3.6

Reflection of the Mucoperiosteum

Reflection is performed to separate the mucoperiosteal flap from the underlying bone. The elevator is in direct contact with bone and reflection starts at the incision, usually at an angle (Fig. 3.16), and is completed with gentle, steady strokes towards the labial or buccal vestibule, without damaging the tissues. When the attachment between bone and periosteum is strong or if symphysis occurs, then scissors or surgical blades may be used.

3.7 Suturing

Suturing of the surgical wound is necessary, aiming at holding a flap over the wound, reapproximating the wound edges, protecting underlying tissues from infection or other irritating factors, and preventing postoperative hemorrhage. Suturing may also aid in the following:

ΟWhen hemorrhage is present deep in the tissues and ligation is required or for ligation of a large vessel

ΟFor laceration of soft tissues in general

ΟIn cases of severe hemorrhage where the suture holds the hemostatic plug in place

ΟFor infections, after the incision, for stabilization of the rubber drain at the site of incision

ΟFor immobilization of pedicle flaps in their new position, etc.

Fig. 3.18. The two ends of the suture are tightened to create a surgeon’s knot over the wound (double knot)

Stabilization of sutures is achieved with knots, which may be simple or a surgeon’s knot, and are either tied with the fingers of both hands or with the help of the needle holder.

The technique applied for tying knots is as follows: after the needle passes through both wound edges, the suture is pulled, so that the needle-bearing end is longer. Afterwards, the long end of the suture is wrapped around the handle of the needle holder twice (Fig. 3.17). The short end of the suture (which is usually held by the assistant with anatomic forceps) is grasped by the needle holder and pulled through the loops. The suture is then tightened by way of its two ends, thus creating the first double-wrapped knot, which is called a surgeon’s knot (Fig. 3.18). The flap is therefore replaced in the desired position. A single-wrap knot is then created, in the counterclockwise direction, which is named a safety knot (Figs. 3.19, 3.20). The

Fig. 3.19. Safety knot, created by the single wrap of the suture in the counterclockwise direction as opposed to Fig. 3.17

Fig. 3.20. Tightening of the safety knot over the initial surgeon’s knot

knot must always be to the side and never on the incision itself. This makes tightening easier, irritates the wound less, and facilitates cutting and removing the suture.

3.7.1

Suturing Techniques

The main sutures used in oral surgery are the interrupted, continuous, and mattress sutures.

Interrupted Suture. This is the simplest and most frequently used type, and may be used in all surgical procedures of the mouth (Fig. 3.21). The needle enters

2–3 mm away from the margin of the flap (mobile tissue) and exits at the same distance on the opposite side. The two ends of the suture are then tied in a knot and are cut 0.8 cm above the knot. To avoid tearing the flap, the needle must pass through the wound margins one at a time, and be at least 0.5 cm away from the edges. Over-tightening of the suture must also be avoided (risk of tissue necrosis), as well as overlapping of wound edges when positioning the knot. The advantage of the interrupted suture is that when sutures are placed in a row, inadvertent loosening of one or even losing one will not influence the rest.

Continuous Suture. This is usually used for the suturing of wounds that are superficial but long, e.g., for recontouring of the alveolar ridge in the maxilla and mandible.

The technique applied is as follows: after passing the needle through both flap margins, an initial knot is made just as in the interrupted suture but only the

free end of the suture is cut off. The needle-bearing suture is then used to create successive continuous sutures at the wound margins (Fig. 3.22). The last suture is not tightened, but the loop created actually serves as the free end of the suture. Afterwards, the needlebearing suture is wrapped around the needle holder twice, which grasps the curved suture (first loop), pulling it through the second loop. The two ends are tightened, thus creating the surgeon’s knot.

The continuous locking suture is a variation of the continuous simple suture. This type of suture is created exactly as described above, except that the needle passes through every loop before passing through the tissues, which secures the suture after tightening. Suturing continues with the creation of such loops, which make up parts of a chain along the incision (Fig. 3.23). These loops are positioned on the buccal side of the wound, after being tightened.

The advantage of the continuous suture is that it is quicker and requires fewer knots, so that the wound

margins are not tightened too much, thus avoiding the risk of ischemia of the area. Its only disadvantage is that if the suture is inadvertently cut or loosened, the entire suture becomes loose.

Mattress Suture. This is a special type of suture and is described as horizontal (interrupted and continuous) (Figs. 3.24, 3.25) and vertical (Fig. 3.26). It is indicated in cases where strong and secure reapproximation of wound margins is required. The vertical suture may be used for deep incisions, while the horizontal suture is used in cases which require limiting or closure of soft tissues over osseous cavities, e.g., postextraction tooth sockets. Reinforcement of the mattress suture is achieved with insertion of pieces of a rubber drain.

The technique used for the mattress suture is as follows: in the interrupted suture (horizontal and vertical), the needle passes through the wound margins at a right angle, and the needle always enters and exits

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