and continuous stitches have their own pros and cons, but what matters most is that they help the wound heal properly.
What Else Should I Know About Oral Surgery Suturing?
If you’re getting procedures like a dental implant, grafting of soft tissues, or bone harvesting, the skill and knowledge of your dentist or oral surgeon is vital. This applies particularly to their use of suture techniques and materials – the things they use to stitch up the surgical area. With recent advancements in these materials, complications after surgery and infections have greatly decreased.
As healthcare providers, it’s their job to stay updated with the latest developments in these areas. This continuous learning helps ensure they provide you with the best possible care.
