Suture Materials and Suturing Techniques - Presented by Dr. Prasanjit Das and group as a part of Dhaka Dental College, OMS Department weekly presentation program.

1. DAS_49DDCH_2017
SUTURE MATERIALS &
SUTURINGTECHNIQUES

2. Content
o Definitions
o Goals of suturing
o Suture characteristics
o Armamentarium of suturing
o Suture materials
o Principles of suturing
o Suturing techniques
o Surgical knot
o Removal of suture
o Reasons for failure of suture
o Possible complications
o Alternatives to suture

3. DEFINITIONS:
 what is suture?
Suture is a stich or series of stiches made
to secure apposition of the edges of a surgical
or traumatic wound.
 What is suture materials?
Suture materials is an artificial fibers used
to keep wound together until they hold
themselves by natural which is synthesized &
oven into a stronger scar.

4. GOALS OF SUTURING
Wound edge apposition.
Provide adequate tension.
 Maintain hemostasis.
 Aid in wound healing.
 Avoid wound infection.
 Produce aesthetically pleasing scar by
approximating skin edges.

5. SUTURE CHARACTERISTICS
 physical structure:
 Monofilament-
 This suture material is smooth & tends to
slide through tissues easily.
 Difficult to knot.
 Can be damaged by gripping it with needle
holder or forceps.That can lead to fracture of
the suture materials.

6. SUTURE CHARACTERISTICS
 Multifilaments-
 Easy to knot.
 Have a greater surface area than
monofilaments.
 Have a capillary actions where bacteria
may lodge & be responsible for persistent
infections.
This material can be coated with silicone in
order to make it smooth.

8. SUTURE CHARACTERISTICS
 Tensile Strength:
It can be expressed as the force required to
break it when pulling the two ends apart.It
depends upon –
 Constituent of suture materials.
 Thickness of suture materials.
 How it is handled in the tissues.

9. SUTURE CHARACTERISTICS
 Absorbability:
Suture materials may be absorbable or non-absorbable.This property must be
taken into consideration when choosing suture materials for specific wound closures.
Oral mucosa & Deep sturcture need to be absorbable suture materials but vascular
anastomoses need non-absorbable suture materials.
 Biological Behaviour:
It depends upon the constituent of raw materials.

10. Armamentarium of suturing
 Needle holder
A suture
needle
 Suture material

11. Needle holder
Parts:
 Working tip/jaws
 Hinge joint
 Shank/body
 Catch mechanism/ratchet
 Grip area

12. Needle holder
 How to hold?
The needle holder is held with
thumb & ring finger through the
rings & with the index finger along
the length of needle holder to
provide stability & control.

13. A suture needle
 Made up of either SS(stainless
steel) or carbon steel.
 Parts:
1.tip/point
2. body/shaft
3.eye/swaged end

14. A suture needle
 Shape of needle:

15. Classification of needle
 According to
Shape:
1.Straight
2.Curved
 According to eye:
1.Eyed needle/Traumatic
2.Eyeless needle/Atraumatic

16. Classification of needle
 According to cutting
edge
1.Round body
2.Cutting body-
Conventional
Reverse cutting
 According to its tip
1.Triangular
2.Round
3.Blunt

17. Suture materials

18. Suture materials
Ideal properties:
 Easy to handle.
 Predictable behaviour in tissues.
 Predictable tensile strength.
 Sterile.
 Secure knotting ability.
 Minimal tissue reaction.
 Non-alergenic,non-carcinogenic,non-shrinkage.

19. CLASSIFICATIONS OF SUTURE
MATERIALS
 According to source:
1.Natural
2.Synthetic
3.Metallic
According to structure:
1.Monofilament
2.Multifilament

20. CLASSIFICATIONS OF
SUTURE MATERIALS
 According to fate:
1.Absobable
2.Non-absorbable
 According to coating:
1.Coated
2.Uncoated

21. Natural
Absorbable
• catgut
• Chromic
catgut
• Collagen
• Fascia lata
• Beef tendon
Non-
absorbable
• Silk
• Silk worm gut
• Linen
• Cotton
• Ramie

22. Synthetic
Absorbable
 Polyglycolic acid
 Polyglactic acid
 Polyglactin(vicryl)
 Polydioxanone(PDS)
Non-
absorbable
 nylone(polyamide)
 Polypropyline(Prolene)
 Polyesters
 polyethelene

23. Metallic
• SS(stainless
steel)
• Tantalum
• Silver
• Gold
• Aluminium

24. Monofilament
Absorbable
• Catgut
• Chromic
catgut
• Vicryl
• PDS
Non-absorbable
• Polyoropylene
• Polyester
• Nylone
• Polyvenyleidene
fluoride/PVDF
suture

25. Multifilament
Absorbable
• Vicryl
• Polyglycolic
acid
Non-
absorbable
• Silk
• Cotton
• linen

26. Monofilament vs
multifilment
 Monofilament
 Has no capillary action
 Less infection risk
 Smooth tissue passage
 Higher tensile strength
 More throws required
 Multifilament
 Has capillary action
 Increased infection risk
 Less smooth passage
 Less tensile strength
 Better knot security

27. Absorbable vs Non-
absorbable
 Absorbable
 Degraded by
enzymes,hydrolysis or
phagocytosis
 Used to hold the edges in
approximation
temporarily until the
wound is heal
 Non-
absorbable
 Encapsulated or walled off
by fibrosis
 Used to suture at sites
where tensile strength
need to be maintained

28. overview

29. Selection of suture materials
 Condition of the wound.
 Tissues to be repaired.
 Tensile strength.
 Knot holding characteristics.
 Reaction of surrounding tissues.

30. Commonly Used Suture
Materials
 Polypropylene(prolene)
 It is synthetic ,non-absorbable monofilament suture materials.
 Polymer of propylene.
 Uses:
1.General surgery.
2.Plastic surgery.
3.Cardiovascular surgery.
4.Skin closure.

31.  Advantages:
1.Won’t loose tensile
strength over time.
2.Good knot security.
3.Very little tissue reaction.
4.High plasticity.
 Disadvantage:
1.Stretch when pulled.
2.Loosens when edema
subsides.

32. Commonly Used Suture
Materials
 Silk:
 It is natural,non-absorbable multifilament suture materials.
 Made from the filament spun by silkworm larva.
 Uses:
1.Opthalmic surgery.
2.General surgery.
3.plastic surgery.

33.  Advantage:
1.Ease of handling.
2.Good knot security.
3.Cost effective.
 Disadvantage:
1.Very reactive.
2.can’t be used in presence
of infection.

34. Commonly Used Suture
Materials
 Vicryl:
 It is synthetic & absorbable suture materials.
 Monofilament/multifilament & coated/uncoated.
 Available in purple color/undyed.
 Uses:
1.Intra oral suturing.
2.Gut anastomoses.
3.Vascular ligature.
4.Opthalmic surgery
5. Superficial soft tissue approximation of the skin and mucosa.

35.  Advantage:
1.Minimal tissue reactivity.
2.Can be used in infected
tissues.
3.Stronger than gut:retains
strength 3 weeks.
 Disadvantage:
1.In case of prolong
approximation can’t be used.
2.Delayed absorption &
increased infalmmation.

36. Uses of different sizes of
suture

37. Biological response to suture
materials
 The early response is a generalized
acute aseptic inflammation involving
primarily polymorphonuclear
leucocytes.
 After few days mononuclear cells
fibroblast & histiocytes become
evident.
 Capillary formation occurs at the end
of this initial phase.

38. Biological response to suture
materials
 Natural absorbable-
 Proteolytic degradation.
 Intense tissue response.
 Synthetic absorbable-
 Hydrolysis.
 Less intense response.
 Non-absorbable-
 Encapsulation.
 Acellular response.

39. Principle of suturing

40. Principle of suturing
 The needle should be
grasped at
approximately 1/3 of
the distance from the
eye & 2/3 from point.
 The needle should be
pierced the tissue
perpendicular to its
surface.
 The needle should be
placed equidistant (2-
3mm) from the
incision line.

41. Principle of suturing
 The depth of penetration
should be equal on both
side of incision line.
 The needle always passes
from –
• The movable tissue to the
fixed tissue.
• Thinner tissue to the
thicker tissue.
• Deeper tissue to the
superficial tissue.

42. Principle of suturing
 The tissue never be closed
under tension.
 Each suture must be
placed 3-4 mm apart from
the incision line.

43. Suturing techniques
Interrupted suture.
Continuous suture.
Mattress suture.
Figure of 8(eight) suture.
Subcuticular suture.

44. Interrupted sutures
 Use:
closure of wound after –
 Single tooth extraction.
 3rd molar extraction.
 Biopsy.
 Dental implant.

45. Interrupted sutures
Advantages:
 Simple
 Performed in urgent situations
 Easy to remove
Disadvantage:
 Failed to bring all surfaces in contact
 Less supportive for healing

46. Technique for interrupted sutures
 Cleansing & debridement.
 Selection of appropriate suture.
 Wound margins are accurately opposed.
 Suture needle is held with the needle holder positioned at least one third of
the length of the suture away from the end of suture attachment.
 A ‘bite of skin is taken at a landmarked site.
 The suture needle is advanced to the depth of the wound margin & then out
through the wound opening.
 The needle is next inserted via the depth of the wound & rotated up through
the opposite skin margin & the landmarked site for apposition of the wound.

47. Technique for interrupted
sutures

48. Continuous sutures
Continuous suture are of 3 types-
Simple continuous suture.
Locking continuous suture.
Continuous over & over suture.

49. Simple continuous sutures
uses:
 Well approximated wounds with minimal
tension.
Advantage:
 Rapid technique for closure.
 Even distribution of tension over the suture
line.
 Can be used in swelled up tissues.

50. Simple continuous sutures
 Disadvantage:
 Shouldn’t be used
in areas of existing
tension.
 Not possible to
free a few sutures
at a time.
 When one suture
breaks it affects
the whole closure.

51. Technique for simple continuous
sutures
 The beginning of the simple continuous suture is
similar to the simple interrupted suture.
 The needle is then reinserted in a continuous fashion
such that the suture passes perpendicular to the
incision line.
 The suture is ended by passing a square knot over
the untightened end of the suture.

52. Technique for simple continuous
sutures

53. Locking continuous sutures
 Uses:
 Long edentulous areas.
 Tuberosities/retromolar areas.
 Advantage:
 Avoid the multiple knot of the interrupted
suture.

54. Locking continuous sutures
 Technique:
 At first a single interrupted suture is used to make a tie.
 The needle is next inserted through the underlying surface of the flap.
 The needle is then passed through the remaining loop of the suture & the
suture is pulled tightly,thus loocking it.
 This procedure is continued until the final suture is tied off at the terminal end.

55. Locking continuous sutures

56. Continuous over & over
suture
 Initially a simple interrupted suture is placed & the needle is then reinserted
in a continuous fashion such that the suture passes perpendicular to the
incision line below & obliquely above.
 The suture is ended by passing a knot over the untightened end of the
suture.
 It provides a rapid technique for closure & distribute the tension uniformly
over the suture line.
 It also offers a more water tight closure.

57. Continuous over & over
suture

58. Layered closure
 Wounds that involved only the skin are often best closed with a single layer
of interrupted suture
 In case of deep wounds, tissue should be closed in layers to remove dead
space & confer strength to the wound
 The technique for layered closures involves closing the deeper tissues
first,usually with a continuous sutures & then closing the skin with
interrupted sutures.

59. Layered closure

60. Mattress sutures
 These suture may be –
Horizontal.
Vertical.

61. Horizontal mattress sutures
 Uses:
 Intraoral bone grafting.
 Closure of extraction socket.
 Advantage:
 Provides a broad contact of the wound margin.
 Provides a water tight closure.
 Disadvantage:
 If improperly used bone necrosis & wound dehiscence may occur due to limited
blood supply.

62. Horizontal mattress sutures
 Technique:
 The needle is passed from one edge of the
incision to another & again from the latter edge
to the first edge in a horizontal manner & knot is
tied.
 The distance of the needle penetration from the
incisal line & the depth penetration of the needle
is the same for each entry point.
 The horizontal distance of the points of
penetration on the same side of the flap
differs(needle penetration through the surgical
flap should be at least 8mm from flap edge)

63. Horizontal mattress sutures
 This procedure is continued till the entire length of the
incision & a knot is then tied.

64. Vertical mattress sutures
 It is similar to the horizontal mattress
except the depth of penetration, i.e. when
the needle is brought back from the
second flap to the first,the depth of
penetration is more superficial.

65. vertical mattress sutures
 Uses:
 Closing deep wounds abdomen or hip.
 Advantage:
 decreasing the dead space & providing
increased strength.
 doesn’t interfere with healing.
 Disadvantage:
 Approximation is difficult.

66. overview

67. Figure of 8(eight) suture
 Most commocly used for extraction socket closure as
well as adaptation of gingival papilla around the
tooth.
Technique:
 The needle first inserted into the outer surface of the
buccal flap & then the lingual flap.
 Suturing begins on the buccal surface 3-4 mm from
the tip of the papilla.

68. Figure of 8(eight) suture
 Then the needle should be inserted in the same fashion at a
horizontal distance & then both ends tied.
Advantage:
Rapid closure
Disadvantage:
Due to its orientation ,it is difficult to
remove & it leaves a significant amount
of suture threads inside the socket.

69. Figure of 8(eight) suture

70. Subcuticular suture
 Usually a running stitch,but can be interrupted
 Intradermal horizontal bites.
 Allow suture to remain for a longer period of time
without development of crosshatch scaring.
Uses:
Simple,uncomplicated wound.

71. Subcuticular suture
 Advantage:
 Excellent cosmetic
closure.
 No stitch to
remove.
 Disadvantage:
 Technically more
difficult to master.
 Dosen’t hold in thin
skin

72. Surgical Knots

73. Surgical Knot
 Sutured knot has 3
components-
1.Loop- created
by knot.
2.Knot- itself
which is composed
of a number of tight
throw.
3.Ears- which are
the cut ends of the
suture.

74. Principles of knot tying
 Use the simplest knot that will prevent slippage.
 Tying the knot as small as possible & cutting the end of the suture as short
as reasonable to minimize foreign body reaction.
 Avoid friction or sawing.
 Avoid excessive tension.
 Tying sutures too tightly to strangulates the tissues.
 Maintenance of traction at one end of the suture after the first loop is
thrown .

75. Principles of knot tying
 Placing the final throw at horizontally as possible to keep the knot flat.
 Limiting extra throws to the knot as they don’t add strength to a properly
tied knot.

76. Different types of knot
secure/square knot.
Surgeons knot.
Granny’s knot/slip knot.

77. Square knot
 The first throw is placed in
precise position for the
knot,using a double loop.
 The second throw is tied
using horizontal tension.
 Additional 2 throws are
desirable.
 Totally there should be 4
throws.
 Best for catgut,silk,cotton
& SS(stainless steel).

78. Surgeons knot
 Formed by two throws on
the first tie & one throw in
the opposite direction in
the second tie .
 Recommended for tying
polyester suture materials
such as vicryl & mersiline.

79. Granny’s knot
 A tie in one direction
followed by a tie in the
same direction & a third
tie in the opposite
direction to square the
knot & hold it
permanently.
 Can be used in
silk,chromic catgut/plain
catgut.

80. overview

81. Removal of suture
 All sutures,being foreign bodies,cause irritation to the tissues & hence have
the potential to cause scarring.
 Skin sutures are removed as soon as tissue healing allows.
 Non-absorbable sutures are best removed from the face after a period of
5-6 days.Tissues such as the scalp may require a longer period(7-10 days).

82. Removal of suture
 Face 3-5 days
 Lip 3-5 days
 Oral cavity 6-8 days
 Neck 5-6 days
 Scalp 7-10 days
 Chest 10-14 days
 Abdomen 10-14 days
 Leg 10-14 days

83. Principle of suture removal
 Suture area is first clean with normal saline.
 The suture is grasped with non tooth dissecting forceps & lifted above the
epithelial surface.
 Scissors are then passed through one loop & then transected close to the
surface to avoid dragging contaminated suture materials through tissues.
 The suture is then pulled towards the incision line to prevent dehiscence.if
suture entrapped in a scab,application of hydrogen per oxide/normal
saline is necessary.

84. Principle of suture removal
 If pieces of suture left infection may occur.

85. Reasons for failure of
sutures
 Breakage
 Cuts out
 Knot slips
 Extruded suture
 Resorbs too rapidly
 Removed too early

86. Possible complications of
leaving sutures for many
days
 Sutural abscess.
 Scar or stitch mark.
 Dermoid cyst.

87. Alternatives to suture
Name:
 Staples
 Tissue adhesives
 Tape
Disadvantage:
 Not absolute alternative to mechanical means
 More tissue reaction

89. Bibliography
1)Textbook of Oral & Maxillofacial Surgery
 Neelima Anil Malik
2)Textbook of Oral & Maxillofacial Surgery
 S M Balaji
3)An Introduction of Oral & Maxillofacial Surgery
 David A Mitchell
4)Contemporary of Oral & Maxillofacial Surgery (5th ed.)
 Hupp,Ellis,Tucker
5)Oral & Maxillofacial Surgery (Vol-1)
 Luskin
6)Principles of Oral & Maxillofacial Surgery(6th ed.)
 U J Moore
7)Baily & Love’s Short Practice of Surgery(26th ed)
 Norman S. WIlliams