SUTURING MATERIALS

AND TECHNIQUES
Introduction
• The 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 prevent
direct apposiotion of tissues and provide an environment favorable
for bacterial growth.
• Sutures also distribute the tension of wound closure over a large
volume of tissues.
History
• Surgical sutures have been used to close wounds since prehistoric
times.
• needles were made up of bones or metals (silver, copper ,bronze)
and sutures were made up of plant materials (hemp, flax,cotton) or
animal material (tendons,hair,muscle strips,arteries).
 Definition
• Suture material is an artificial fiber used to keep wound together until they hold
sufficiently well by themselves by natural fiber (collagen ) which is synthesized
and woven into a stronger scar.

• It is said that an old method of wound closure has been using large black ants ,
which bite the wound edges together and the ants body being twisted off
leaving the head in place.
 Goals of suturing
• Maintain hemostasis
• Permit primary intention healing
• Provide support for tissue margins
• Reduce post operative pain
• Prevent bone exposure
• Permit proper flap position.
Things to be done prior to suturing
Check for completion of procedure
Remove any sharp bony spicules and smoothen bone margins.
Remove any loose tissue tags or non vital tissue as it may be a further
source of infection
Ensure complete hemostasis
Check if the wound can be approximated without any tension.if
not ,undermine the tissues to ensure tension free closure.
For large wounds,and possible dead space place a temporary drain
prior to suturing.
 Requisities of an ideal suture
• Tensile strength-adequate material strength will prevent suture
breakdown and use of proper knots for the material used will prevent
untying or knot slippage.
• Tissue biocompatibility-sutures made from organic material will evoke
a higher tissue response than synthetic sutures.
• It should have less capillary action.it should absorb less fluids when it is
within the tissues and so its strength remains for longer time.
• Good handling and knotting properties.
• Sterilization- without deterioration of properties,most sutures available
in packages are sterilized by dry heat and ethylene oxide gas.
 Suture material
• Suture material comes in various sizes
• Sizes 5 to 12-0 (numbers alone indicate progressively
larger sutures , whereas numbers followed by 0
indicate progressively smaller)
• 5 > 4 > 3 > 2 > 1 > 2 - 0 > 3-0
• 10-0 for microsurgical repair
• 5-0,6-0 fo suturing of skin on face
• 4-0,5-0 used for suturing in extremities
• 3-0 scalp sutures
• 3-0,4-0 in oral surgical procedures.
Classification of suture materials
I . based on degradation III. based on number of filaments
A. Absorbable A.Monofilament
B.Non absorbable B.Multifilament
C.Pseudomonofilament
II . based on source
A.Natural IV. based on coating material
B.Synthetic A. Teflon coated
C.Metallic B. chromic coated
 Absorbable suture materials
CATGUT
• also called surgical gut , derived from cattle intima.
• poor tensile strength and high tissue reactivity.
• gut soaked in chromic acid salts will have reduction in tissue
reactivity as compared to untreated catgut.
• types-plaingut, chromic gut, fast absorbing surgical gut.
• POLYGLYCOLIC ACID (DEXON)
• first synthetic absorbable suture to become available.
• renowned for its superb tensile and knot strengths in addition
to having delayed absorption and dimnished tissue reactivity.
• less of inflammatory response due to absorption of
polyglycolic acid by hydrolysis.

• POLYGLACTIC ACID (VICRYL)

• copolymer of lactide and glycolide, manufactured with a
coating of polyglactin 370 and calcium stearate.
• lubricant coating provides vicryl with its superb handling and
smooth tie down propeties.
• degraded by hydrolysis like all synthetic polyesters and thus
causes minimal tissue reaction.
 Non absorbable suture material
SILK

• created from natural protein filaments spun by the silkworm

larva.
• silk is braided , soft and easiest suture material to handle and tie.
• lowest tensile strength.
• elicits more inflammatory reaction, should be avoided in areas
prone to infection.
• in cutaneous surgery can be used around eyelids and lips where it
lies flat, cause minimal irritation and has low potential for
infection.
• NYLON(ethilon-ethicon)
• most widely used in cutaneous surgery as monofilament.
• high tensile strength,excellent elastic properties,minimal tissue
reactivity and low cost.
• multifilamentous braided nylon suture are seldom used because of
higher infection rate and increased cost.
• encounters partial degradation through hydrolysis at very slow rate.
• POLYESTER
• multifilamentous braided suture.,also available in coated forms.
• coating makes it more softer,pliable and easy to handle.
• high tensile strength,easy suture handling ,good knot security, low
tissue reaction.
• used in suturing of skin and mucosa.
 Suturing armamentarium

NEEDLE HOLDER
SUTURING MATERIAL
SUTURING NEEDLES

SUTURE CUTTING SCISSORS

TOOTHED AND NON TOOTHES TISSUE HOLDING FORCEPS
Classification of surgical needles
I. based on needle design III. based on how material connects to
• a. straight needles needle
• b. curved needles • a. eyed needle
• b.swaged needle.
II. based on cross section
• a. round body (tapering)
• b. cutting needle-conventional
• -reverse cutting
 Principles of suturing
1. needle should be grasped with help of needle holders at approximately 3/4th of its distance
from tip of the needle.
2. needle should never be held at the suture end as its the weakest point of the needle and
grasping at this point results in either bending or breakage of the needle
3. needle should pierce the tissue perpendicular to its surface.
4. curved needles should be passed through the tissues following the curvature of the needle
to prevent tearing of tissues.
5. suture should be placed equidistant (2-3mm) from incision line.
6. the needle is passed through the free side of flap first and then through the fixed side.
7. needle should be passed through the thinner flap than thicker flap.
8. needle is passed from the deeper flap to superficial flap.
9. when needle is passing through the tissues,the depth of penetration should be more than
the distance from the wound edges.
10. suture should not be tied so tighly that it results in blanching of tissues
11. each suture should be placed 3-4mm.
12. the knot should not be placed over the wound margins.
 Suturing methods
• SIMPLE INTERRUPTED SUTURE
• do the pass technique,2 loops around the needle holder,then grab
the tail and do the knot.
• most commonly used
• sutures are placed independently.
• provides greater strength.

• indications: single tooth extraction,third molar extraction

flaps,biopsies,implants etc
• advantages: selective adjustments of wound edges can be made.
• failure of one stich does not prejudice the other.
• disadvantages: can lead to suture marks after post op edema has
occured.
• strength of thread reduced by upto 50%due to increased number
of knots.
 Simple continuous suture

• start it with simple interrupted suture

• then you cut the tail off and leave that last piece loose then you can do your loops.
• provides rapid secure closure with even distribution of tension along length of wound
preventing excess tightness.
• provides more water tight closure as required by intraoral bone grafting.
• should not be used in areas of already existing tension.

• indications: well approximated wounds with minimal tension that have been initially created
by well placed buried sutures.

• advantages: quick and has fewer knots

• disadvantages: not possible to free a a few sutures at a time.even when one breaks , entire
closure is affected.
Locking continuous
• a degree of locking is provided
by withdrawing the suture
through its own loops.
• tissues align themselves
perpendicular to the incision.
• prevents continuous tightening
of suture as the wound closure
progresses.
Mattress suture
• commonly used in the regions of abdomen and hip
• useful in closing the wound of iliac and rib bone graft.
• provides more tissue eversion.

• A. VERTICAL MATTRESS SUTURE- the far,far,near , near technique

• placed by first taking a large bite of the tissue from the wound edge and
crossingthrough the tissue to an equal distance in opposite side of the wound.
• needle is then reversed and returned with a very small bite at the epidermal/dermal
edge in order to closely approximate wound edge.

• advantages: decreases dead space and providing increased strength.

• does not interfere with healing as suture runs parallel to blood supply.

• disadvantages: fine wound edge approximation is difficult, scar formation

Horizontal mattress suture
• used for intraoral bone grafting.
• needle is passed from one edge of incision to other
and again from latter to the first edge.
• procedure is continued till entire length of incision and
a knot is then tied.

• advantages:good for hemostasis,less prominent

scarring.

• disadvantages: blood supply to the flap edge may be

dimnished and cause necrosis if not used properly.
 Figure of 8 suture

• pattern goes 1-2-3-4-1

• indication:extractionsocket closure, adaptation of the gingival
papilla along the adjacent teeth& bone graft placement in socket.
• adv: rapid closure
• disadv: due to its orientation,it is difficult to remove and it leaves
a significant amount of suture threads inside the socket.
 Suture removal
• skin wounds regain TS slowly.it can be removed in 3-10 days when the
wound gained 5-10% of final TS.
• Skin sutures on face removed between 3-5 days.
• intraoral-mucoperiosteal closure (without tension) 5-7 days.
• when there is tension on suture eg:oro antral fistula 7-10 days.
• back and legs where cosmetics is less important 10-14 days
• continuous subcuticular can be left for 3-4 weeks without formation of
suture tracks.
• a good guide is that as soon as they begin to get loose they should be taken
out.
• suture area is first cleaned with normal saline.
• the suture is grasped with non toothed dissecting
forceps and lifted above the epithelial surface.
• scissors are then passes through one loop and then
transected close to the surface to avoid dragging
contaminated suture material through tissues.
• the suture is then pulled out towards incision line to
prevent dehiscence.if suture entrapped in a
scab,application of hydrogenpeoxide or saline solution
is necessary.
• if any suture is left out,infection or granuloma
formation can occur.
• possible complication of leaving suture for many days
-sutural abcess,suture scarring,implanted dermoid
cyst.
Alternative to suturing
 Conclusion
• due to daily surgical procedures carried by dentists , a greater
knowledge of suturing armamentarium and materials is needed.
• the success of technique-sensitive surgeries depends on the clinicians
knowledge and skills to close the wound and achieve optimal healing
• the innovations in suturing materials decreases the potential for
postoperative infections.