SUTURES AND SUTURING TECHNIQUES

A SEMINAR BY
SAUMYA SHARMA
 Contents

What is a Suture ?? Knots

Purpose of suturing Principles of Suturing
Ideal properties of Sutures Techniques of Suturing
Suture materials Periodontal Suturing
Tissue Reactions to Sutures Other methods of wound closure
Other Instruments : Needles Summary & Conclusion
Needle holder
Scissors
 What is a Suture ??

A surgical suture is one that approximates the

adjacent cut surfaces or compresses blood vessels.

Suturing is the act of bringing tissues together and

holding them in apposition until healing takes place.
 What is the Purpose or Goal of Suturing ??

Provide adequate tension of wound closure without dead space…but loose enough

to obliviate tissue ischaemia & necrosis.

Maintain Haemostasis.

Healing by primary intension.

Provide support for healing until it is no longer needed.

Post operative pain control.

Prevention of bone exposure.

Proper flap positioning.

 Ideal properties of Sutures
Good handling characteristics.
Non-reactivity with tissue.
Knot security.
Adequate tensile strength.
Sterile, non-allergenic.
Favorable absorption profile.
Resistant to infection.

Essential suture Characteristics

Sterility.
Uniform diameter and size.
Pliability and tensile strength.
Freedom from irritants and impurities.
Available Suture Sizes
 Classification of Suture Materials

ABSORBABLE NON-ABSORBABLE

MONOFILAMENT MULTIFILAMENT MONOFILAMENT MULTIFILAMENT

NATURAL NATURAL NATURAL NATURAL

SURGICALGUT SURGICAL SILK

SYNTHETIC SYNTHETIC SYNTHETIC SYNTHETIC

POLYDIOXANONE POLYGLACTIN 910 PROLINE NYLON
 Monofilament

Multifilament
 Absorbabale Sutures
Surgical Gut
Oldest known absorbable suture material.

Derived from sheep intestinal mucosa / bovine intestinal serosa.

Comes from the Arabic word “kitstring” or “kitgut”…..

Consists of several piles that have been twisted slightly & then machine

ground & polished…

Most variable in terms of tensile strength & absorbability. (Gaskin and

Childers 1963)
’s
Organic & highly susceptible to enzymatic degradation….isopropyl alcohol.
Rapid loss of tensile strength…
Absorbed by proteolytic action…inflammation and tissue reaction.
Absorbed in 3-5 days.
Stiff and insecure knot holding characteristics.

Chromic Gut
Plain gut tanned with solution of chromium salts…
Slightly increased strength, lesser tissue reaction and prolonged rate of
absorption…
Degraded by 7 days when used intraorally ( Wallace, Maxwell & Cavalaris 1970).
Much variability exists.
 Collagen

Obtained by grinding the native collagen of the deep flexor tendons of

cattle……acidified to form gel……extruded into neutralizing dehydration
bath.
It undergoes premature absorption ( Truhlsen & Fitzpatrick 1964)

Polyglycolic Acid ( Dexon)

•Hydroxyacetic acid heat + catalyst HMwt. Linear

chain polymer
 ’s
Synthetic polymers produce very minimal tissue reaction &
are resorbed by hydrolysis .
Well tolerated when implanted or placed intraorally.
4 months intraoral life.
Degradation products of polyglycolic acid destroy bacteria in the wound thereby
minimizing tissue reaction.

’s
Loss of tensile strength extremely rapid.
Difficulty in tying suture material.
Expensive.
 Polyglactin 910 (Vicryl)
Braided configuration.

Copolymer of glycolide and lactide which are derived from hydroxyacetic acid and
lactic acid respectively. … coated with polyglactin 370 & calcium stearate.

’s
Strongest of absorbable materials.

Well tolerated by tissues.

Quicker dissolution compared to polyglycolic acid….60-90 days.

Maintains tensile strength for longer duration.

’s
Potential for scar formation.
Polydioxanone (PDS)
Polyester monofilament suture.
Absorbed in 120-180 days.
Minimal tissue reaction and maintains breakin strength for 6 wks.

Polyglyconate ( Maxon)
Monofilament
Absorbed in 180 days.
Maintains breaking strength for 3 weeks.

Monocryl
Polyglecaprone 25 copolymer of glycolide & caprolactone.
Absorbed in 90-120 days.
Very good tensile strength and minimal tissue reaction.
Non-Absorbable Sutures
Silk
Organic and undergoes slow proteolysis when implanted ( Douglas 1949)
Most popular for intra oral use.
’s
Braided…excellent handling.
Does not irritate adjacent mucous membrane.
Inexpensive.

’s
Moderate tissue reaction.
One of the lowest tensile strengths …….just above that of collagen and
gut.
Lowest knot holding ability….
 Nylon

Braided or monofilament forms. ( most popular skin suture material )

Minimal tissue reaction….degradation products cause decreased bacterial loads.

“Memory” property…..

Fairly good tensile strength ( Herrmann 1971).

Infrequently used within oral cavity :

Stiffness.

Requirement of large knot.

Tendency to tear through

non-keratinised tissue.
 Cotton and Linen

Cotton suture is made up of non-continuous fibers of cotton …….combined into

yarns & twisted into piles.

Strength is comparable to silk….

Tissue reaction is similar to that of silk.

Linen is a little stronger than cotton.

 Metal

Stainless steel or tantalum sutures are either monofilament or braided.

Strongest & most secure knot of suture materials ( Herrmann 1971).

Good tissue tolerance…

Degradation through corrosion….tissue reaction to released ions.

Stiff & do not conform to the suture pathway during host movement.

Usually used for suspension of splints and revision of keloid scars …….not intra

orally.
 Dacron polyester, Polypropylene, Polyethylene, Teflon-
coated or impregnated Dacron polyester, Silicon coated
Dacron polyester.

Braided with great tensile strength & knot holding ability ( Herrmann 1971)

Minimal tissue reaction and unaffected by teflon coating.

Possesses high co-efficient of friction…interferes with the ties being slipped into

place.

No difference in infection is seen with regards to both the uncoated and coated

versions.
 Polypropylene

Monofilamentous with minimal inflammatory reaction.

Preferred for skin sutures.

Gore-Tex

Absorbable, monofilamentous ePTFE.

Low tissue reaction.
Used mostly in cardiovascular surgery.
 Tissue Reactions to Sutures

Early response : PMNs are responsible for a generalised acute inflammatory

response.
After an interval of few days : Monocytes , histiocytes & fibroblasts
predominate…angiogenesis.
Tissue response after 1 week is determined by the type of suture material.
Suture tracks ??
Rail road track scar….
Monofilament vs Multifilament…??
Wicking..??
Time of removal……skin - 3-5 days.
intraoral - 5-7 days.
 Needles

Wound closure and healing is affected by the initial injury caused by the

needle penetration and subsequent suture passage. Needle selection, surface

characteristics of needle ( co-efficient of friction ) and suture coated

materials selected for wound closure are important factors to be considered

by the surgeon.
 Ideal properties of Needles

High quality stainless steel

Smallest diameter possible

Capable of implanting sutures with minimal trauma to tissues.

Stable in the needle holder

Should be sharp.

Sterile and corrosion resistant.

 Needle Performance Characteristics
Strength : Resistance to deformation during repeated passes through the tissue.

Ductility : Resistance to breakage under a given amount of deformation.

Sharpness : Measure of ability of the needle to penetrate the tissue.

Clamping moment : Stability of the needle in the needle holder.

Anatomy of a Needle
 Tapered

Cutting Reverse cutting

Suture loop inserted through eye

Loop placed over tip

Loop drawn back

Suture tied on eyed needle

 Placement of a Needle into the Tissue ( Ethicon 1985)

1. Force should always be applied in the direction that follows the curvature

of the needle.

2. Movable to a non-movable tissue.

3. Only sharp needles with minimal force.

4. Never force the needle through the tissue.

5. Avoid retrieving the needle from the tissue by the tip.

6. Sutures should be placed in keratinised tissue whenever possible.

7. Grasp the needle in the body 1/4th to half of the length from the swaged area.

8. Do not hold the needle by the swaged area or the eye.

9. Avoid excessive tissue bites with small needles, as it will be difficult to retrieve

them
 Needle Holder

Locking handle + Short stout beak.

6” long…..Beak is shorter & stronger than beak of the hemostat.

Face of the beak is crosshatched.

 Needle Holder Selection ( Ethicon 1985 )

1. Use an approximate size for the given needle.

2. Needles should be grasped 1/4th to half the distance from the eye or the

swaged area.

3. The tips of the jaws of the needle holder must meet before the remaining

portions of the jaws.

4. The needle should be placed securely in the tips of the jaws and should

not rock, twist or turn.

5. The needle holder must not be overclosed.

 Scissors

They have relatively long handles and thumb/ finger rings.

Held similar to the needle holder

Short cutting edges….blades maybe curved or angled

Dean Scissors…
 Knots

Suture Securing : Ability of the knot & the materials to maintain tissue

approximation during the healing process….Thacker et al 1975.

Knot slippage or security depends upon :

1. Nature of the material.

2. Suture diameter.

3. Type of knot.
 Monofilament & coated sutures (Teflon)

Low co-efficient of friction High degree of slippage

Braided & twisted sutures ( uncoated Dacron, Catgut )

High co-efficient of friction Greater knot security

Sutured Knot Components
 Types of Knots

Square Knot :
Surgeons Knot :
Granny Knot :
 Knot tying…Ethicon 1985.
1. Knot must be firm ….no slippage.

2. Knot should not be placed on the incision lines to avoid wicking.

3. Avoid excessive tension…..crimping of suture.

4. Maintain adequate tension …….avoid excess……..necrosis.

5. Knot ends must be 2-3mm.

6. An added throw does not increase the strength of the knot.

7. After the first loop is tied it is necessary to maintain traction at one end
of the strand to avoid loosening of the throw.

8. Final tension or final throw should be as nearly horizontal as possible.

 Principles of Suturing

1. Sutures should be placed at an equal distance (2-3mm) and equal depth

from the incision line.

2. Needle should be passed from :

a. Movable to fixed tissue.
b. Thinner to thicker tissue.
c. Deeper to superficial tissue.

3. Tissue eversion.

4. Tissues must never be closed under tension….

5. Tissue must approximate ….not blanch.

6. Place sutures 3-4mm apart.

7. Knot must not be placed on the incision line.

8. Prevention of Dog Ears…

 Time of Suture Removal

Skin……..3-5 days

Intra-oral………7 days

Areas of tension……….10 days

Swab the area with hydrogen peroxide .

Use extremely sharp scissors.

Grasp the knot with the tweezers & cut very close to the mucosa….
 Classification of Suture Techniques

INTERRUPTED CONTINUOUS

DIRECT / LOOP IDEPENDENT SLING

FIGURE OF 8 VERTICAL MATTRESS

VERTICAL / HORIZONTAL
HORIZONTAL MATTRESS MATTRESS

INTRA-PAPILLARY
 Interrupted Sutures

Each suture is independent of each other.

Advantages :

1. Distance between each suture and between that of the suture and the
incision line can be pre-decided or determined.
2. They are stronger & loosening of any one suture will not cause the others
to loosen.
3. In areas of tension when strong closure is required…interrupted sutures
are preferred.
4. Incase of infection….removal of infected sutures is sufficient.
 Indications

Widman flaps, open flap curettage, unrepositioned flaps or apically positioned

flaps where maximum interproximal coverage is required.

Edentulous areas…..tuberosity & molar areas.

Partial thickness flaps.

Incase of vertical incisions.

Bone regeneration procedures.

Osseointegrated implants.
 Direct Loop Suture

Indications
1. Need for coverage of interdental bone with interdental papilla.
2. Incase of bone graft usage.

3. When a close apposition of scalloped incision is required.

 Figure of 8 Suture

When flaps are not in close apposition because of apical flap displacement.

The major disadvantage being presence of suture between the 2 flaps.

 Mattress Sutures

Horizontal Mattress Suture

1. Used in areas of diastema or wide interdental spaces to properly adapt
the inter-proximal papilla.
2. Helps in tissue eversion.
3. May cause constriction of blood supply at the edge of the incision.
 Vertical Mattress Suture
1. Recommended for bone regeneration procedures……provides maximum tissue
closure………avoids suture contact with implanted
material………avoiding wicking.

2. Particularly suited for papillary management.

Subcuticular Sutures
 Continuous Sutures
Advantages:

1. One can include as many teeth as required.

2. The teeth are used to anchor the flap.

3. Precise flap placement.

4. Minimizes need for multiple knots.

5. Allows independent placement & tension of buccal & lingual/ palatal flaps….

6. Greater distribution of forces over the flaps.

7. Simple.

Disadvantages
 Independent Sling Sutures

Can be started as a continuation of tuberosity or retromolar suturing or with a

looped suture about the terminal papilla.

Continued through next interproximal embrassure such that the suture encircles the

neck of the teeth.

Needle can then be passed, either over the papilla or underneath through the

undersurface of the C.T.

Repeat procedure.
Vertical & Horizontal Mattress Sutures.
 Continuous Locking Suture
Usually used in long edentulous areas.

Though it avoids multiple knots in suture….breakage at one junction can

cause the entire suture to untie.

Technique :

1. Initially a single interrupted suture is given.

2. Needle is inserted from outer surface of buccal flap & inner aspect of the
lingual flap.

3. Needle then passed through the remaining loop of the suture & pulled
tight.

4. Procedure continued & final suture tied at the terminal end.

 Anchor Sutures

Used mainly in the mesial or distal wedge procedure.

Closes the facial & lingual flaps & adapts them around the tooth.
 Periosteal Sutures

Used to hold apically displaced flaps in place

Mainly consists of 2 sutures

1. Holding sutures

2. Closing sutures
Technique
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.
 Other Methods of Wound Closure
Cyanoacrylates
- n-butyl cyanoacrylate is the active ingredient.
Advantages :

1. Strong bonding to tissues in presence of moisture

2. Biodegradable, bacteriostatic & hemostatic.

3. Reduced post operative pain & facilitates healing.

4. Good shelf life.

5. Produces little or no heat during polymerisation.

6. Bonding is by secondary intermolecular forces aided by mechanical interlocking of

irregular forces.
 Ligating Clips
Usually made up of stainless steel, tantalum or titanium.
Can be resorbable or non-resorbable
Tubular structures are ligated.

Surgical Staples

Used for skin closure.

Speedy procedure with minimal tissue
reaction.
Summary & Conclusion
 References

Daniel .M. Laskin….Oral & Maxillofacial Surgery.

Peterson, Ellis, Hupp & Tucker……Contemporary Oral & Maxillofacial Surgery.

Kwon & Laskin…Clinician’s Manual of OMFS.

Carranza…..Glickman’s Clinical Periodontology.

Cohen….Atlas of Cosmetic & Constructive Periodontal Surgery.

Stephen Lai…..Sutures & Needles…..emedicine.

Selvig & Biagotti….Oral tissue reactions to suture materials….Int. Journal of

Periodont Rest Dent 1998 ; 18: 475-487.

Ethicon’s Surgical Manual.