INCISION, SUTURE & SUTURE MATERIAL

INCISION

Definition :-a cut or wound deliberately made

by an operator in the skin or mucosa using a

sharp instrument such as a surgical blade

cautery, so that the underlying structures can

be exposed adequately for surgical access.(NB:- sound anatomical knowledge is essential in planing incision)

PRINCIPLES OF INCISION

Incision is placed parallel to the structures without causing damage to the vital structures .

Sharp bade of proper size & shape should be used.

Clean , single stroke incision without much tissue damage.

Incision is placed on the sound bone , or away from the surgical area to ensure the prevention of wound dehiscence

Pen grasp for intra oral incision & table knife grasp for extra oral incision is used.

Skin or mucosa to be incised , should be stabilized with finger pressure to guide the passage of the blade.

Long firm continuous stroke are used to minimise tissue damage.

No sharp angles are given instead curve are given to reduce slough due to poor circulation.

Incision through epithelial surfaces is made with blade perpendicular to the epithelial surface

INCISION IN THE ORAL CAVITY

It is desirable to incise

through attached gingiva

and over a healthy bone

.

Incision placed near the

teeth for extraction

should be made in the

gingival sulcus.

Integrity of the inter

dental papillae is

maintained as far as

possible.

Blood supply to

incision should be

adequate.

Incision should be at

right angle to mucosa

to prevent shelfing

edges, that might

cause necrosis of the

undermined part.

CONTRAINDICATION FOR PLACEMENT OF

INCISION LINES

Avoid placing incision :-

i. Over canine prominence – soft tissue defect will be created due to bony fenestration

ii. Vertical incision in the mental nerve region

iii. On the palate – near the greater palatine vessels

iv. Through incisive papillae

v. Over bony lesions – dehiscence

vi. Vertical incision on the lingual side of the mandibular arch

TYPES OF INCISION

Horizontal :- Seldom used. Incisions are directed along the gingival margin either mesially or distally. Generally used in periodontal flap surgery.

Vertical:- Most desirable . Aka releasing incision. Generally placed at obtuse angle to horizontal incision.

Semilunar :- This incision is used to keep attached gingivaintact around teeth & for endodontic surgery. A gap of 5mm is present from the base of the gingival slucus to the incision .

INSTRUMENT USED FOR INCISION Scalpel & dissecting

scissors

FLAP

Flap is a section of soft tissue that is outlined by a surgical incision , carries its own blood supply, allows surgical access to underlying tissue ; can be replaced in the original position , and can be maintained by sutures and is expected to heal.

COMPLICATION OF FLAP SURGERY Flap tearing:- Flap should be

large enough to prevent tearing

Flap necrosis:- side of flap should be parallel or convergent from base . Length of flap is not more than twice the width of the base . Axial blood supply should be included in base of the flap. Base of the flap is not excessively twisted , stretched, or grasped that might damage its blood supply.

Flap dehiscence:- Flap edges are approximated over healthy bone and not placing flap under tension.

TYPES OF FLAP

A Full thickness flap –

mucoperiosteal flap

Partial thickness

B Envelope flap

Two sided triangular flap

Three sided rhomboid flap

Semilunar flap

C Labial,buccal flap

Palatal, lingual flap

ENVELOPE FLAP

Most common type of flap.

Incision is made to any length intraorallyaround the necks of the teeth along the free gingival margin on the buccal or lingual aspect including the interdentalpapillae.

The entire mucoperiosteal flap is raised by using periosteal elevator to a point to the apical 1/3 of the tooth

This is mainly used for surgical extraction of tooth or root.

TWO SIDED TRIANGULAR FLAP Vertical releasing incision is

made to envelop flap on one side.

Gives better access.

Vertical incision is given in interproximal area as the tissue is thick.

To avoid periodontal defect , the incision should never lie directly on facial aspect of the tooth.

Flap is reflected towards base using periosteal elevator.

THREE SIDED RHOMBOID FLAP

Additional vertical incision is

given

Improves visibility and

access

Base of the flap is greater

than apes to ensure

adequate blood supply

SEMILUNAR FLAP This flap is designed whenever

periapical area is required to be exposed for periapicalsurgery

Base is border than apex

Incision is taken at least 5 cm away from free gingival margin.

Advantage:- This flap is useful to prevent damage to interdental papilla and periodontal post surgical defects.

In case of crowding , suture is not a problem.

Disadvantage :- It often lies on

SUTURE

Definition:-a suture is a strand or thread of

material used to approximate tissues and also

ligate blood vessels.

To suture is the act of swing or bringing

tissues or flap edges together and holding

them in apposition untill normal healing takes

place.

CLASSIFICATION

Based on diameter or thickness

• From 1-0 to 10-0

• Higher no of zeros corresponding to thinner

more delicate thread

• Most commonly used suture in suturing oral

mucosa is 3-0 thread

• Smaller size suture are used for suturing

conspicuous places on the skin such as face.

Based on resorbability

1. Absorbable :- All suture materials that are

digested by the body enzyme or are hydrolyzed

by the tissue fluids are absorbable

a. Synthetic

b. Natural

2. Non absorbable :- sutures that can not be

digested by tissue enzymes are encapsulated

or walled off are non absorbable

a. Natural

b. Metallic

c. synthetic

Based on type of filament

1. Monofilament type:- made of single strand , resist harbouring micro-organisms & ties smoothly. It has to be handled delicately.

2. Multifilament type :- several filaments are twisted or braided together into a single strand . It gives good handling & tying characteristics.

Based on coating

a. Coated :- polyester sutures are usually coating with biologically inert non resorbable compound . Coating is done to reduce friction of braid.

b. Non-coated

REQUISITES OF SUTURE MATERIALS

1. Tensile strength

2. Tissue biocompatibility, low tissue irritation

and reaction

3. Low capillarity

4. Good handling & knotting properties

5. Sterilization without detoriation of properties

.

SUTURE MATERIAL

SUTURE NEEDLES

Types

Eyed

Eyeless

PARTS OF NEEDEL

CLASSIFICATION BASED ON CURVATURE ,

RADIUS &SHAPE

PRINCIPLES OF SUTURING 1. The needle should be grasped at

approximately 1/3 rd the distance from the eye and 2/3 from the point

2. The needle should enter the tissue perpendicular to the tissue surface

3. The needle should be passed through the tissues along its curve

4. The suture should be passed at an equal depth and distance from the incision on both sides

5. The needle always passes from the movable tissue to fixed tissue

6. The needle always passes through the thinner tissue to the thicker tissue

7. The needle always passes from deeper tissue to superficial tissue

8. Tissues must never be closed under tension

9. Suture is tied only to approximate tissue not to blanch

10. Knot should not lie on incision line

11. Sutures should be placed at a greater depth than the distance from the incision , so as to evert the wound margins

12. Skin sutures are removed in 5 days & intra

SUTURING TECHNIQUE

Interrupted suture-sling suture Most commonly used

suture

The suture is passed through both the edges at an equal depth & distance from the incision

Needle penetration should be 3 mm from the wound edges

Continuous over and over

suture

Initially a simple interrupted

suture is placed

The needle is reinserted in a

continuous fashion such that

the suture passes

perpendicular to the incision

line below and obliquely

above.

The suture is ended by

passing a knot over the

untightened end of the suture.

It provide rapid technique for

closer and distribution of the

tension uniformly over the

suture line.

It offers a more water tight

closer.

Continuous locking suture

Similar to continuous suture

But locking is provided by

withdrawing the suture through

its own loop.

The suture passes

perpendicular to incision line.

Locking prevent excessive

tightening of the suture as the

wound closer progresses

MATTRESS SUTURE

Horizontal mattress suture The needle is passed from one edge

of the incision to another & again from the latter edge to the 1st edge in a horizontal manner & knot is tied.

The distance of needle penetration from the incision line & the depth of penetration of the needle is the same for each entry point

Horizontal distance of the points of penetration on the same side of the flap differs

This provide broad contact of the wound margins

Eg:- closer of extraction socket

Vertical mattress

suture

Similar to horizontal

suture

But depth of

penetration varies

When needle is

brought back from the

second flap to 1st flap ,

the depth of

penetration is more

superficial.

It is used for closing

deep wounds.

FIGURE OF 8 SUTURE

Used for the

extraction socket

closer and adaptation

of gingival papillae

around the teeth.

SUBCUTICULAR SUTURES The subcuticular layer of

tough connective tissue if sutured will hold the skin edges in close approximation when cosmetic results are desired

Continuous short lateral stiches are taken beneath the epithelial layer of the skin

Ends of the suture comes out at each end of the incision and are knotted.

This tye of suture leaves cosmetic scar.

KNOT

Definition :- A knot is an interwining of threads for the purpose of joining them.

Component of sutured knot

a. The loop created by the knot

b. The knot itself , which is composed of a number of tight throws , each throw represents a weave of two strands

c. The ears, which are the cut ends of the suture

TYPES OF KNOT

Square knot(sequre /

half hitch / Reef/ single

knot)

There are four throws

The 1st throw is placed in

precise position for the

knot , using a double

loop.

2nd throw is tied using

horizontal tension .

Additional 2 throws are

given

Ends are cut long.

SURGEON’S KNOT

It is formed by two

throws of the suture

around the needle

holder on the first tie

and one throw in the

opposite direction in

the second tie

Granny’’s knot / slip knot

It involves a tie in one direction followed by a

second tie in the same direction & a 3rd tie in the

opposite direction to square the knot and hold it

sequrely.

Used with silk , chromic catgut or plain catgut

suture material.

BIBLIOGRAPHY

SANJUKTA SAHA

FINAL YEAR

HIDSAR

THANK YOU