The Art of Dental Suturing

A Clinical Guide

A. Burak Çankaya, Korkud Demirel

• Publisher: Quintessenz Verlag
• Year: 2021
• ISBN:
  9783868675580
• Edition: 1
• Topic: Medicine
• Subtopic: Oral Health & Surgery

Although the field of dental surgery has witnessed significant changes over the past decade, perfect wound closure remains a key aspect for uneventful wound healing. The Art of Dental Suturing is a unique overview of the diff erent aspects of wound closure. Written by two experts in the field, this fully illustrated clinical guide on the management of suturing is intended to impart all the information necessary to achieve successful wound closure.In line with the current dental literature, and carefully constructed in a concise and simple way, the book is divided into three chapters. The first chapter deals with general characteristics of wound healing and provides information to dental clinicians and surgeons on the basic principles involved. The second chapter presents the instruments and materials required for all the categories of wound closure in every clinical situation. The third chapter is a complete guide to the various wound closure methods and techniques required in dental surgery. It is constructed in a step-by-step manner for clear understanding and is accompanied by carefully designed, large-format illustrations and photographs to impart the essential knowledge needed to facilitate perfect suturing.We hope that this book will serve as a reference guide to for all those in the profession who are tasked with the crucial role of successful wound closure.

CHAPTER 1

WOUND HEALING

INTRODUCTION

All surgical residents, as rookies, are somehow first assigned suturing tasks. In fact, suturing is one of the most important phases of surgery, if not the most important, requiring utmost concentration and adaptation of the technique to prevailing circumstances. Therefore, considering its significant contribution to the success of surgical procedures in general, we feel that suturing ought to be approached as an art that deserves appreciation and advancement.

The use of sutures in surgical procedures dates back to the 16th century BC. Various materials have been used since then, including horse mane hair, bristle, gold or silver filigrees, silk, silkworm guts, linen, cotton, and the tendons or viscera of various animals. The common function of these materials and procedures is to hold wound edges in approximation until the time of completion of healing, to secure them at the desired position, to protect the wound from physical external factors or microorganisms, to stabilize clots for hemostatic purposes, and to keep the tissues together with the aim of shortening healing time and thus improving the patient’s quality of life.

Biologic and technological advances in recent years have resulted in a variety of suture threads being introduced. Factors influencing the choice of suture to be used may vary depending on the patient, wound, tissue characteristics, anatomical position, and procedure to be performed. The preference of the surgeon also plays an important part; the surgeon’s experience is relevant because a good knowledge of the properties of suture materials is essential in making the correct choice.

No single suture material currently available on the market can fulfill all surgical requirements. Consequently, the structural characteristics of sutures should be considered for a better understanding of where best to use them. These characteristics include, but are not limited to, suture thread materials, capillarity, tensile strength, knot holding security, elasticity, memory, tissue reactivity, ease of handling, and ready-to-use form. By the same token, no single suture is ideal in all circumstances or conditions. More importantly, suture type should be chosen based on the characteristics of the wound, considering the aforementioned aspects.

Wound characteristics play a key role in wound healing. Therefore, an accurate assessment of the wound healing phases would facilitate decision making compatible with the circumstances.

This book comprehensively covers the healing of surgical wounds, with a focus on scalpel-induced incision wounds. It should be borne in mind, however, that although wound healing phases and tissue response are identical in traumatic injuries, irregularity of wound edges and additional problems introduced by microorganism contamination may further complicate the healing process.

PHASES OF WOUND HEALING

Wound healing is basically divided into three major phases. The first is hemostasis and inflammation, where there is an attempt by the body to restore the tissue integrity and during which contaminated components are removed from the wound. The next is the proliferation phase, where the cells required for reorganization migrate from neighboring tissue and new tissue is formed. The last is the remodeling and maturation phase, where the newly formed tissue is organized to harmonize with the peripheral tissue.

Hemostasis and inflammation

Intraoral soft tissue healing is subject to the same principles as the healing of other bodily tissues. Wound healing starts with hemostasis to preserve the integrity of the organism; the organized form of this is known as coagulation. Traumatic and/or surgical damage results in capillary injury and hemorrhaging, which is the organism’s self-protection mechanism. Wound healing is delayed if hemorrhaging starts and stops repeatedly, as this impairs granulation tissue formation. The development of alveolitis and the resultant pain in patients with recurrent hemorrhaging following surgery may be associated with this impairment. The consequences of low viscosity, including the problem of the instability of blood, are addressed by the coagulation process. Coagulum serves two main functions: to temporarily protect the exposed tissue, and to create a temporary matrix – known as the fibrin plug – for the cells to migrate from neighboring wound edges. Coagulation is followed by inflammation, constituting the basis for wound healing.

Wound healing is a well-managed interaction between the cells of key importance (i.e. neutrophils, monocytes, lymphocytes, endothelial cells, and fibroblasts) and soluble regulating and signaling molecules (mediators) moderating intercellular substance synthesis. Coagulum typically contains a high number of neutrophils and macrophages that are released immediately following injury. These cells start to remove the necrotic and/or damaged tissue and microorganisms by secreting phagocytosis, toxic oxygenation products, and enzymes, and by releasing signaling molecules rich in polypeptide mediators, addressing cells that are effective in the wound healing process. These growth factors and cytokines released by macrophages play a central role in the proliferation of primarily fibroblasts and endothelial cells as well as smooth muscle cells, indicating the transition to the proliferation phase of healing. Although inflammation is an indispensable healing phase, the over or under release of inflammatory mediators may adversely affect the wound healing process. Inflammation reaches its final stage on or around the third day.

Proliferation

This complex process incorporates angiogenesis, the formation of granulation tissue, collagen deposition, epithelialization, and wound retraction. These processes occur simultaneously at various levels in different parts of the wound. Angiogenesis is triggered from the moment the hemostatic plug has formed, once the platelets have released growth factors. As the process of angiogenesis progresses, a rich vascular network of capillaries is formed; thus, nutrients and new cells are transferred to the healing front. With the cellular level signaling, fibroblasts populate the wound space and excrete the extracellular matrix proteins. This clot is gradually replaced by vulnerable hemorrhagic vascular tissue, which is called granulation tissue. This tissue lays the foundation for epithelial migration, where epithelial cells migrate from the edges of the wound to seal the surface and provide the basis for the formation of connective tissue. During this period, the color of the wound starts to return to normal, with typical characteristics, and it develops resistance to trauma.

Although healing takes place in a hierarchical manner, all the stages of healing are always present at all times in a healing wound because the healing potential is not the same throughout the wound. Wound contraction, which is facilitated by myofibroblasts, may not seem very prominent in extraction sockets, yet it very often happens in wounds that lack keratinization. What is important to note is that the greater the wound space, the more granulation tissue will be required by the wound in the secondary healing phase, which results in faster repair potential and more scar formation. However, the extraction socket is an exception to this rule.

Remodeling and maturation

This process is the longest-lasting phase of wound healing, taking up to a year after proliferation ends. The duration of proliferation is closely related to the volume and function of the tissues. Proliferation takes longer in tissues with a thick phenotype than in those with a thin one. Downregulated mechanosensory signals during remodeling reduce the cellular activity, terminating intercellular matrix formation and the extermination of myofibroblasts (a type of cell between a fibroblast and a smooth muscle cell, narrowing the wound area) through apoptosis.

The final phase of wound healing typically comprises the formation of a tensile, sensitive scar tissue with random collagen fibers. However, a scarless type of tissue mimicking the histologic properties of intact connective tissue is formed during the wound healing process in certain intraoral areas such as the hard palate. Nonetheless, molecular bases of this type of healing that occurs without leaving a scar still remain to be elucidated.

Wound healing is completed by the end of the maturation period, and no alteration in the size of the newly formed tissue should be anticipated. Factors prevailing in the individual phases of wound healing are the main determinants of how rapidly and uneventfully this final stage can be achieved.

TYPICAL CHARACTERISTICS OF ORAL MUCOSAL WOUND HEALING

It is well established that oral mucosa wounds heal rapidly without leaving any complications or scars. Both cellular and intercellular substance as well as collagen fibers are arranged irregularly when a scar is formed, resulting in low matching with the neighboring tissue properties. Studies on healing models of oral mucosa in pigs and rodents have demonstrated that healing is more rapid and clinical, and histologic scar formation is less, when compared with similar skin injuries. However, the reason for the difference in healing between the skin and the oral mucosa is still unclear. It has been suggested that slow wound closure resulting in low-quality healing of the connective tissue and scar formation is inhibited by evolutionary selection to protect the tissue from microbial infections. In other words, since any delay in wound healing in the oral cavity may lead to difficulties in eating and the disablement of the organism, it can be speculated that oral mucosa has acquired faster and improved wound healing properties compared with the skin in the evolutionary development process.

Furthermore, studies have also suggested that improved wound healing properties of the oral mucosa do not solely originate from peripheral therapeutic opportunities offered by the oral environment, and that signals transmitted by the intercellular substance, which play an important role in regulating cellular functions, are different from those of the skin.

Other mechanisms enabling the tissues to heal without scar formation include continuous bathing of the oral mucosa with saliva and strong inflammatory response. Saliva contains cytokines (i.e. cell-to-cell communication molecules) supporting wound healing, and growth factors such as epidermal growth factor (EGF), transforming growth factor beta (TGF-ß), and insulin-like growth factor (IGF). Delayed intraoral wound healing where there is insufficient saliva supports this hypothesis. However, the influence of saliva on scar formation is not yet clearly understood.

On the other hand, it should be borne in mind that infection-free healing, atraumatic surgical techniques, and uncompromised systemic health are as effective as the basic biologic mechanisms in wound healing.

WOUND HEALING AND SYSTEMIC FACTORS

Systemic factors are as effective as local factors for uneventful and scar-free wound healing. The following discussion covers some systemic factors that have been selected due to their significance and prevalence, although this is not an exhaustive list.

Age

Aging is a natural life process associated with anatomical, biochemical, and physiologic alterations in all systems of the human body. Aging by itself does not affect the healing of intraoral wounds. However, chronic diseases acquired due to aging, medications, and drug-drug interactions may have an adverse effect on wound healing. In addition, dementia may occur at advanced ages, which together with malnutrition has an adverse effect on the healing process. Other factors that influence healing are lax adherence to prescribed drug regimens and poor oral hygiene.

Nutrition

Nutrition does not usually have an effect on wound healing in healthy individuals as it would, for example, in those with malnutrition induced by systemic disease. However, the availability of sufficient protein, zinc, and vitamins (A, B, and C) during the recovery of the body’s immunity, which declines immediately following an injury, can support cellular activity and secure the required collagen synthesis at the wound site. However, malabsorption due to gastrointestinal diseases (e.g. Crohn’s disease, ulcerative colitis, gastritis, or prolonged use of proton pump inhibitors) may result in malnutrition, leading eventually to a deficiency of essential vitamins and minerals as well as soft and/or hard tissue healing problems.

Dehydration

Electrolyte imbalance resulting from fluid loss or reduced intake may cause cardiac and renal dysfunction as well as functional disorders of the cellular metabolism, the oxygenation of blood, and hormonal activities. It is therefore recommended to inform patients regarding possible risks of dehydration in wound healing.

Diabetes

Certain chronic systemic diseases adversely affect the magnitude and quality of post-injury tissue response by modulating the hematopoietic system, while others modulate the endocrine system. In this context, diabetes has a special clinical significance. In 2019, the International Diabetes Federation (IDF) announced that there were 463 million people with diabetes globally, ranging in age from 20 to 79 years (according to the IDF Diabetes Atlas). This figure is expected to rise to 700 million by 2045. It is estimated that almost half (49.7 %) of diabetic patients have not yet been diagnosed.

In 2019, approximately 4.2 million adults aged 20 to 79 years were estimated to die as a result of diabetes and its complications. Al...