Sutures are used in the veterinary surgery to connect the damaged tissues or tissue incisions and for ligature applications. With the opportunities provided by the technology and science of today, there are numerous suture materials and each suture has unique usage areas and properties. The support provided by suture materials in scar and tissue recovery period plays an important role for the veterinary surgery. Please click here for the suture techniques used in the veterinary surgery. When choosing a suture, scar/incision conditions as well as physical, chemical and biologic properties of the sutures should be considered. In this article, we will talk about the properties of veterinary sutures.

What Are The Properties of Veterinary Surgery Suture Materials?

Surgical process that is implemented to connect the tissues and wounds in surgical operations or traumatic damages is called suturing (1). Sutures plays an important role in the veterinary surgery as they support tissue restoring and wound healing. Sutures in veterinary surgical operations are often preferred to close the tissues/wounds on skin, facia and muscle; digestive and urogenital system surgery, to stop the bleeding and in cardiovascular surgery (2).

Veterinary Surgery Suture Properties

Production Format

Most of the synthetic sutures are formed by polymerizing the liquid resin; silk suture formed from natural fibers is formed by bending and catguts are formed by stratification and bending after creating stripe forms (3).

Elasticity

The elasticity is the elongation of the suture by pulling and suture returning back to the previous position when set free. Elasticity is a desired property for the sutures. This elasticity also represents the strength. The power that the suture can withstand during flexing is defined as the strength. To prevent tissue tightening and cut due to oedema that might occur in the tissue after the suture is implanted to the wound might and tissue retract after the resorbation of oedema, the suture must get shorter to keep the tissues in the suitable shape and position (4,5).

Plasticity

This term represents the elongation of the suture materials with pulling and tugging but staying that way instead of returning to the initial position. In short, the suture elongates and cannot go back to the previous position. When this type of sutures are implanted to the tissue, the sutures will elongate without cutting or pressing the tissue which does not prevent the blood circulation around the wound. However, elongated suture due to tissue retraction after the resorbation of the oedama is unable to keep the tissues together. While most of the sutures have elastic property, some of them have plasticity (4,5).

Friction Surface

The suture surface must be uniform and smooth. However, sutures with too glossy and slippery surfaces are not preferred since these sutures do not hold the knots well (5). The granular suture surfaces are desired for knot security. The disadvantage of these sutures is that they cause trauma when passed through the tissue and cut the vein surface and cause thrombosis. These types of disadvantages are minimised by coating the sutures with silicon etc. materials. Multifilament (braided) sutures have more friction surface than monofilament (stripe/non-braided) sutures. Multifilament suture cause more trauma when passed through the tissues (6).

Memory

This represents that the suture cannot be changed easily. Sutures with high memory tend to go back to their packed format (4, 5) when the sutures are taken out of the package (5, 6) during and after manipulation (4,5).

Tensile Strength

The tensile strength of the suture represents the tensile breaking force (4, 5, 8). The suture tension starts to decrease after implantation. The tensile strength is related to the diameter of the suture and as the suture diameter increases, tensile strength increases. The weakest point of the suture is the knot. Therefore, tensile strength is measured from knotted suture (9). Knotted suture has the 3/2 strength of the unknotted suture (5). Each additional knot decreases the tensile strength of the suture by 30-40% and cause more foreign object to be on the tissue (6). The tensile strength especially plays an important role in tense areas such as linea alba (9). The results of Greenwald (10) that investigated the tensile strength of 10 different sutures with the same thickness for 6 weeks before and after in vivo incubation are given in Table 1.

Usage Property

This represents a wide range of usage quality. This property is affected from suture handling, fraction coefficient, knot safety and memory (11).

Capillarity

This represents the liquid absorption by the surgical suture and keeping the absorbed liquid along the suture (4). Sutures with capillarity acts like a bougie (8, 12) and absorb the serum and bacteria in the implanted region and carry these along the suture (5, 8, 12). Most of the time the capillarity of the multifilament sutures are higher than monofilament sutures (4, 5, 12). Sutures with capillarity that are preferred on the skin permit microorganism transfer between external and internal environment and lead to contamination. The capillarity of the surgical sutures are minimised by coating with materials such as silicon, Teflon or resin (13).

Size

Surgical suture size are classified as “USP” in American Pharmacopeia and “EP” in European Pharmacopeia. The European codex uses metric system (5, 11, 12). Today, surgical suture sizes are often considered for USP classification. USP classification is done according to suture diameter, knot security and tension. Additionally, the classification changes for natural or synthetic structure and absorbable or non-absorbable nature of the suture. In EP classification, the millimetre width of the suture is considered as the measurement. The EP codes range between 0.1 and 20. Minimum radius can be found in terms of millimetre by dividing the code number with 10 (11).

Tissue Reaction

All sutures are a foreign substance for the tissues and lead to direct tissue reaction (8, 15). This reaction reaches the peak in 2-7 days depending on suture amount, type, configuration and implantation (4). Histologically, reaction implantation against the sutures are polymorphonuclear leucocyte between days 1-4, macrophage and fibroblast infiltration between days 4-7 and chronic inflammatory reaction and fibrose tissue formation after day 7 (15). In the meantime, fibrose capsule formation is observed around the sutures that are not absorbed on 28th day (6, 15) and inflammation continues until the sutures are completely absorbed for absorbable sutures (15).

Significant inflammatory reaction on the tissue decrease the strength of the wound against infection and delays wound healing (5). Sutures that lead to excessive tissue reaction might lead functional (capillary repair and ureteral anastomosis) or cosmetic problems (skin) due to excessive scar development (12). Tissue reaction is more in natural sutures compared to synthetic sutures and more in intestine and bladder than muscle and facia (6). Multifilament sutures cause more tissue reaction than monofilament sutures due to their capillary properties and increase the risk of infection (6, 15).

A study on rats showed that the most common inflammation reaction for wounds closed with chromium catguts, polyglycolic, silk and polypropylene were for catgut, silk, polypropylene and polyglycolic acid respectively (16). Kirpensteijn et al. worked on closing the dog skin incisions with polyglactin and poliglecaprone and found that poliglecaprone lead to less tissue reaction compared to polyglactin at the first stages of healing and there was no significant difference between two groups in the following stages of incision healing (17).

Physical Configuration

This defines whether the suture is monofilament or multifilament (4). Multifilament sutures are created by braiding or twisting multiple threads, monofilament sutures are formed by single thread (12). The threads in multifilament sutures prevent the bacteria to be phagocyted by the macrophage (6, 15). Multifilament sutures might absorb tissue fluid, swell and therefore lead the knots to be untied easily. Due to these properties, multifilament sutures lead to more tissue reactions (18).

Bibliography

(1) Samsar E, Akın F, Anteplioğlu H. (1996) Klinik Tanı Yöntemleri ve Genel Cerrahi. “6.Baskı” Tamer Matbaacılık. Ankara

(2) Tan R, Bell R, Dowling B, Dart A (2003) Suture Materials; Composition and Applications in Veterinary Wound Repair, Aust Vet J, 81(3):140-45

(3) Katz AR, Mukherjee DP, Kaganov AL, Gordon S (1985) A New Synthetic Monofilament YYÜ Vet Fak Derg, 2006, 17 (1-2):37-44
Absorbable Suture Made From Polytrimethlyene Carbonate. Surg Gynecol Obstet, 161(3): 213-22

(4) Moy RL, Lee A, Zalka A (1991): Commonly Used Suture Materials in Skin Surgery, Am Fam Physician, 44(6):2123-8

(5) Terhune, M (2002): Materials for wound closure, http://www.emedicine.com

(6) Monnet, E (2002): New Suture Materials Offer More Options for Wound Closures, The Newsmagazine of Veterinery Medicine, Oct, 1

(7) Leapar ,DJ (2001): Wound closure, EWMA, 1(2):19-24

(8) Niles J, Williams J (1999): Suture Materials and Patterns, In Practice, 21:308-20

(9) Taylor B, Bayat A (2003 ): Basic Plastic Surgery Techniques and Principles: Choosing the Right Suture Material, Student B.M.J., 11:140-41

(10) Greenwald D, Albear P, Gotlieb L (1994): Mechanical Comparison of 10 Suture Materials Before and After in Vivo İncubation, J Surg Res, 56: 372-77

(11) Henderson, RA (2005): The Veterinarian’s Suture Guide http://www.vetmed.auburn.edu

(12) Smeak, DD (1990): Selection and Use of Currently Available Suture Material, (in) Current Techniques in Small Animal Surgery, MJ Bojrab (Editor), chapter 3, 3^nd Ed, Lea & Febiger , Philadelphia

(13) Katz AR, Mukherjee DP, Kaganov AL, Gordon S (1985): A New Synthetic Monofilament Absorbable Suture Made From Polytrimethlyene Carbonate Surg Gynecol Obstet, 161(3): 213-22

(14) Chu, CC (2001): Textile-Based Biomaterials for Surgical Aplications. (in) Polymeric Biomaterials Second Edition Revised and Expanded, S. Dumitriu, (Editör) Chapter 19, Marcel Dekker, New York.

(15) Sherbeeny, AM (2004): Needdles, Sutures and Knots Part III: Spesific Suture Materials, ASJOG, 1:167- 70

(16) Yaltirik M, Dedeoğlu K, Bilgic B, Koray M, Ersev H, Dulger O, Soley S (2003): Comparison of Four Different Suture in Soft Tissues of Rats, Oral Diseases, 9, 284-286.

(17) Kirpensteijn J, Maarschalkerweerd RJ, Koeman JP, Kooistra HS, Sluijs FJ (1997): Comparison of Two Suture Materials for Intradermal Skin Closure in Dog, Vet.Q.,19(1):20-22

(18) Parell, GJ 2003): Comparison of Absorbable with Nonabsorbable Sutures in Closure of Facial Skin Wounds, Arch Facial Plast Surg, 5, 6, 488-490

For veterinary surgeons, correct material selection and correct suturing technique plays an important role for traumatic surgical operations. Just like animals, suturing is one of the indispensable and common surgical operations in animal anatomy. Veterinary surgeons apply special suturing techniques depending on the wound condition. Surgeons must be aware of the suture needle, thread, knots, strength, usage type to correctly close the wound of the individual undergoing a surgical operation. Click here to learn more about veterinary suture types, materials and properties before veterinary suture techniques.

Veterinary Suture Techniques

There are numerous suture techniques. Each suture technique depends on wound shape and depth. The most important purpose for suturing is to ensure fast recovery with minimum tissue reaction. Suture selection is highly critical for the wound or incision to heal sufficiently and on-time. The veterinary suturing suture techniques are listed below:

• Simple Suture
• Cross Suture
• Horizontal Mattress Suture
• Vertical Mattress Suture
• Halsted Suture
• Lembert Suture
• Gambee Suture
• Continuous Suture
• Subcutaneous Suture
• Ford Locking Suture
• Bag Ring Suture
• Chinese Finger Trap Suture

We have listed the most preferred suture techniques. You can click on all the techniques here to view the sutures with visuals and texts.

Simple Suture

Simple sutures are placed horizontally from right to left. The direction is the opposite for left-handed surgeons. The needle is handled by the needle holder, pressed to the opposite side of the wound 2-5 mm away from the edge of the tissue, taken above the skin and connected.

Figure 1 – Simple Suture Technique (1)

Cross Suture

This is a commonly preferred method by surgeons by creating a simple suture connected with a knot. The most important advantage is connecting the tissues tighter. Just like the simple suture, the first step is to enter subcutaneously to the opposite side of the wound from 2-5 mm away from the tissue. Then, the needle transits to the opposite side from the exit point and the first step is repeated and the suture is completed with a knot.

Figure 2 – Cross Suture Technique (1)

Horizontal Mattress Suture

In this method, the needle is subcutaneously pricked from 2-5 mm away from the tissue edge and taken out from the opposite site horizontally and a knot is formed. The pressure is applied to a larger area and tissue rupturing risk is minimised.

Figure 3 – Horizontal Mattress Suture Technique (1)

Vertical Mattress Suture

By using the needle holder, the needle is subcutaneously pricked 8-100 mm away on the opposite side and a knot is formed. This technique has stronger tension than horizontal mattress suture.

Figure 4 – Vertical Mattress Suture Technique (1)

Halsted Suture

This technique is similar to vertical suturing. But before making a knot, the suture is implanted parallelly to the incision region. Halsted suture looks like a dashed pattern because the wound edges are reversed.

Figure 5 – Halsted Suture Technique (1)

Lembert Suture

This technique is similar to mattress suture and preferred for repairing caveated organs. Since the adherence layer is submucosa, the suture must be adjusted not to enter the lumen and the suture must not be tightened too much. If the suture is tightened too much before the knot, the wounded tissue might turned upside down.

Figure 6 – Lembert Suture Technique (1)

Gambee Suture

This technique is often preferred in intestine repairs. The purpose to use this suture is to decrease mucosa eversion and serosa surface rupture of the intestine.

Figure 7 – Gambee Suture Technique (1)

Continuous Suture

If the incision is long, continuous suture technique is used. In this technique, instead of losing time with knotting after every suture, a long incision area is sutured in a short time. At the same time, the tensile strength on the suture can be more equally distributed around the tissue. One of the disadvantages of continuous suture technique is that if one of the cycles is lose or ruptures, the thread will disintegrate.

Figure 8 – Continuous Suture Technique (1)

Subcutaneous Suture

This suture is applied subcutaneously in simple and continuous pattern. The needle can enter horizontally or vertically. This technique is also called embedded suture due to application type. This technique is used for avoiding any suture marks on the tissue and to reduce scarring.

Figure 9 – Subcutaneous Suture Technique (1)

Ford Locking Suture

This type of suture which is applied with locking style required more suturing materials than other suture techniques. Locking technique makes the suture stronger against patient’s intervention or external interventions. This technique is preferred to prevent a suture material subjected to external intervention to damage the internal tissues.

Figure 10 – Ford Locking Suture Technique (1)

Bag Ring Suture

This technique is preferred to fix visceral logs, and percutaneous tubes to a vicus in gastronomic and cystostomy procedures.

Figure 11 – Bag Ring Suture Technique (1)

Chinese Finger Trap Suture

This is a technique consisting of a series of knots to fix a tube in subcutaneous sucking and discharge. If the tension on the tube increases when the tube is taken out, this suture prevents the tube to be taken out.

Figure 12 – Chinese Finger Trap Suture Technique (2)

Veterinary Suture Knot Techniques

Knotting is as important as suturing. Suture must be connected with a correct knot to avoid the suture to get lose, move, or damage the tissue. The veterinary suture knot techniques are listed below:

• Square Knot
• Sliding Knot
• Rounded Knot
• Surgical Knot
• Subcutaneous Knot

We have listed the most preferred knot techniques. You can click on all the techniques here to view the sutures with visuals and texts.

Figure 13 – Suture Knot Techniques – Square Knot, Sliding Knot, Rounded Knot, Surgical Knot (3)

Square Knot

This technique is the most common knot type and used for fixing most of the suture patterns.

Sliding Knot

Other than lower tension, this knot is similar to the square knot. The thread is hold facing upwards and suture is completed with sliding knot for tightening or loosening.

Rounded Knot

Rounded knot is a commonly preferred knotting technique. This knotting technique is fast and durable.

Surgical Knot

This technique created minimum tissue trauma. Surgical knot is asymmetrical. Therefore, a square knot is applied to the top for security.

Subcutaneous Knot

Subcutaneous or embedded knots are preferred to decrease the irritation that might be caused by the knots rubbing to the external tissue.

Figure 14 – Subcutaneous Knot Technique (3)

Bibliography

(1) Reproduced with permission from Stephen Baines, Vicky Lipscomb and Tim Hutchinson: BSAVA Canine and Feline Surgical Principles, 2012, originally illustrated by Samantha J Elmhurst.

(2) With permission from Baines S, Lipscomb V and Hutchinson T. (2012) Manual of Canine and Feline Surgical Principles, BSAVA Gloucester, p 289.

(3) veteriankey.com Suturing Techniques and Common Surgical Procedures, bağlantı

In oral and maxillofacial surgery, incision and implant design can require suturing while placement of implant based on original anatomic position or operation properties. Last step of surgical operations that require incision/laceration is suturing.

Suture techniques are critical in surgery. At this point, it is vital to select appropriate material for traumatic surgical operations. When materials and methods to close the wound are inappropriate, normal healing process can become longer. Additionally, one of the few indicators that patients who completed oral surgery treatment to determine skills of the doctors is the look of sutured wound.

Generally, preference and habits of surgical doctor are effective in suture selection. Effective use of suture is only possible when the surgeon knows properties of needles and sutures and surgeons applies these in certain areas. (1)

Dental Suture

Suturing is an application to provide tissue integrity that decayed after surgical operation and controls resulting bleeding (2). Sutures are materials that are comprehensively and commonly used in all fields of surgery. (3)

Suture Materials

Needle Holder

This tool holds the needle while suturing. Handle part can be locked. These needle holders are available with thick and thin ends. Needle holder tip is shorter and stronger than hemostat. Part that holds the suture is staggered-tooth and enables stability. (4)

Needle

These are high-quality steel developed to pass the suture from tissue with minimal damage. Suture needles are available in wide range from small to large. Tips can be in round form like sewing needle or in triangle form. (Figure 1)

Figure 1 – Needle Tip Types (4)

Needle shapes: These needles could be straight or curved. Curved type: These can be in 1/2, 1,4, 3/8, 5/8 or J shaped circle form. (Figure 2) (2, 4)

Figure 2 – Curved Needle Shapes (2)

Sutures

Selecting appropriate sutures may depend on biological structure of the wound and anatomic localisation. This selection is as important as technique and experience of the surgeon. Properties of ideal suture can be listed as follows:

1. Perfect tension strength
2. Easy to use
3. Good know safety
4. Minimum tissue reaction
5. Compliance with tissue oedema or contraction
6. Prevent infection

Things to Be Considered When Selecting Sutures

Tension Strength

This value is obtained by dividing weight that will cause suture to rip to cross-sectional area of the suture. This value is proportional with suture diameter. This value is standardised and numbered based on American Pharmacopeia. Numbering is as #/0. As number increases, diameter and tension strength decreases. (2) To enable wound closure in periodontal plastic surgery, minimum tension force should be applied on suture material.

Knot Strength

This is the force necessary to untangle the knot. This is related with slipperiness of the suture. (2)

Capillarity

This is related with physical configuration. Sutures have monofilament and multifilament structure. Twisted and braided structure of multifilament sutures enables ease-of-use however, micro cavities between filaments makes it easy for liquids to move along suture. This property is called capillarity. High capillarity means high infection risk. (2)

Elasticity

This is the property of the suture to get back to old form and length after tension. This way, suture stretches during tissue oedema and returns to old form after oedema disappears. (2)

Tissue Reaction

This is inflammation of wound tissue around suture. Since all suture materials are foreign, these sutures cause mild or severe reaction. Tissue reaction is peaked between day 2 and 7. This time and intensity of the reaction is related with suture type and amount. Multifilament cause higher tissue reaction than monofilaments and natural sutures cause higher tissue reaction than synthetic options. More than normal material within wound tissue will also increase infection risk. (2)

Suture Types for Absorption

Absorbable Sutures

These are operation sutures generally used to close dermis to decrease tension at the edges of epidermal wounds. High tension strength, absorption time, low tissue reaction, and good knot safety are important properties. There are synthetic and natural types: While natural sutures only have plain catgut and chromic catgut, synthetic absorbable ones include polyglycolic acid (PGA), polyglycolide lactic acid (PGLA), polydioxanone (PDO), and polyglycolide caprolactone (PGCL). (Table 1) (2, 5)

Table 1 – Absorbable Sutures (5)

Non-Absorbable Sutures

These sutures are durable against proteolysis and hydrolysis. These sutures can have tension strength on 60th day. Non-absorbable suture types: silk, nylon polyamide (PA), polypropylene (PP), polyester polytetrafluoroethylene (PTFE), and stainless steel. (Table 2)

Table 2 – Non-absorbable Sutures (5)

Silk is commonly preferred by surgeons. These sutures are manufactured from natural proteins obtained from silkworm cocoon. Silk is multifilament (naturally braided) and these sutures are perfect for usage, suturing, and knotting. Since it is natural fibre, this suture doesn’t cause significant tissue inflammation. It has high capillarity. Elasticity and plasticity are low. To understand the product easily, there are necessary information on suture packages for surgeons. (Figure 3) (2, 5)

Figure 3 – Suture fabrication tag information (2)

Suture Principles

Needle holder should hold the needle at 1/3 back of the needle. Needle should be applied with a right angle (90º). This way, tissue ruptures are prevented. Tissue should pass from the tissue with its own curve to prevent rupture. Needle should be pricked at least 3 mm away from both sides of wound tissue and to same dept. If two sides of the wound has different thickness, needle should be pricked from thin side to thick side. While suturing, tissue should not be pulled and stretched. If tissues are sutures by stretching, stiches will open. If know is too tight, tissue may rupture and cause ischemia. Knots should be on incision line. Each knot should have 3-4 mm between them.

While suturing, corners or papilla are sutured first, and vertical and horizontal incisions are sutured later. If one of the wound sides is upright, knot is positioned on the stable side, tightened, and both sides of the wound are levelled. If tissues have different thickness, suturing should be deeper on the thinner side or needle should be pricked from further of incision in thin side, and two sides of the wound should be connected.

If there is no special case, sutures are removed in 5-7 days. When sutures are removed, suture is hold and pulled upwards with a dental tweezer or forceps and one side of the suture beneath knots are cut. Before removing sutures, it is recommended to rinse the mouth with anti-septic. (4) To decrease tension between flap edges, before suturing, flap tissue should be positioned into designed area in passive form. Tissue trauma such as tension, rupture, or distortion should always be avoided. Gentle and careful manipulations with micro surgical instruments are beneficial.

Since each suture causes extra damage around wound edges, possibly lowest number of sutures should be applied. 6/0 and 8/0 non-resorbed suture material should be selected. Resorbable material be selected for multi-layered closure. Sutures should not act as ligatures and minimum tension should be applied. (6)

Dental Suture Suturing Types

Simple Suture

This is the most common suture technique within mouth cavity. Suture passes from one side of the wound, exits from the other side, and knotted at the top. (Figure 4) (4)

Figure 4 – Simple Suture Technique (4)

Vertical Mattress Suture

Vertical mattress suture technique is applied in two stages especially on tissue on skin. (Figure 5) (4)

Figure 5 – Vertical Mattress Suture Technique (4)

Horizontal Mattress Suture

Horizontal mattress suture technique tightens both sides of the wound. This is beneficial to close soft tissues. This is the easiest way to fix two papilla with single knot. (Figure 6) (4)

Figure 6 – Horizontal Mattress Suture Technique (4)

8 Figure Suture

This is a modified version of horizontal mattress suture. While closing both side of the soft tissue, 8 sutures helps preserving the position of clot. (Figure 7) (4)

Figure 7 – 8 Suture Technique (4)

Continuous Suture

If there is long incision, continuous suture technique is preferred. In this technique, instead of applying a knot every time, long incision line can be sutured in a short time. This could have knotted style or simple technique. (Figure 8) Disadvantage of continuous suture is when there is a rupture, suture below can loosen. (4)

Figure 8 – Continuous Suture Technique (4)

Sling Suture

When surgical operations are applied on limited regions, for example, if lambo is lifted from one side, this suture technique is common. This is also applied when buccal and lingual flaps are desired to be placed on different positions. Needle passed from hemisects of tooth to outer surface of buccal flap, perambulates the teeth and passed from palatial flap in distal. Suture is brought back to hemisects where suture starts, passed from internal surface of buccal flap, and knotted. (Figure 9) (7)

Figure 9 – Sling Suture Technique (8)

First step of most surgical operations is incision. A surgeon holding the bistoury should know what to do, localisation of anatomic structures around operation field, and creating maximum effect with minimum trauma after the intervention. Following the incision, infection around operation field should be post-operatively prevented and suturation should be applied to close the wound to provide high-comfort to patient. Closure of wound is as important as incision. Therefore, in addition to experience and skills of the surgeon, material knowledge is required. In this article, information regarding common suture operation techniques and used materials which will be used are presented and explained for dentist.

To view articles, posts, and technical details regarding suture use in other surgical operation, you can use our website. Additionally, you can select and view dental suture products of Boz Medical. You can click here for your orders and support. Our sales representatives will be happy to answer all your questions and meet your demands.

Bibliography

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(2) Altınyazar H. C., Koca R. DERMATOLOJİK CERRAHİDE SIK KULLANILAN SÜTÜR MATERYALLERİ, Zonguldak Karaelmas Üniversitesi Tıp Fakültesi • Dermatoloji Anabilim Dalı, ZONGULDAK, 2004.

(3) Parirokh M, Asgary S, Eghbal M J, Stowe S , Kakoei S. A SCANNING ELECTRON MICROSCOPE STUDY OF PLAQUE ACCUMULATION ON SILK AND PVDF SUTURE MATERIALS IN ORAL MUCOSA, International Endodontic Journal, 2004; 37:776–781

(4) Türker M, Yücetaş Ş. AĞIZ DİŞ ÇENE HASTALIKLARI VE CERRAHİSİ, Üçüncü baskı, ANKARA, 2004.

(5) Akça T., Mersin Üniversitesi Tıp Fakültesi • Genel Cerrahi Anabilim Dalı, 4. Sınıf Ders notları, MERSİN.

(6) Velvart P, Peters C, Peters O A. SOFT TISSUE MANAGEMENT: SUTURING AND WOUND CLOSURE, Endodontic Topics 2005; 11:179–195

(7) Evrenesoğlu E., Ege Üniversitesi Diş Hekimliği Fakültesi • Periodontoloji Ana Bilim Dalı, 4. Sınıf Ders Notları, İZMİR.

(8) Jansson L, Sandstedt P, Laftman AC, Skoglund A. RELATIONSHIP BETWEEN APICAL AND MARGINAL HEALING IN PERIRADICULAR SURGERY Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology, and Endodontology, 1997; 83 :596–601