Professional Documents
Culture Documents
Maintain Hemostasis.
Provide support for tissue margins until they have healed and the
resorption.
3. Sometimes,to secure close apposition of skin edges, skin closure tape may be used
1. Perma-Hand Surgical Silk- derived from the cocoon of the silk worm
larvae
Braided monofilament
Has high tensile strength , which is totally lost after two years.
Tissue reaction is much greater than the synthetic non-absorbable sutures.
Encapsulation occurs in 14 - 21 days.
Handling properties are best of all suture materials and it knots easily and
securely.
Sterilised by gamma irradiation.
Most universally used material in dentistry, as it is relatively inexpensive.
Available as eyeless needled sterile suture in sizes 7-0 to 1-0.
Reels and nonsterile sutures are available in sizes 5-0 to 3-0
2. Polyamides- Known as Nylon.
Available in monofilament form.
Passage through tissue is easy, because of low co-efficient of
friction.
Low knot security.
Tissue reaction is minimal.
Stiff for handling.
Available in the braided form also.
Available in sizes ranging from 10-0 to 2-0.
3. ePTFE Monofilament(Gore-tex)
Non-absorbable,synthetic suture
Soft,Flexible & compressible biomaterial for ease in suturing
Extremely low tissue reaction
Good knot & tensile strength
Used mostly in cardiovascular surgeries
4. Polyester Braided
Known as Terelyne /Dacron
Formed from a polymer & braided to make suture
High tensile strength & low tissue reactivity
Excellent handling & knot security
ePTFE coating reduces tendancy to cut through tissues
Uncoated(mersilene)Coated(Ethibond-coated
with Polybutylate)
Mersilene-minimal tissue reation
Ethibond-no tissue reaction
5. Polypropylene(Prolene)- Synthetic,monofilament suture
High tensile strength,retains indefinitely
Extremely low tissue reactivity
Can extend upto 30% before breaking hence, can accommodate
Post-operative swelling.
Sterilized by ethylene oxide
Available sizes 8-0 to 1-0
Used for dental implant surgery, bone graft procedures.
Absorbable (Resorbable)
Sutures
Should be sharp.
1. Less trauma to the tissues, since a single strand of suture material has to
be drawn through the tissues and this creates a smaller hole.
2. Each patient has the benefit of a new, sharp, guaranteed sterile needle.
3. No chances of accidental unthreading of the needle and losing it while
suturing.
4. Faster and more efficient procedure.
5. Needles are made up of high quality steel.
6. Tru-tempering process gives uniform strength.
7. By merely quoting the Code Number, the surgeon indicates the type,
size, length of the suture as well as the details of the needle.
8. Nurse working hours are saved- no need of ordering, cleaning, sterilising
and threading the eyed needles.
2. The body/shaft section-It is the widest point of the needle also
referred to as the grasping area.
The cross-sectional configuration of the body-
round,oval,rectangular,trapezoid or side flattened.
The longitudinal shape of the body may be straight, half
curved, curved (1/4th, ½, 3/8th or 5/8th) or compound curved.
3. Needle point-The point is the extreme tip of the needle to the
maximum cross section of the body.
The tip can be cutting, round or blunt.
Cutting edges can be conventional, reverse or side cutting,taper
cut,taper & blunt.
They are ideal for suturing keratinized tissues like the skin,
palatal mucosa, buccal and alveolar mucosa.
They are triangular in cross-section.
Round/tapered needles are used for suturing soft and
nonkeratinized tissues like muscle, fascia, and neural sheath.
4. The chord length is the straight line distance between the point of a
curved needle and the swage.
5. The radius is the distance measured from the center of the circle to
the body of the needle if the curvature of the needle was continued
to make a full circle.
Placement of Needle in Tissue
Ethicon (1985) gives the following principles for placing the needle
in tissue:
1. Force should always be applied in the direction that follows the curvature of the
needle.
2. Suturing should always be from movable to nonmovable tissue.
3. Avoid excessive tissue bites with small needles because it will be difficult to
retrieve them.
4. Use only sharp needles with minimal force. Replace dull needles.
5. Grasp the needle in the body one-quarter to half the length from the swaged area.
Do not hold the swaged area; this may bend or break the needle. Do not grasp the
point area because damage or notching may result..
6. The needle should always penetrate the tissue at right angles. a. Never force the
needle through the tissue.
7. Avoid retrieving the needle from the tissue by the tip. This will damage or dull
the needle. Attempt to grasp the body as far back as possible.
8. An adequate tissue bite (≥ 2–3 mm) is required to prevent the flap from tearing.
Needle Holder
The needle holder is a straight instrument with short working tip.
The working tip has cross hatched serrations with a single vertical
serration to grip the needle.
The handle has a catch.
The instrument is held between the ring finger and the thumb and
the index and the middle finger support the needle holder.
Needle Holder Selection
Ethicon (1985) gives the following pointers for selecting a needle
holder:
1. Use an approximate size for the given needle. The smaller the needle, the
smaller the needle holder required.
2. The needle should be grasped one-quarter to half the distance from the swaged
area to the point.
3. The tips of the jaws of the needle holder should 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. Do not overclose the needle holder. It should close only to the first or second
rachet. This will avoid damaging or notching the needle.
6. Pass the needle holder so that it is always directed by the surgeon’s thumb.
7. Do not use digital pressure on the tissue; this may puncture a glove.
Scissors
Suture Cutting Scissors (Dean‘s)
They are used for cutting the suture ends.
They can be straight or curved, and angulated or non angulated.
The angulation may be at the joint or at the tip to facilitate access to
the posterior areas of the oral cavity.
They have long delicate handles and a short cutting edge.
Knots and Knot tying
“Suture security is the ability of the knot and material to maintain tissue
approximation during the healing process”
Since the knot strength is always less than the tensile strength of the material, when
force is applied, the site of disruption is always the knot.
This is because shear forces produced in the knot lead to breakage. Knot slippage or
security is a function of the coefficient of friction within the knot.
This is determined by the nature of the material, suture diameter, and type of knot.
Monofilament & coated sutures (Teflon)
Secure/Square Knots
Standard Square or Reef knotting method –
It is a special knotting technique, once
tied, the knots are secure.
The first throw is placed in precise
position for the knot, using a double loop.
The second throw is tied using horizontal
tension.
Additional two throws are desirable.
Totally there should be four throws and
the ends should be cut long
Granny‘s Knot or Slip Knot
When using Silk, Chromic catgut or plain catgut
suture material, a slip (Granny‘s) knot can be used.
It involves a tie in one direction followed by a second
tie in the same direction and a third tie in the opposite
direction to square the knot and hold it securely.
Surgeon‘s Knot
It is formed by two throws of the suture around the
needle holder on the first tie and one throw in the
opposite direction in the second tie.
Synthetic resorbabale and non-resorbable suture
materials can be used to prevent untimely knot
untying.
Ethicon (1985) recommends the following principles for
knot tying:
1) The completed knot must be tight, firm, and tied so that slippage
will not occur.
2) To avoid wicking of bacteria, knots should not be placed in
incision lines.
3) Knots should be small and the ends cut short (2–3 mm).
4) Avoid excessive tension to finer-gauge materials because
breakage may occur.
5) Avoid using a jerking motion, which may break the suture.
6) Avoid crushing or crimping of suture materials by not using
hemostats or needle holders on them except on the free end for
tying.
7) Do not tie the suture too tightly because tissue necrosis may occur.
Knot tension should not produce tissue blanching.
8) Maintain adequate traction on one end while tying to avoid loosening the
first loop.
9) The surgeons knot and square knot strength, although generally not
needing more than two throws, will have increased strength with an
additional throw.
10) Granny knots and coated and monofilament sutures require additional throws
for knot security and to prevent slippage.
Principles of suturing
The needle should be grasped at approximately 1/3rd of the distance from the eye
and 2/3rd from the point
The sutures should be tied only to approximate the tissues and not to blanc
Suturing Techniques
1. Interrupted
a. Figure eight
b. Circumferential,direct or loop
c. Mattress—vertical/horizontal
d. Intra-papillary
2. Continuous
a. Independent sling suture
b. Mattress suture
• Vertical mattress
• Horizontal mattress
c. Continuous locking
Interrupted sutures
Indications:
1. Vertical incision
2. Tuberosity and retromolar areas
3. Bone regeneration procedures with/without GTR
4. Widman flaps,open flap curettage, unrepositioned flaps, or apically
positioned flaps where maximum inter-proximal coverage is
required
5. Edentulous areas
6. Partial- or split-thickness flaps
7. Osseo-integrated implants
Advantages
Technique
Begun on the buccal surface 3 to 4 mm from
the tip of the papilla.
The needle is first inserted into the outer
surface of the buccal flap and then through the
outer epithelialized surface (figure eight) of
the lingual flap.
The needle is then returned through the
embrasure and tied buccally.
Indications:
It can be used for the extraction socket
closure
For adaptation of the gingival papilla around
the tooth.
Disadvantage:
Intervening suture material between the tips of
the papilla.
Circumferential, direct, or loop
Indications
To approximate the buccal and lingual flaps
Need for coverage of interdental bone with
interdental papilla.
When a close apposition of scalloped incision is
required.
Technique
The needle penetrates the outer surface of the first
flap.
The undersurface of the opposite flap is engaged.
The suture is brought back to the initial side,where
the knot is tied.
Advantages
It permits greater coaptation and tucking down of the
papilla because of the lack of intervening suture
material between the tips of the papilla during inter-
proximal closure.
Mattress Sutures
The suture is ended by passing a knot over the untightened end of the suture.
Rapid technique for closure & distributes tension uniformly over the suture
line.
Disadvantages
Started as a looped suture about the terminal papilla (buccal, lingual, or palatal).
Passed through next the embrassure encircling the neck of the tooth.
The needle is passed over the papilla and through the outer epithelialized
surface.
The needle is passed again through the embrasure and continued anteriorly.
This is repeated through each successive embrasure until all papillae have been
engaged.
When the last papilla is sutured and the needle is returned through the
Continuous independent sling suture is used to adapt the buccal and lingual flaps
Without tying the buccal flap to the lingual flap
Vertical and Horizontal Mattress Suture
The needle is passed from one edge of the incision to another and again from the
latter edge to the first edge in a horizontal manner and a knot is tied.
It is similar to the horizontal mattress, except that, all factors remaining constant,
the depth of penetration varies.
Continuous Locking Suture
Technique
Closed-Anchor Suture
Ligating Clips
These can be resorbable or nonresorbable.
Ligating clips are made from stainless steel, tantalum or titanium or poly-dioxanone.
They are designed for the ligation of tubular structures.
Surgical Staples
Surgical staples can be used for skin closure and closure of the abdominal layers.
Skin staples are made up of stainless steel, and are placed uniformly to span theincision
line.
They have minimal tissue reaction.
They can be used for routine skin closure anywhere in the body.
Their use is contraindicated when it is not possible to maintain at least 5 mm distance from
the stapled skin to the underlying bone and blood vessels.
Tissue Adhesives
After tight closure of the subcutaneous tissues, the skin layer can be closed
with the help of tissue adhesive like N-butyl cyanoacrylate, which on tissue
contact polymerizes into a hard substance that keeps the wound margins together.
It has three dimensional strength and is three to four times stronger than N-
butyl cyanoacrylate.
This adhesive is applied to the dry skin over the wound by a proper technique
in multiple thin layers (at least three).
It sets within three minutes and offers sutureless skin approximation.
It has no length restrictions and wounds do not need to be linear. It provides a
waterproof clear dressing resulting in excellent cosmetic result.
Suture Removal
Materials
1. Scissors
2. Cotton pliers
3. Double-ended scaler
4. Hydrogen peroxide
5. Topical anesthetic
6. Cotton swabs
Method
1. Scaler is used to remove dressing in apico-coronal direction.
2.The area is then gently swabbed with hydrogen peroxide & rinsed with warm
water.
4.Sharp scissors should be used to cut the loops of the individual or continuous
sutures.
Note: Use the tip of an explorer to gently lift the suture off the tissue prior to
cutting.
5.Interrupted sutures need be cut only on the facial aspect close to the tissue.
7.Once the sutures are removed, the area should again be swabbed with hydrogen
peroxide or chlorhexidine gluconate to remove any residual debris.
8.The teeth should be polished for complete removal of debris and stain.