Perio Sheet #1 By Ibrahim Al-Omari

by **Sura** 25/9/2012, 1:43 am

http://www.4shared.com/file/Zf45NVTC/perio_1.html

by Mohammad Abukar 28/9/2012, 4:17 am

Only admins can see the links.. please Shadi change the privacy :)

by **Shadi Jarrar** 28/9/2012, 5:57 am

http://www.4shared.com/file/Zf45NVTC/perio_1.html

by **Shadi Jarrar** 12/11/2012, 9:12 pm

suturing

Why do we do sutures ??

1-to provide wound closure (if the wound is big it need long time to heel so it need suturing to close it)

2- To position the tissues (to put them in the desired position , like in perio some time we need to put the tissues more coronal or more apical like in crown lengthening )
3- To control the bleeding

4-To reduce post operative pain ( if we exposed bone we will have more pain , so we have to cover it with tissues and suture it to reduce pain )

Primary wound closure is necessary for : (we will understand these criteria when we talk about preio surgery later on )
1-succesful new attachment

2-succesful grafting

3-minimum bone resorption

Principle for successful sutures :

1-least number of sutures necessary to approach the desired result (like if the wound need 3 sutures but if 2 or 1 it will not close properly , and if we put 5 or 4 the bacteria will have more area to accumulate )

2- the tension is sufficient to hold the tissue in place (not big that cause necroses if the tissues were thick , if they were thin it will tear )

3-the suture should be placed on a keratinized tissue whenever possible (that means it's not preferable to put it on the mucosa cause it's movable and highly vascular )
4- take an adequate bite of tissue with a needle to prevent the suture from tearing throw the flap , the best way to achieve this is biting at base of the papilla , not at the tip (it I preferred to suture at the papilla if it's present ) , if we suture at the tip it will cause the destruction of the papilla and that will cause black triangles between teeth which is not aesthetic

Suture materials :

resorbable ( that means it disintegrate by itself )"the doctor don’t recommend it for perio surgery cause some types takes about 60 days to resorbe so it will collect a lot of microbes and when it will resorbe it will leave these microbes on the tissues "

A-surgical gut

B-plain gut –monofilament (last 30 days)

C-chromic gut (last 45-60 days)

noneresorbable (you need to recall the patient after 7-10 days to remove the suture, if you don’t remove the tissue will grow on it and because it collect microbes (even if it's minimum) it will cause inflammation )

A-black-silk (most used in perio surgery, and it's preferred cause it's black that means if you used a white or colorless one you can't see it and you may leave some of them in the patient mouth) and the doctor is advising us to be sure when we buy a silk , it I made from natural silk not from synthetic silk because it collect much less microbes on it

B-nylon

C-EPTFE

D-polyester

synthetic

A-vicryl (it's preferred by many dentists cause it doesn't collect microbes , but the problem that it's color is light violet and sometimes the color after a while goes white which will make it hard to see it to remove )

B-Dexon (RESORBE IN 16-20)

now we have the monofilaments type and polyfilaments , in periosurgery they prefer to use the mono over the poly filaments ( and the most used is Nonresorbable

monofilaments)

Now the size of the needle (not the thread )"the bigger the number the smaller the size , that means 01 is bigger than 06 "
03 and 04 are the mostly used in the oral cavity "it's for all proposes

05 for periosteal of fine sutures

06 is for the aesthetic area

06and 05 are hard to use because they are very fine

The needles have to be circle (not straight) and the tip is cutting or tapered to be used in perio

Basic suturing techniques:

1-Suturing should be from movable to none movable tissues , that means :

When I open a flap , there is part is moving and another one is not (sometimes both sides are movable ), so I start from the movable part cause it's easier to handle and grab, if both sides are movable we start with the thinner cause it' more movable than the thicker area .

2- the node : it should be triple tie to prevent loosening (double tie is enough but we do another one to be sure , like if one lost one we will have another 2 that will do the job , especially when we cut near knot )

يعني بنربط ثلث مرات فوق بعض
3-knote should (not) be tied on the incision line , but to either side of the incision , to prevent microbes from accumulates on the wound and to go to the deeper areas .

4-prper care handling the suture needle (to prevent it from breaking or bending)

Now the needle is curved , so in perio we hold the needle at beginning of the curvature (not at the end like in surgery ) which will prevent it from bending or breaking .

Suturing techniques

There is thousand of ways to suture but we are concerned in four in periosurgery:

1- Interrupted suture /continuous suture.

2- Continuous sling suture.

3- Double sling suture.

4- Mattress suture.

1-interrupted suture: can be used for all graft and flap surgery , it's mostly used when both sides of the flap need the same amount of tension(tension: putting the tissue in proper area, where I need to put them " not pulling the tissue" , like putting one side in the cemntoenamel junction and the other more apical so the we can say the other side have more apical tension) as interproximal tissue approximation

Types of interrupted suture:

Type A: we inter the tissue from the outer part of the tissue toward the inner part of the tissues , from the other side of the tissue we go from inner part toward the outer part (out >> in >> in >> out ) then I turn my needle then I knot.

Type B: we inter the tissue from the outer part of the tissue toward the inner part of the tissues , from the other side of the tissue we go from outer part toward the inner part (out >> in >> out >> in) then I turn my needle then I knot (we end up with the figure of 8 , some times this type is more tense than type A ).

2-Sling suture : ( only used for perio ) Encircle the tooth , and is used when he flap is raised on one side of the tooth , and it's undesirable to tie on the opposite side , it's often used to hold a flab coronally like in the lateral position flap (we will talk about it later)

We go out >> in, in the interproximal area and encircle the tooth then I go again in the inter proximal area and I do my knot.

A, Suture is passed through the facial from outside-in and looped

around the lingual of the tooth. The suture does not enter the lingual flap. B,

The suture is passed through the other facial papilla from the inside-out and

looped back around the lingual of the tooth. C, The suture is tied securely

without creating excess tension on the flap "from the book "

Now the continuous one (the continuous sling suture ):

Similar to the first one but ,we perform it on multiple teeth , and we can use it if we have two flaps (lingual and buccal ) , but we must have deferent tension on each side (the tension in the lingual deferent form the buccal , like we start in the palatal and do the buccal with a deferent tension ) >> if we need the same tension we do the interrupted one

We go out >> in, then encircle the tooth, w enter the interproximal area and we take our bite in the outside, then we encircle the next tooth (we repeat to the last tooth) , then we make our knot ( the Dr advice us to make a knot in the beginning of the thread and at the end )

NOTE: if we do both sides , you make the first one then knot , then you start the other one

3- the double sling suture

A, The suture is passed through the most

anterior facial papilla from outside-in just coronal to the mucogingival

junction and looped around the lingual of the tooth to engage the next facial

papilla. The suture does not enter the lingual flap at this time. B, The suture is

looped around each successive tooth, penetrating the facial papillae just

coronal to the mucogingival junction. C, At the distal end of the flap, the

suture is passed through the facial tissue and looped back around the lingual

of the terminal tooth and through the interdental area mesial to the terminal

tooth. The suture is then slung around the facial surface of the terminal tooth

toward the distal aspect of the lingual flap. Wrapping the suture around the

terminal tooth in this fashion allows the facial flap to be locked in placed and

positioned independently of the lingual or palatal flap. D, The needle is passed

through the most distal aspect of the lingual or palatal flap. The suture is then

looped back around the facial surface of the terminal tooth. E, The suture is

passed through the interdental area to engage the next papilla on the lingual or

palatal flap. F, The lingual flap is sutured in a similar manner as the facial

flap. The suture is tied anteriorly where the suture was initially introduced into

the facial tissue.

4- the mattress suture : it's either vertical or horizantal (we use the vertical if we have long papilla) , it's often used for interproximal tissue aproximation over bone graft in excinal new attachment procediors and replaced flaps.

We go in the papilla out >> in >> in >> out (we end in the outer part of the tissues )

Then we go to the other side and we do the same thing We go in the papilla out >> in >> in >> out

We end up with like two threads , and then I do my knot .

(A- Interupted / B-vertical matress )

Corrections are welcomed

Perio : 1^st lec

Date: 19/9

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