Professional Documents
Culture Documents
SUTURINGTECHNIQUES
DAS_49DDCH_2017
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
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.
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.
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.
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.
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 .
Armamentarium of suturing
Needle holder
A suture
needle
Suture material
Needle holder
Parts:
Working tip/jaws
Hinge joint
Shank/body
Catch mechanism/ratchet
Grip area
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.
A suture needle
Parts:
1.tip/point
2. body/shaft
3.eye/swaged end
A suture needle
Shape of needle:
Classification of needle
According to
Shape:
1.Straight
2.Curved
According to eye:
1.Eyed needle/Traumatic
2.Eyeless needle/Atraumatic
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
Suture materials
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.
CLASSIFICATIONS OF SUTURE
MATERIALS
According to source:
1.Natural
2.Synthetic
3.Metallic
According to structure:
1.Monofilament
2.Multifilament
CLASSIFICATIONS OF
SUTURE MATERIALS
According to fate:
1.Absobable
2.Non-absorbable
According to coating:
1.Coated
2.Uncoated
Natural
Non-
Absorbable absorbable
• catgut • Silk
• Chromic • Silk worm gut
catgut • Linen
• Collagen • Cotton
• Fascia lata • Ramie
• Beef tendon
Synthetic
Absorbable
Polyglycolic acid Non-
Polyglactic acid
Polyglactin(vicryl)
absorbable
nylone(polyamide)
Polydioxanone(PDS)
Polypropyline(Prolene)
Polyesters
polyethelene
Metallic
• SS(stainless
steel)
• Tantalum
• Silver
• Gold
• Aluminium
Monofilament
Non-absorbable
Absorbable • Polyoropylene
• Catgut • Polyester
• Chromic • Nylone
catgut
• Polyvenyleidene
• Vicryl fluoride/PVDF
• PDS suture
Multifilament
Non-
Absorbable absorbable
• Vicryl • Silk
• Polyglycolic • Cotton
acid • linen
Monofilament vs
multifilment
Monofilament Multifilament
Has no capillary action Has capillary action
Less infection risk Increased infection risk
Smooth tissue passage Less smooth passage
Higher tensile strength Less tensile strength
More throws required Better knot security
Absorbable vs Non-
absorbable
Absorbable Non-
Degraded by absorbable
enzymes,hydrolysis or
phagocytosis Encapsulated or walled off
by fibrosis
Used to hold the edges in
approximation
temporarily until the
Used to suture at sites
wound is heal
where tensile strength
need to be maintained
overview
Selection of suture materials
Uses:
1.General surgery.
2.Plastic surgery.
3.Cardiovascular surgery.
4.Skin closure.
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.
Commonly Used Suture
Materials
Silk:
It is natural,non-absorbable multifilament suture materials.
2.General surgery .
3.plastic surgery.
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.
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.
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.
Uses of different sizes of
suture
Biological response to suture
materials
Interrupted suture.
Continuous suture.
Mattress suture.
Figure of 8(eight) suture.
Subcuticular suture.
Interrupted sutures
Use:
closure of wound after –
Single tooth extraction.
3rd molar extraction.
Biopsy.
Dental implant.
Interrupted sutures
Advantages:
Simple
Performed in urgent situations
Easy to remove
Disadvantage:
Failed to bring all surfaces in contact
Less supportive for healing
Technique for interrupted sutures
uses:
Wellapproximated wounds with minimal
tension.
Advantage:
Rapid technique for closure.
Even distribution of tension over the suture
line.
Can be used in swelled up tissues.
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.
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.
Technique for simple continuous
sutures
Locking continuous sutures
Uses:
Long edentulous areas.
Tuberosities/retromolar areas.
Advantage:
Avoid the multiple knot of the interrupted
suture.
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.
Locking continuous sutures
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.
Continuous over & over
suture
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.
Layered closure
Mattress sutures
These suture may be –
Horizontal.
Vertical.
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.
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)
Horizontal mattress sutures
Approximation is difficult.
overview
Figure of 8(eight) suture
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.
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.
Figure of 8(eight) suture
Subcuticular suture
Uses:
Simple,uncomplicated wound.
Subcuticular suture
Advantage:
Excellent cosmetic
closure.
No stitch to
remove.
Disadvantage:
Technically more
difficult to master.
Dosen’t hold in thin
skin
Surgical Knots
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.
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 .
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.
Different types of knot
secure/square knot.
Surgeons knot.
Dermoid cyst.
Alternatives to suture
Name:
Staples
Tissue adhesives
Tape
Disadvantage:
Not absolute alternative to mechanical means
More tissue reaction
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