Printed in U.S.A. VOL. 27, No. 10, OCTOEER 2001
OF ENDODONTICS Copyright 0 2001 by The American Association of Endodontists JOURNAL
CLINICAL AID The Continuous Locking Suture Technique Donald J. Kleier, DMD
The locking loops are placed -2 to 3 mm apart until the distal end of the flap is reached. The terminal suture is tied by having the surgical assistant close the last loop to form an end that the surgeon uses to tie the last suture (Fig. 6). The last suture is tied off and cut resulting in a terminal knot with 3 tags (Fig. 7). After initial healing the sutures are easily removed by cutting the loops close to the tissue on the tlap side. This minimizes dragging contaminated suture material through the flap. Two clinical cases are shown in Figs. 8 and 9 to demonstrate the appearance of a sutured flap in both the anterior and posterior regions. Both patients were good candidates for the Ochsenbein-Luebke flap. Advantages:
The continuous locking suture technique is described for use in endodontic surgery. The technique is an effective way to close OchsenbeinLuebke flaps. The importance of the assistant’s role is described. The technique’s advantages and disadvantages are discussed.
The purpose of suturing is to approximate surgical tlap margins to ensure optimal healing. The endodontic surgeon has a wide variety of suture materials and techniques available to facilitate closure of soft tissue flaps. Perhaps the easiest and most commonplace method of suturing is the interrupted suture technique. One disadvantage of placing interrupted sutures is that a knot must be tied for each suture placed. This can take considerable time and result in knots tied with unequal tightness. Knots can collect debris, irritate underlying soft tissue, and contribute to postsurgical pain (1). An alternative to interrupted sutures for the Ochsenbein-Luebke flap is the continuous locking suture technique. This technique has the advantage of requiring only two knots and allowing controlled tension on the flap margin throughout the suturing procedure ( I , 2). The purpose of this article is to describe how the endodontic surgeon and surgical assistant can work as a team to effectively and efficiently use this technique.
Efficiently placed with fewer knots to become buried or to irritate underlying tissue. Allows controlled tension on the tlap margin as the wound is closed. Easier to keep clean. Sutures are easily removed.
TECHNIQUE Suturing begins at one end of the flap by placing an interrupted suture. The suture should penetrate the tissue from the most mobile tissue to the least mobile tissue. This is usually from the flap to unreflected adjacent tissue. Needle penetration should be at least 2 to 3 mm from the incision line to prevent tear-through ofthe suture. Once the interrupted suture is tied only the short tag end is cut leaving the long end connected to the suture needle (Fig. I). The surgical assistant holds the long end of the suture to form a loop and to keep the suture from dragging on the patient’s skin or surgical drapes (Fig. 2 ) . Passing the through the loop Of Suture and pulling the SUtUre tight against the adjacent tissue forms the locks. The assistant can tighten the suture while the surgeon readies the needle for another penetration of the flap (Figs. 3 to 5).
FIG1. Continuous locking suture begins with an interruptedsuture at one end of the flap, The short tag end of the suture is cut leaving the long end to form a loop that the assistant controls. The surgeon then begins another pass from flap to adjacent tissue. 624
Vol. 27, No. 10, October 2001
Suturing for Endodontic Surgery
FIG2. Each suture penetration of the flap and adjacent tissue results in a loop controlled by the assistant. The assistant controls tension on the previously “locked” sutures while the surgeon begins another penetration of the flap.
FIG 5. By arcing the suture mesially and distally the assistant produces closing tension on the flap and further locks the suture in place. The surgeon simultaneously prepares the needle for another penetration.
FIG3. As the surgeon pulls the suture through adjacent tissue the loop becomes smaller and smaller. The assistant compensates by bringing the loop closer to the incision line.
FIG 4. Once the loop becomes too small to hold the assistant releases it and takes the long end of the suture. By pulling on the suture the loop closes and locks the most recently placed suture.
If any sutures pull through the tissue the integrity of the suture line could become compromised. Patients should be informed of this possibility.
FIG 6. Suturing continues as described in the previous figures until the last suture is to be placed. The assistant then takes the loop and forms it into a tag loop that will be used to tie the terminal knot.
DISCUSSION The continuous locking suture i s an efficient way to close soft tissue in any edentulous area (3). Galgut (3) cites examples of using the continuous locking suture technique to close periodontal
Journal of Endodontics
FIG7. A surgeon’s knot is tied using the tag loop and the needle free end. The final cut results in a knot with three tag ends.
FIG9. Clinical example of the continuous locking suture used in the maxillary posterior region. The patient required endodontic surgery on the buccal roots of tooth #14.
of a chlorhexidine gluconate mouthwash can reduce bacterial populations on sutures and wound margins (5). Patients placed on antimicrobial mouthwashes typically report for suture removal with minimal plaque buildup and minimal soft tissue inflammation. Alternatives to silk are available but each material has its own unique handling properties. It is recommended that any change in suture material or technique be accompanied by in vitro practice to achieve proficiency. Regardless of the material chosen sutures should be kept in place only long enough to ensure initial healing by primary intention. FIG8. Clinical example of the continuous locking suture used in the maxillary anterior region. The patient required endodontic surgery on tooth #8.
flaps used in conservative surgical techniques such as the modified Widman procedure (4).These full-thickness flaps that include the gingival margin are the types of flap designs used for some endodontic surgical procedures. The technique is equally useful in closing Ochsenbein-Luebke flaps. A variety of suture materials and needle types are available to the endodontic surgeon. The two clinical cases presented show the use of 4-0silk suture material. Silk is readily available and easy to tie but tends to support bacterial growth (4).The use
Dr. Kleier is affiliated with the University of Colorado School of Dentistry, Denver, CO. Address requests for reprints to Dr. Donald J. Kleier, Box ‘2-284, 4200 E. 9th Avenue, Denver, CO 80262.
References 1. Arens D. Practical lessons in endodontic surgery. Carol Stream, IL: Quintessence Books, 1998:136-44. 2. Silverstein L. Principles of dental suturing. Mahwah: Montage Media Corporation, 1999:46-7. 3. Galgut P. Suturing techniques in periodontal surgery. Br Dent J 1989; 167:29-31. 4. Cohen S, Burns R. Pathways of the pulp. 7th ed. St. Louis: Mosby, 1998:641-51. 5. O’Neal R, Alleyn C. Suture materials and techniques. Curr Opin Periodontol 1997;4:89-95.
ERRATUM In the June 2001 Journal of Endodontics there appeared a misspelling of one of the author’s names for the article “Setting Times for Endodontic Sealers Under Clinical Usage and In Vitro Conditions”(J Endod 2001;27:421-3). The authors are Neal A. Allan, Richard C. Walton, and Michelle A. Schaeffer. Dr. Schaeffer’s name was misspelled as %chaffer.” We regret the error and apologize for any resultant confusion.