Dentoalveolar Suturing

 In comparison to other areas of the body, the tissues and surgical environment in the dentoalveolar region are unique. As a result, the wound closure requirements vary. In instances like these, suturing is used to close wounds in dentoalveolar surgery.

1. Suturing of buccal and/or lingual flaps back to its place after dentoalveolar surgery around teeth or implant accessories.

2. Wound closure after tooth extraction.

3. Flap closure in edentulous ridge.

The needle passes through keratinized mucosa with little or no subcutaneous tissue in most cases, eliminating the requirement for multilayered closure. Because one side of the flap has teeth or an artificial crown, the surgeon must modify the fundamental suture design. Another distinction is how the extraction wound is closed—the wound is frequently simply closed at the margins, leaving the middle substantially accessible. In addition, the suture site will have to contend with the presence of saliva, food ingredients, and a highly dynamic environment in which tongue motions and masticatory pressures abound.

The wound closure models are usually not different from the general cutaneous designs outlined in the preceding section if marginal gingiva is not included in the flap (as in a semilunar flap).

Simple Interrupted Suture (Interdental Suture)

The basic interrupted suture, as with any wound closure, is the backbone in closing dentoalveolar flaps. Suturing the separated interdental papillae together is the standard procedure. The needle enters the inner aspect of the lingual flap from the buccal aspect of the buccal flap, emerges on the inside of the flap, and then passes between the tooth roots. The needle is twisted around and transported back to the buccal side via the interdental region as it pierces the lingual flap and emerges through the mucosa. After that, the two suture tags are tied together. As a result, the knot remains on the buccal side and is easily removed.

The needle can still pass through the associated lingual flap if only one flap (typically buccal) has been elevated, and the suture design remains the same. The process is the same in post-extraction wounds, and the tooth socket space is not completely closed.

Interrupted Reversing Suture

The needle is reversed in this modified interrupted suture in order to engage the lingual papilla. The needle orientation is reversed after it passes through the buccal papilla and reaches the lingual side, and it is made to enter the lingual papilla from the outside (lingual side). The needle emerges from the inside of the flap, crosses to the buccal side, and is then knotted. As a result, both papillae are oriented 'outside to inside,' resulting in a figure-of-eight arrangement in the vertical plane.

Interrupted reverse Interdental suture

This approach is notably effective in periodontal procedures, because both buccal and lingual flaps are raised during surgery.

Vertical Mattress Suture

In dentoalveolar surgery, the vertical mattress technique is a variation of the papilla-attaching simple interrupted technique. The needle is turned back after passing through the buccal and lingual papillae and picks a little bite at the tip of the lingual papilla before returning to the buccal side. Then it pierces the tip of the buccal papilla one more before tying the knot.

While this approach aids in the insertion of the papilla into the interdental space, it is not widely used due to the difficulties of obtaining a solid bite at the papilla tip without 'cutting through.' Obviously, an atraumatic needle with a small thread (4–0 or smaller) is required for this task.

Horizontal Mattress Suture

The suture thread is distributed horizontally across the tissues in this two-dimensional suturing procedure. It is not widely used for cutaneous suturing in general, but it is particularly beneficial in dentoalveolar surgery.

In edentulous areas, the needle must first travel through both flaps before sealing them. Then it's reinserted into the flap on the opposite side, a bit further away from where it came out before. The reinserted needle now passes through both flaps and emerges approximately the same distance from the original entry location. Both thread tags are now connected together on the same side.

This procedure stitches two adjacent papillae together in dentulous areas, finally joining four papillae segments in a horizontal square around a tooth. Only the papillae are approximated during closing extraction wounds, and the tooth socket gap is not completely closed.

The benefit of this approach is that a single horizontal mattress suture acts as two distinct interrupted sutures, reducing the number of sutures needed. It helps in haemostasis by compressing the wound from all four corners. It also causes wound eversion to some extent.

Simple Continuous Suture

Continuous sutures are virtually solely employed for edentulous and post-extraction closure circumstances. The longer tag is not cut after constructing a standard interrupted suture knot; instead, it is used to make a succession of 'running loops' that approximate the subsequent pair of papillae one by one. To keep the loops tight while the needle passes through the next tissue, maintain gentle stress on the thread. Knots are tied only at the other end of the lengthy wound, not for each loop. After 3 or 4 running loops, some surgeons like to tie a knot. Finally, the segment of the suture that passes through the inner tissues is perpendicular to the wound, while the exposed, superficial parts lie across it. In an oblique fashion, the wound was created.

While closing long-span wounds, continuous sutures save time and labour. It also ensures that strain is distributed evenly across the wound. The obvious downside is that if one loop or part of the suture is weakened (by untying, cutting through, or loosening), the entire suture line loosens.

Continuous Locking Suture

The continuous locking suture is a continuous suture that incorporates a 'lock' by threading the thread beneath the preceding loop before pulling it through the tissue. As the needle makes its next pass through the tissue, it's critical to sustain the tension on the prior loops.

This method guarantees that the sutures are properly oriented in relation to the wound. The suture's exposed, superficial sections are perpendicular to the wound, allowing for better anatomic wound approximation.

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