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Transcript of Suturing technique
SUTURES AND SUTURING TECHNIQUES
ByDR VASUNDHARA.VDEPT OF CONSERVATIVE DENTISTRY AND ENDODONTICS
Introduction
Definition
History
Goals
Requisites for suture materials
Principles of suture selection
Principles of suturing
Suture needles
Suture materials
Classification
Characteristics of suture materials
Absorbable suture materials
Non- absorbable suture materials
Newer materials for suturing
Needle holders
Suturing techniques
Types of knots
Tissue reaction to sutures
Suture removal
Suture sterilization
Other Supplements / Adjuncts To Wound Closure
Conclusion
References
INTRODUCTION
Any break in the continuity of the tissue is called as a wound
It may be caused by
Trauma
Voluntary event
Surgery
Burn
In all these cases, the wounded tissues react with a repair or regeneration process known as healing
Correct approximation of the Flaps of the wound is desirable since it makes it possible to accelerate the healing process
Wound healing involves 2 fundamental mechanisms namely,
Primary intention- is defined as healing of wound which are clean and
unifected, surgically incised, without much loss of cells and tissue and
edges of wound are approximated by surgical suture
Healing by secondary intention- where it is impossible to achieve
primary approximation of tissues owing to extensive loss of tissue or
secondary dehiscence of the surgical wound or the onset of super
infection.
It is said that most common cause of postoperative infections
is poor surgical techniques, usually related to devitalized
tissues remaining in the wound and also inadequate closure.
Thus closure of wound by suturing helps to obliterate dead
space where accumulation of blood or other tissue fluids could
seep in and prevent direct apposition of tissues providing an
environment favourable for bacterial growth.
The importance of soft tissue management is an absolute priority in any
intra and extra oral surgical procedure if a correct esthetic and
functional result is to be achieved .
DEFINITION OF SUTURE
A sutures is any thread or strand which brings into apposition
surfaces or tissues.
Surgical sutures, or stitches, are used to sew an incision. Much
like sewing fabric, a strand of material is used to connect the
edges of a wound, pulling them closer together so that they
may heal.
In endodontic surgery, the most common method of wound
closure uses sutures. The primary objectives of suturing are
to stabilize and to secure tissues in their desired locations.
Somewhere between 50,000 and 30,000 B.C. eyed needles
were invented and by 20,000 B.C. bone needles became the
standard that was not improved until the Renaissance.
HISTORY OF SUTURES
East African tribes ligate blood vessels with tendons and close
wounds with acacia thorns pushed through the wound with
strips of vegetation wound round the protruding ends in a
figure-of-eight.
South American method of wound closure uses large black ants
which bite the wound edges together, their powerful jaws acting
in a similar manner to Michel clips. The ant's body is then twisted
off leaving the head in place.
Indian surgery was considerably ahead of any other early
civilization and we must assume that much of Egyptian,
Babylonian, Greek and Arabic surgery originated in India. (The
Scottish Society of the History of Medicine 1971)
The first written description of sutures used in operative
procedures is recorded in the Edwin Smith Papyrus dated to the
4000 B.C.
(130-200 AD)- Gold metallic sutures were used by Greece –
Galen
15 Centuries later- Hicronymus-used the same material.
1816-Philip Syug Physick – used lead wire
1860-Lord Joseph Lister’s –introduced catgut
1881-Lord Joseph Lister’s –chromic catgut
The development of scientific principles started only in
1931
1931-Poly Entero Phthalate Ester
1950-Polyester
1970-Poly Glycolic Acid
1975-Khubchandini-mono filament stainless
1978-Dr.Joseph Quill-described mono filament stainless
steel
GOALS:
• Provide an adequate tension of wound closure without dead
space but loose enough to obviate tissue ischemia and
necrosis.
• Maintain hemostasis.
• Permit primary intention healing.
• Provide support for tissue margins until they have healed and the
support is no longer needed.
• Reduce postoperative pain.
• Prevent bone exposure resulting in delayed healing and
unnecessary resorption.
REQUISITES FOR SUTURE MATERIALS:
Ethicon (1985)
• High uniform tensile strength, permitting use of finer sizes.
• High tensile strength retention in vivo, holding the wound
securely throughout the critical healing period, followed by rapid
absorption.
• Sterile.
• Pliable for ease of handling and
knot security.
• Freedom from irritating
substances or impurities for
optimum tissue acceptance.
• Predictable performance.
Prevent or limit bacterial adhesion and proliferation
Uniform diameter
Noncarcinogenic
Biologically inactive
With the possible exception of coated Vicryl, none of the sutures
available today meet these criteria.
PRINCIPLES OF SUTURE SELECTION
The selection of a suture material by a surgeon must be based
on a sound knowledge of the
healing characteristics of the tissues which are to be
approximated,
the physical and biological properties of the suture materials,
the condition of the wound to be closed and
probable post-operative course of the patient.
• When a wound has reached maximal strength, sutures
are no longer needed.
• Multifilament sutures should be avoided in contaminated
wounds as bacteria can linger within them and may
convert it into an infected one.
• Where cosmetic results are important, close and
prolonged apposition of wounds and avoidance of
irritants will produce the best results.
• So, the smallest inert monofilament suture materials such
as polyamide or prolene should be used.
• Skin sutures should be avoided and subcuticular closure
should be performed wherever possible.
PRINCIPLES OF SUTURING
The needle holder should grasp the needle at approximately 1/4
of the distance from the end.
The needle should enter the tissue perpendicular to the surface.
If the needle pierces the tissue obliquely, a tear may develop.
The needle should be passed through the tissue following the
curve of the needle.
The suture should be placed at an equal distance from the incision
on both the sides and at an equal depth.
• The needle should pass from the free tissue to the fixed side.
• If one tissue side is thinner than the other the needle should
pass from the thinner tissue to the thicker one.
If one tissue plane is deeper than the other, then the needle should
pass from the deeper to the superficial side.
The distance that the needle is passed into the tissue should be
greater than the distance from the tissue edge.
The tissues should not be closed under tension, since they will tear
or necrose around the suture. If tension is present the tissues
should be undermined to relieve it.
The suture should be tied so that the tissue is merely
approximated and the edges are everted.
The knot should not be placed over the incision line.
Sutures should be placed approximately 3-4mm apart. Closer
spaced sutures are indicated in areas of tension.
SURGICAL NEEDLES:
Proper suturing begins with an understanding of the physical
and biologic properties of both the needle and suture
material.
The surgical needles are sharp, pointed instruments used for
puncturing the tissue for guiding the thread. They are
available in a wide range of types, shapes, lengths and
thickness.
Needles are either made of stainless steel or carbon steel.
Most surgical needles are fabricated from heat treated steel
and possess a micro-silicon finish to diminish tissue drag and
a tip that is extremely sharp and has undergone
electropolishing (Ethicon 1985).IDEAL SURGICAL NEEDLE CHARACTERISTICS
High quality stainless steel.
Smallest diameter possible.
Stable in grasp of the needle holder.
Sharp enough to penetrate tissue with minimal resistance.
Sterile and corrosion resistant .
Classification of Surgical Needles:
According to its eye:
Eyeless needles.
Needles with eye.
According to shape:
Straight needles.
Curved needles.
Semi curved needles
According to cutting edge:
Conventional cutting needles.
Reverse cutting needles.
According to its tip.
Triangular tipped needles.
Round tipped needles.
Blunt point needles.
THE ANATOMY OF THE NEEDLE
THREE DISTINCT PARTS:
1.The attachment
end
2.The body
3.The point
TERMINOLOGIES
1.Chord length
2.Needle length
3.Radius
4.Diameter(gauge)
THE ATTACHMENT ENDMay be
1.Swaged ( eyeless ) / atraumatic needles
2.Closed eye / traumatic needles
3.French eye ( split or spring )
CLOSED EYE /TRAUMATIC NEEDLES
Similar to house hold needle. It consists of a hole / eye
through which the suture material can be threaded.
As the eye of the needle necessarily larger than the diameter
of the needle , they produce larger hole in the tissue than the
diameter of their own .
These eyes have a slit from inside the eye to the end of the needle
with ridges that catch and hold the suture in place.
FRENCH EYE
SWAGED / ATRAUMATIC NEEDLES
The suture material is inserted into
the hollow end during manufacture
& the metal is compressed around
it.
This doesn’t cause injury to the
tissues as much as eyed needle ,
hence termed as atraumatic
needles. But they are not reusable.
NEEDLE BODY
The body is the widest portion of the needle and is also
referred to as the grasping area which is grasped by the
needle holder during the surgical procedure.
The body comes in a number of shapes:
Curved , semicurved ,straight, compound curvature.
STRAIGHT NEEDLE
Preferred in suturing easily accessible areas
Keith needle –used primarily for skin closure of
abdominal wounds
Bunnell (BN) needle- used in tendon repairs.
HALF CURVED (SKI) NEEDLE
Used for skin closure
Its use is rare Because of its poor handling property
They allow predictable needle turn out from tissue and are therefore used most often
The curvatures are ¼ ,3/8 ,½ or 3/4
CURVED NEEDLE
Radius of curvature of the body
Clinical uses
STRAIGHT NEEDLE Skin surgeriesLimited use in oral surgery
¼ CIRCLE Needle of choice in microsurgery associated with very fine sutures; ophthalmology
3/8 CIRCLE Oral surgeryMay be used in almost all surgical wounds
½ CIRCLE Needle of choice in oral surgery
Variable radius (Fishermen’s needle)
Oral surgeryOphthalmology
The point runs from the tip to
the maximum cross-sectional
area of the body.
Depending upon shape of tip-
cutting needle and blunt
needles
Cutting can be further
subdivided into- classical
cutting, reverse cutting,
lateral cutting, taper cut and
bevelled needles
NEEDLE POINT
CONVENTIONAL CUTTING NEEDLE:
The point of this needle is triangular in cross-section with the
apex cutting edge on the inside of the needle curvature. It is
used for keratinized mucosa, skin or subcuticular layers where
the tissue is difficult to penetrate. Cuts more tissue than
necessary. Risk of accidental cutting from a depth upwards is
maximum
REVERSE CUTTING NEEDLE:
The body of this needle is triangular in cross-section with the
apex cutting edge on the outside of the needle curvature. This
improves the strength of the needle and particularly increases
resistance to bending. The tissue is protected in case of
accidental traction
TROCAR POINT NEEDLE:
This needle has a strong cutting head, which
merges into a robust round body. The design
of the cutting head is such that it ensures
powerful penetration even when deep in the
dense tissue.
SPATULA TIPS• Tips with only 2 lateral cutting edges.
• Never used in oral surgery.
• Used only in ophthalmic surgeries .
TAPER-CUT NEEDLES
• Combine characteristics of reverse cutting and bevelled
needles. Used in oral surgeries
BEVELLED NEEDLES
• Used occasionally in oral surgery
• Mainly indicated for suturing on more than one plane
BLUNT TIPSNeedles without cutting tips completely lost their importance
in our fields of surgery some years ago.
Their capability to penetrate tissue is very low but the
appearance of high-risk patients (HIV,HCV,etc.) has caused
their use in oral surgery to be revaluated
SELECTION CRITERIA OF SUTURING NEEDLES :
DEPENDING UPON ITS CURVATURE:
3/8 & ½ circle needles are the most commonly used
The 3/8th needle allows the clinician to pass the needle from
buccal surface to the lingual surface in one motion.
The ¼ & ½ circle needles are more appropriate to be used in
restricted areas such as buccal aspect of maxillary 2nd & 3rd
molar area
The 3/4th circle needle , when used at the mandibular incisors
because of its curvature prevents injury to the tongue
The ½ circle needle is routinely used for periosteal &
mucogingival surgery.
SUTURE MATERIALS
Absorbable
Non-absorbabl
e
Monofilamentous
Multifilamentous
Natural Syntheti
c
CLASSIFICATION
ABSORBABLECatgutCollagenHomopolymer of glycolide (PGA)Copolymer of glycolide and lactide (PGA910)PolydiaxononePolyglecaprone 25
NON ABSORBABLESilkCotton and linenPolyesterPolyamidePolyproplenePolyethyleneSteel
CLASSIFICATION
MULTI FILAMENTPolyesterPolyamidePolyglycolidePolylactideSilkCotton, linen
MONOFILAMENTPolyamidePolypropylenePolyethylenePolydiaxononePolyglecaprone 25Catgut
CLASSIFICATION
COATEDPolyesterPolyglycolidePolylactideCottonLinenPolyetheleneCatgut
UNCOATED
PolyamidePolypropylene
CLASSIFICATION
BRAIDEDPolyesterPolyamidePolyglycolidePolylactideSilk
TWISTEDCotton Linen
CHARACTERISTICS OF SUTURE MATERIAL
1. Handling ability
2. Elastic memory
3. Knot security
4. Capillarity
5. Tensile strength
6. Size
7. Atraumatic behaviour
8. Colonization of bacteria
1. Handling ability Easy to handle and glide easily through the tissues.
Excellent handling - silk
2. Elastic memory This memory is actually built in orientation of the polymer
produced by extruding and stretching during manufacture of
the filament.
When tied, suture tends to remember that it was originally a
straight fiber and knot slips and untie.
High for nylon,
Lower for silk,
minimum for Gore tex
3. Knot security Is as a rule inversely proportional to the thread’ ability to
glide.
The better the thread glides, the more probable will it be that
knots accidentally come undone.
Drawback resolved by increasing number of clockwise and
anti-clockwise half knots.
But hinders healing of the wound
Knot made of high elastic memory- Ex: nylon
4. Capillarity
Is the phenomenon whereby a liquid diffuses
inside a capillary.
The 3 ‘D’ structure and technological
characteristics of a thread act directly on
it capillarity.
Ideally, should limit c.
• Lower the c, the less the suture will absorb liquids.
• If suture absorbed liquids, its removal is inevitably more
laborious.
• Neutralizing capacity to absorb liquids also reduce
inflammatory response, advantage of wound healing.
• C is lower with monofilaments and with synthetic.
5. Tensile strength
Knot tensile strength is the force which the
suture strand can withstand before it breaks when knotted.
The tensile strength of the tissue to be mended determines the
size and tensile strength.
The accepted rule is that the tensile strength of the suture
should never exceed the tensile strength of the tissue.
6. Size Size denotes the diameter of the suture material.
The more zeroes in the number, the smaller the diameter.
Smaller the section, less damage produced to the tissues, less
the foreign material dispersed.
The accepted surgical practice is to use the smallest diameter
The smaller the size, the less tensile strength the suture will
have.
7. Atraumatic behaviour
Given by 3D structure.
When the thread glides inside the tissue , if it move with
some speed, the friction between thread and tissue may
be converted to heat and create micro-burns along the
line of suture. This may leave small openings along the
line and facilitate bacterial colonization.
It should move slowly.
Friction minimum for monofilaments and maximum for
non coated multifilaments.
8. Colonization of bacteria
Also known as bacterial wicking.
Suture material draws bacteria and fluids into the wound
site.
Eg: silk
MONOFILAMENT VS.MULTIFILAMENT STRANDS
Monofilament sutures
Are made of a single strand of material. simplified structure, less resistance as they pass through tissue Better ability to slide Less frictionIncreases their ability to glide Less traumatic
smooth, closed surface and completely closed interior, have no capillarity.
3D Structure of single fiber
No cavities that could be colonized by
microorganisms
Reduces the risk of contamination
Disadvantage Knot more likely to come undone. Detriorates more easily, stretched or folded by the
needle holder, never be employed in crucial position.
Multifilament sutures
Consist of several filaments, or strands, twisted or braided together. Greater tensile strength, pliability, and
flexibility. Have higher friction, reduction in smoothness, increased overheating of the wound
Better knot holding security
Coated multifilament threads – silicone or polybutilite
Coated to help them pass relatively smoothly through tissue
and enhance handling characteristics.
Are less stiff and wiry than monofilament threads.
The coating also reduces capillarity.
In 3D structure, some area unreachable by the immune
system, allows greater colonization of bacteria.
Greater risk for infection.
Wicking effect.
TwistedTheir surface is mostly rough.The longitudinal orientation of the individual filaments within the thread results in relatively high capillarity.
Braided The individual filaments lie more or less obliquely to the longitudinal axis of the thread. This tends to impede the passage of fluid.The capillarity therefore less than that of twisted threads.
Braided vs Monofilament
Has capillary action Increased infection
risk Less smooth
passage Higher tensile
strength Better handling Better knot security
No capillary action Less infection risk Smooth tissue
passage Less tensile
strength Has memory More throws
required
ABSORBABLE SUTURE MATERIALS
Sutures that undergo rapid degradation in tissues, losing their
tensile strength within 60 days, are considered absorbable
sutures.
Prepared either from the collagen of healthy mammals or from
synthetic polymers.
Some are absorbed rapidly, while others are treated or
chemically structured to lengthen absorption time.
Absorption time or half life, which is defined as the time
required for the tensile strength of a material to be reduced to
half its original value.
Dissolution time is the time that elapses before a thread is
completely dissolved.
These times are influenced by a large number of factors
including thread thickness, type of tissue, age, gender and
general condition of the patient.
ABSORBABLE SUTURE MATERIALS
Natural SyntheticDigested by body enzymes
Endocellular degradation
Hydrolyzation
Cleavage by water molecules
• Hydrolyzation results in a lesser degree of tissue reaction following implantation.
• Choice- in oral surgery
Limitations
If a patient has a fever or infection….
If the sutures become wet or moist during handling…
Patients with impaired healing…
Resorbable suture are highly reactive,.
Advantages
Avoid recalling of the patient.
In complex suturing technique, involving more than one
plane.
It is the oldest known absorbable suture material.
According to Katz and Turner (1970), Galen referred to
gut suture as early as 175 A.D.
It is derived from sheep or bovine intestine and is
classified as natural, monofilament and absorbable suture.
Gut is the most variable suture material in
terms of tensile strength and absorbability.
GUT
GUT SUTURE
Gut has the smallest strength of any of the commonly used
suture materials (Herrmann 1971).
The percentage of collagen in the suture determines its tensile
strength and its ability to be absorbed by the body without
adverse reaction.
When placed intraorally through mucosal surfaces, the
sutures resorb in 3-5 days.
GUT SUTURE
Because it is organic material and highly susceptible to
enzymatic degradation, it is packaged in isopropyl alcohol as
a preservative.
The suture should not be soaked in saline - loses from 20% to
30% of its tensile strength. (Katz and Turner)
Gut suture is absorbed by proteolytic degradation and
phagocytosis.
PLAIN SURGICAL GUT Rapidly absorbed.
Tensile strength is maintained for only 7 to 10 days and
absorption is complete within 70 days.
Can also be specially heat-treated to accelerate tensile
strength loss and absorption.
Used primarily for epidermal suturing where sutures are
required for only 5 to 7 days.
CHROMIC GUT
It is plain gut that has been treated with a solution of
buffered chrome tanning solution to resist body enzymes,
prior to being spin, ground and polished.
It prolongs the absorption time over 90 days.
The chromic salt acts as a cross-linking agent and increases
the tensile strength and its resistance to absorption of the
body (Edlich et al 1973).
Chromic gut sutures minimize tissue irritation, causing less
reaction than plain surgical gut during the early stages of
wound healing.
Tensile strength may be retained for 10 to 14 days, with some
measurable strength remaining for up to 21 days.Contraindications:
Being absorbable should not be used when prolonged
approximation of tissues under stress is required.
In intraoral Surgery
PLAIN GUT Used occasionally, manipulation difficult
Knot holding property- poor
Becomes hard, can traumatize – mucosa
CHROMIC GUT Not particularly good choice
Stiff, difficult to handle and tie
Does not rapidly resorb.
It is natural, monofilament, absorbable.
Reconstituted collagen sutures are obtained by grinding the native
collagen of deep flexor tendons of cattle, which is then acidified to
form gel and extruded into a neutralizing dehydration bath.
It takes 5-6 days to get absorbed.
After 10 days only 10% of the tensile strength
remains, hence cannot be used where tissue
healing is slow.
Tissue reaction is minimal.
COLLAGEN
POLYGLYCOLIC ACID Is a homopolymer of glycolic acid (Polyhydroxyacetic
acid) coated with polaxamer 188.
Is manufactured by orienting these filaments by means of
stretching and braiding.
It is a multifilament suture , which is braided and coated.
Trade name “Dexon”
Absorbed by hydrolysis in 60-90 days.
POLYGLACTIN 910
They come under trade name “Vicryl”
Synthetic absorbable sterile surgical suture composed of a
copolymer made from 90% glycolide and 10% L-lactide.
Coated vicryl suture is prepared by coating vicryl suture
material with a mixture composed of equal parts of
copolymer of glycolide and lactide (polyglactin 370) and
calcium stearate.
Dexon and Vicryl, when braided are the strongest of the
absorbable suture materials.
According to Dardik, and Lanfman (1971), metabolites of
polyglycolic acid are metabolised via the citric acid cycle and
produce energy, Co2 and water.
Available as braided dyed violet or undyed natural strands in a
variety of lengths with or without needles.
COATED VICRYL PLUS ANTIBACTERIAL (POLYGLACTIN 910) SUTURE
Coated VICRYL Plus Antibacterial suture contains one of the
purest forms of the broad-spectrum antibacterial agent
triclosan .
Coated VICRYL Plus Antibacterial suture offers protection
against bacterial colonization of the suture.
Degree of inflammation is less as
seen in plain/chromic catgut sutures.
In vivo studies demonstrate that
Coated VICRYL Plus Antibacterial suture has a zone of
inhibition that is effective against the pathogens that most
often cause surgical site infection (SSI)
Staphylococcus aureus, methicillin-resistant Staphy aureus
(MRSA),
Staphy epidermidis, methicillin-resistant Staphy epidermidis
(MRSE)
(Rothenburger S et al 2002)
VICRYL Plus Antibacterial suture has no adverse effect on
normal wound healing. (Gilbert P et al 2002)
POLYGLECAPRONE 25 Trade name – “Monocryl”
It is a synthetic, monofilament, absorbable suture material
made up of co-polymer of 75% glycolide and 25% epsilon-
caprolactone.
It undergoes hydrolysis and absorption by 90-120 days.
Tissue reaction is minimal.
It has good knot strength.
It is the most pliable and is used in soft tissue closure.
Biologic behaviour similar to that of PGA 910.
Narry Filho 2002 - Because of its favorable characteristics it
can be used not only deep in tissues, but also in superficial
tissues of oral mucosa.
Tremendous tensile strength (highest) but is very stiff.
POLYDIOXANONE (PDS)
It is a synthetic, monofilament, absorbable suture.
It is comprised of the polyester poly(p-dioxanone).
It combines the features of soft, pliable, monofilament
construction with absorbability and extended wound support
for up to 6 weeks.
It undergoes slow hydrolysis and takes 110-210 days to get
absorbed.
It has good tensile strength and moderate knot tensile
strength. PDS sutures are available clear or dyed violet to
enhance visibility.Uses:
Absorbable suture with extended wound support.
Contraindication:
Being absorbable should not be used when prolonged
approximation of tissues under stress is required.
NON RESORBABLE SUTURE MATERIALS
SURGICAL SILK It is a natural, multifilament, non-absorbable suture.
Silk is an organic substance that undergoes slow
proteolysis when implanted (Douglas, 1949)
It is a natural protein fiber of raw silk,
which is treated with silicon protein or wax.
Silk loses most of the tensile strength after 1 year of
implantation and usually disappears after 2 years.
It is the most popular inexpensive suture material for intraoral
use.
It is braided, which gives it excellent handling characteristics.
Types: According to preparation.
Perma hand surgical silk.
Virgin silk suture which is prepared from the glands of silk
worm before their pupae stage.
According to fiber pattern:
Braided.
Twisted.
Floss.
Postlethwait (1970) and Van Winkle and Co-workers
(1975)- Silk initially produces more tissue reaction
(inflammation) than synthetic non-absorbable sutures.
According to Herrmann (1971), silk has one of the lowest
tensile strengths among suture materials, ranking just above
gut and collagen and in terms of knot-holding ability it ranks
the lowest of all the commonly used suture materials.
Therefore, at least three ties should be used for each knot.
Addition of wax or silicon to reduce the tissue reaction and
prevent wicking further diminishes knot security (Hermann,
1971).
It has the “ wicking effect ” i.e, it pulls the bacteria & fluid
into the wound site .
COTTON
Natural, multifilament and non-absorbable.
Made from non-continuous natural fibers of Egyptian cotton.
Following the report by Mead and Oshsner (1940) cotton
became popular during World War II when silk was relatively
unavailable.
strength is similar to silk, their handling characteristics are
inferior.
Tissue reaction is moderate.
LINEN
It is also natural, multifilament and non-absorbable suture.
It is derived from staple flax fibers.
somewhat stronger than cotton but otherwise has similar
characteristics of cotton.
Tissue reaction is minimal.
Because of its poor tensile strength, cannot be used for
suturing under tension.
NYLON
It is synthetic, non-absorbable suture material available in
braided (or) monofilament forms.
Comprises of polymers of hexamethylene diamine and
adipic acid.
The monofilament form - Duralon and Ethilon.
The multifilament form is - Nurolon and Surgilon.
Nylon possesses the property of “memory”
Generally, multiple square knots are necessary to maintain
the tie.
It degrades at a rate of 15-20% per year.
Herrmann (1971) has shown that nylon has good tensile
strength but ranks below that of steel.
Limitations
Because of its stiffness, the large knot is required.
Since it has a tendency to tear through non-keratinsed tissue,
nylon is not frequently used intraorally.
METAL
316 L Stainless steel or tantalum sutures are either
monofilament or braided.
They are the strongest and produce the most secure knot of
any suture materials (Herrmann 1971).
Tissue tolerance is good but is less than that found with nylon.
Metallic materials may undergo degradation through
corrosion, resulting in transfer of ions from the suture to the
tissue.
Tissue reaction to these ions can occur.
Metallic sutures are stiff and do not conform to the suture
pathway during host movement.
The resultant irritation may produce tissue damage and
increased susceptibility to infection.
In oral and maxillofacial surgery used for suspension of splints
(or) arch bars not as suture material.
POLYESTER
“Dacron, Mersilene, Ethibond” (polyester) are braided
suture materials.
Composed of polymers of polyethylene terephthalate.
exhibits the greatest tensile strength and knot holding ability
of the non-metallic suture materials (Herrmann, 1971).
The tissue reaction is minimal and is unaffected by the
presence of an inert coating or impregnation with silicon or
Teflon (Edlich et al 1973).
POLYPROPYLENE
Trade name – “Prolene”
It is synthetic, monofilament and non-absorbable.
Composed of an isotactic crystalline stereoisomer of
polypropylene.
It exhibits good tensile strength, minimal and transient tissue
reaction.
It is used in all types of soft tissue approximation.
It shows excellent handling characteristics.
Advantage of plasticity of prolene
When swelling occurs , prolene will stretch to
accommodate the wound ,thus there will be little cutting
through the tissue.
When swelling recedes , the suture will remain loose &
keep the edges properly approximated
EXPANDED POLYTETRAFLUROETHYLENE
(E-PTFE) GORE-TEX It is the most recent material to be used as suture material.
It is monofilament strand obtained by polymerization of
Tetrafluroethylene & is expanded mechanically to increase
its flexibility.
• It is easy to handle , sterilize, tie knot & has good tensile
strength.
• It can be used for closure of flaps where the same material
used as barrier membrane.
NEWER MATERIALS
Monofilament synthetic nonabsorbable Butylene terephthalate (84%) and polytetramethylene
ether glycol terephthalate (16%). strength, lack of package memory, elasticity, and
flexibility which made suturing quicker and easier. can be used safely on skin and mucosal wounds
THE POLYBUTESTER SUTURE (NOVAFIL™)
2. POLYSORB- MONOFILAMENT, ABORBABLE
Copolymers of glycolide and lactide were then
synthesized to produce a Lactomer™ copolymer).
Glycolide provides for high initial tensile strength, but
hydrolyses rapidly in tissue. Lactide has a slower and
controlled rate of hydrolysis, and provides for prolonged
tensile strength in tissue.
The Lactomer™ copolymer consists of glycolide and lactide
in a 9:1 ratio.
The handling characteristics were found to be superior to
those of the Polyglactin 910™ suture.
3. MAXON- MONOFILAMENT ABSORBABLE
A suture (Maxon™) has been developed
using trimethylene carbonate.
The strength is better than the braided
synthetic absorbable suture
4. BIOSYN-MONOFILAMENT SYNTHETIC ABSORBABLE
Production of Glycomer 631, a terpolymer composed of
glycolide (60%), trimethylene carbonate (26%), and dioxanone
(14%) advantages over the braided synthetic absorbable.
First, is significantly stronger over four weeks of
implantation potentiates less bacterial infection.
The handling characteristic of this monofilament
suture is superior to the braided suture because
it encounters lower drag forces in the tissue
5. CAPROSYN- MONOFILAMENT ABSORBABLE
Rapidly absorbing
Are prepared from Polyglytone™ 6211 synthetic polyester
which is composed of glycolide, caprolactone, trimethylene
carbonate, and lactide.
Compared to chromic gut it has:
Significantly greater mean breaking strength, handling
properties were far superior, The smooth surface of the
Caprosyn™ sutures encountered lower drag forces, it was
much easier to reposition the Caprosyn™ knotted sutures.
Are an excellent alternative to Chromic Gut sutures.
Suturing is defined as a process of holding severed tissue in close approximation until the healing process provides wound with sufficient strength to withstand stress without the need for support.
Armamenterium SUTURE MATERIAL
SUTURING NEEDLE
NEEDLE HOLDER
TISSUE HOLDING FORCEP
SUTURE CUTTING SCISSOR
NEEDLE HOLDERS
Must be made of non corrosive,
high strength good quality
steel alloy with jaws designed
for holding the suture needle
securely.
It may be short or long ,broad
or narrow, slotted or flat,
concave or convex.
Jaws with tungsten carbide particles embedded in them offer
two distinct advantages.
Good holding power
Less damage to suture material
How to hold needle with needle holder ?
Grasp the needle with the tip of the needle holder jaws in an approximately 1/3rd to ½ of the distance from the attachment end to point.
Do not grasp the needle too tight.
SUTURING TECHNIQUE
CONTINUOUS
Sling suture
Vertical mattress
Horizontal mattress
Locking suture
INTERRUPTED
Circumferential direct loop
Figure of eight
Mattress - Horizontal,
vertical
Sling sutures
Closed Anchor suture
Distal wedge suture
INTERRUPTED SUTURES
They are also called “ solitary sutures ” .They have shorter span & close only a shorter distance of flap.
Indications:• Vertical incision• Tuberosity and retromolar areas• Bone regeneration procedures with or without guided tissue
regeneration• Widman flaps, open flap curettage, unrepositioned flaps, or
apically positioned flaps where maximum interproximal coverage is required
• Edentulous areas, osseointegrated implants• Partial or split-thickness flaps
Advantages: Successive sutures can be placed to fit individual
requirement
The loosening of one suture will not produce loosening of other suture.
When required , selected sutures may be removed without interfering other.Disadvantages:
• Time consuming as many individual sutures has to be placed to close the entire flap.
• Many knots have to be placed.
They have a long span & close the entire distance of the flap
Advantages : Time saving
In case of continuous sling, buccal and lingual flaps are independent of each other preventing tension in the flap.
Can include as many teeth as required.
The teeth are used to anchor the flap.
CONTINUOUS SUTURE
Disadvantages : If the suture breaks, the flap may become loose or the suture may come untied from multiple teeth.
SIMPLE LOOP SUTURE
It is the most commonly used suture because of its simplicity.
Simple loop suture is used to approximate the buccal and lingual
flaps.
The suture forms a simple circular loop uniting the two edges of
surgical incision.
TECHNIQUENeedle penetrates the outer surface of the first flap , then undersurface of the opposite flap is engaged , and the suture is brought back to the initial side where the knot is tied.
FIGURE OF EIGHT
Bite is taken from the buccal flap and needle is passed
through the interdental space and again bite is taken from
the epithelial surface of lingual flap.
The needle is then returned through the embrasure and
tied buccally.
SLING SUTURE
This is primarily used for a flap that has been raised on only one
side of the tooth, involving one or two adjacent papillae
• Coronally and laterally positioned flaps
• The technique involves use of interrupted sutures, which is
either anchored about the adjacent tooth or slung around the
tooth to hold both papillae.
MATTRESS SUTURES
They are used for greater flap security and control.
They permit more precise flap placement.
They allow for good papillary stabilization and placement.
• Vertical mattress sutures are used in narrower interdental
areas when greater control of the papilla tip is required.
• A P-3 needle is inserted 7 to 10mm apical to the tip of papilla.
It is then passed to emerge again from the epithelial surface of
the flap 2 to 3 mm from the tip of the papilla. The needle is
brought through the embrassure, where the technique is again
repeated lingually. The suture is then tied buccally.
HORIZONTAL MATTRESS SUTURE
A P-3 needle is inserted 7 to 8 mm apical to and to one side
of the midline of the papilla, emerging again 4 to 5 mm
through the epithelialized surface on the opposite side of the
midline
The needle is then passed through the embrasure and after
being repeated lingually, the knot is tied buccally.
Internal mattress suture The internal mattress suture allows both the facial and
lingual or palatal papillae to stay upright, filling the
embrasure space in an esthetic area.
The suture enters the facial tissue just apical to the base of
the papilla, runs across the top of the alveolar crest, and
penetrates the lingual tissue from the inside-out apical to
the base of the lingual papilla.
The suture passes back through the lingual papilla from the
outside-in, 2 to 3 mm coronal to the previous point of suture
penetration, and courses back across the alveolar crest exiting
through the facial papilla from the inside-out at a point 2 to 3
mm coronal to the initial facial entry point.
The facial and lingual papillae are positioned together and
the suture is tied on the facial. The majority of the suture
material lies under the flap in the interdental area.
ANCHOR SUTURE
The closing of flap mesial
or distal to a tooth, as in
mesial or distal wedge
procedures, is best
accomplished by the
anchor suture.
The needle is placed at the line-angle area of the facial or
lingual flap adjacent to the tooth , anchored around the
tooth , passed beneath the opposite flap, and tied.
CLOSED ANCHOR SUTURE
Another technique to close a
flap located in an edentulous
area mesial or distal to a tooth
consists of tying a direct
suture that closes the
proximal flap, carrying one of
the threads around the tooth
to anchor the tissue against
the tooth, and then tying the
two threads .
CONTINUOUS SLING SUTURE
The two flaps are completely independent of each other.
The suture is initiated as a loop suture
The needle engages the outer surface of flap and encircles
the tooth and outer surface of the same flap of adjacent
interdental area is engaged and the procedure is continued
upto the last tooth and it is encircled to the last tooth and
same procedure follows on the lingual or palatal side of flap
upto the starting point of suture and tied buccally.
PERIOSTEAL SUTURE This type of suture is used to hold in place apically displaced
partial-thickness flaps.
Two types : Holding suture and Closing suture
The holding suture is a horizontal mattress suture placed at the base of the displaced flap to secure it into the new position.
Closing sutures are used to secure the flap edges to the periosteum.
The needle point is perpendicular to the tissue
surface…..Penetration.
Body of the needle is now rotated….Rotation.
The needle point is permitted to glide against the
bone….Glide.
As it glides, it is rotated about the body……Rotation.
Exit.
Chaiken 1977
LOCKING SUTURE
The procedure is simple and
repetitive.
A single interrupted suture is
used to make the initial tie.
The needle is next inserted
through the outer surface of
the buccal flap and the
underlying surface of the
lingual flap.
• The needle is then passed through the remaining loop of the
suture, and the suture is pulled tightly, thus locking it.
• This procedure is continued until the final suture is tied off at
the terminal end .
SUTURING TECHNIQUE IN ENDODONTIC MICROSURGERY
Suturing tech in microsurgery enhances the surgeon’s ability to view inaccuracies in wound closure
AIM
Accomplish passive and primary wound closure.
The execution of proper surgical tech with smaller and sharper instruments limits collateral tissue damage.
Gentle coaptation of the wound following the geometric principles of suturing prevents overlapping or incomplete closure of the wound.
It circumvents dead space and shear forces.
MICROSURGICAL KNOT TYING
The art of tying good surgeon’s knot, or cinching knot can only be mastered through repeated laboratory practice under the microscope.
Geometry of microsurgical suturing
Needle angle: slightly less than 90 degreesBite size: 1.5 times the tissue thicknessSymmetry: equal bite sizes on both sides of the woundDirection of needle passage: perpendicular to the wound
KNOTS
“Everyone knows how to tie a knot but few knows how to tie a knot well”
The purpose of knots is to join the two ends of the suture in a
secure but gentle way. Knots must be placed tightly enough
to prevent slippage and loosening of the flap but not to blanch
the tissues. They are generally placed on buccal aspects of
flaps.
A sutured knot has three components (Thacker et al , 1975).
The “LOOP” created by the knot.
The knot itself, which is composed of a number of tight “throws”:
each throw represents a weave of the two strands.
The “EARS” which are the cut ends of the suture.
The knot may be tied in 2 techniques
INSTRUMENT TIE Using needle holder
ONE- HANDED & TWO-HANDED TIE Using fingers
As periradicular surgeries are involved in inaccessible areas of mouth, the instrument tie is the most appropriate & extensively used technique.
Types of knots
Overhang knot
Square knot
Surgeon’s knot
Slip (or) Granny knot
OVERHANG KNOT
It is the basic knot which is simple loop made by crossing the free end of the suture over the standing part one time.
SQUARE KNOT
It is made by tying two overhang knots each done in opposite directions.
This knot is easy to tie but loosen when synthetic/ monofilament sutures are used.
SLIP/GRANNY KNOT It is similar to square knot , in
it both the overhang knots are
placed in same direction.
The advantage of this knot is
even after placing the second
knot it can be further
tightened with one or two
additional overhang knots.
SURGEONS KNOT It is the most commonly
used knot as it reduces slippage of the first tie , while the 2nd tie is placed.
It is formed by tying 2 ties. The first tie is formed by 2 throws of suture around needle holder in one direction & the 2nd tie by throwing the suture in opposite direction.
METHOD OF KNOT TYING
1 2
3
4
5
Ethicon (1985) recommends the following principles for knot tying:
Suture should be placed in the interdental space below the base of the imaginary triangle in the papilla .
The completed knot must be tight, firm, and tied so that slippage will not occur.
To avoid wicking of bacteria, knots should not be placed in incision lines.• Knots should be small and the ends cut short (2 to 3 mm).
• Avoid excessive tension to finer gauge materials as breakage may occur.
• Avoid using a jerking motion, which may break the suture.
• Avoid crushing or crimping of suture materials by not using hemostats or needle holders on them except on the free end for tying.
Do not tie suture too tightly as tissue necrosis may occur. Knot tension should not produce tissue blanching.
Maintain adequate traction on one end while tying to avoid loosening the first loop.
The surgeons and square knot strength, although generally not needing more than two throws, will have increased strength with an additional throw.
Granny knots and coated and monofilament sutures do require additional throws for knot security and to prevent slippage. Coated vicryl will hold with four throws-two full square knots.
Ethicon (1985) recommends the following principles of suture removal.
1. Area should be swabbed with H2O2 for removal of encroached necrotic debris and serum from sutures.
2. A sharp pair of suture scissors should be used to cut the loops of individual continuous sutures about the teeth. It is often helpful to use a No.23 explorer to help lift the sutures if they are within the sulcus or in close apposition to tissue. This will avoid tissue damage and unnecessary pain.
3. A cotton plier is now used to remove the sutures. The location of knots Should be noted so that they can be removed first. This will prevent unnecessary entrapment the flap.
ALTERNATIVES TO SUTURE MATERIALS
GLUSTITCH PERIACRYL®
Tissue Adhesive - considered by many specialists to be
essential for oral microsurgeries.
Fast-setting cyanoacrylate (CA) formula adheres to moist,
living tissues with no toxic or foreign body reaction.
Violet color ensures visibility.
Eye protection required.
Two-year shelf life.
SURGICAL STAPLES
Staples are formed from high-quality stainless steel and are
available in regular and wide sizes.
STERI-STRIPS
Sterile adhesive tapes
Available in different widths.
Frequently used with subcuticular sutures.
Used following staple or suture removal.
Can be used for delayed closure.
USED TO:
Secure sutures, or in lieu of sutures in specific periradicular
surgeries.
Protect and stabilize membranes, or as a sealing and
supporting agent for socket preservation.
Cover collagen plugs post-extraction.
Dress donor and/or recipient sites.
Mussel Adhesive Protein (MAP):
This is obtained from the blue mussel, Mussel Adhesive protein is in
experimental phase.
One of the unique structural features of mussel adhesive proteins
(MAPs) is the presence of L-3,4-dihydroxyphenylalanine (DOPA), an amino
acid that is believed to be responsible for both adhesive and crosslinking
characteristics of MAPs. DOPA is formed in these proteins by post-
translational hydroxylation of tyrosine residues.
TISSUE REACTION TO SUTURES
INITIAL RESPONSEAlmost identical in the first 4-7 days, regardless of the suture material The damage done to the tissues by the needle evoke a significant inflammatory response even without the presence of suture materialThe early response is a generalized acute aseptic inflammation, involving primarily PMN, Leucocytes.
After a few days, mononuclear cells, fibroblast and histiocytes (tissue macrophages) become evident.
Capillary formation occurs at the end of this initial phase.
AFTER 4-7 DAYS
The response is related more to the type of suture material.
For eg. Plain gut elicits an intense reaction with macrophages
and polymorphonuclear leucocytes predominating, while non-
absorbable materials show a less intense relatively acellular
histological pattern.
In human study conducted by Elen and Conen the presence of
the suture increased the susceptibility to infection by a factor
of 10,000 times.
Generally sutures should be removed after 3-5 days in
skin of head & neck, 5-7 days intraorally 5-10 days in
other sites.
STERILIZATION OF SUTURES
Sterilization differs according to the suture material and are usually done by the manufacturer.
Some sutures are sterilized with gamma radiation like silk, nylon, e-PTFE.
Some suture material cannot withstand gamma
radiation like plain catgut, chromic catgut, PGA 910. Ethylene oxide gas.
The component layers of packaging materials do not permit
exposure to high temperatures or extremes of pressure
without affecting package and product integrity. For this
reason, all sterile products manufactured are clearly labeled
"DO NOT RESTERILIZE."
The practice of resterilization is not recommended, except for
pre-cut steel sutures and spools or cardreels of nonabsorbable
materials supplied nonsterile.
PACKAGING…
Expiry dateBatch NumberDo Not Re-use
Product (re-order) CodeImperial GaugeMetric Gauge
Needle size & curvature
Needle type
Needle point
See Instructions for use
Needle profile
SterilisedEthylene Oxide
Suture length
boxes have specific indications, likeF S ……….. for skinP S ……….. for plastic skinP ……….. for precision pointP C…….…. Precision cosmetic
CONCLUSION “The success of surgery starts
with a good incision , but becomes
perfectly complete only with good
suturing”
Great Teacher of Surgery
Dr. Hamilton Bailey (1894-
1961)
REFERENCES
Atlas of cosmetic and reconstructive periodontal surgery.
Edward S Cohen, 2nd Edition
Oral and maxillofacial surgery. Daniel M Laskin
Suture material techniques and knots. Serag wieesner
Ethicon, Wound closure manual. Somerville, New Jersey,
Ethicon, Inc, 1985
Surgical Knot tying- Ethicon manual.
• Oral tissue reaction to suture materials: A review.
Periodontal Abstracts 2004:52;2,37-44.
• Wound healing and surgery. Postlethwait, R.W.: Somerville,
New Jersey, Ethicon, Inc., 1971
• Suturing technique – Sandro Sievro
• Textbook of clinical periodontology - Carranza 10th Ed.
• Text book of Periodontics. Louis f rose brian l mealey.