Suturing technique

SUTURES AND SUTURING TECHNIQUES

ByDR VASUNDHARA.VDEPT OF CONSERVATIVE DENTISTRY AND ENDODONTICS

Introduction

Definition

History

Goals

Requisites for suture materials

Principles of suture selection

Principles of suturing

Suture needles

Suture materials

Classification

Characteristics of suture materials

Absorbable suture materials

Non- absorbable suture materials

Newer materials for suturing

Needle holders

Suturing techniques

Types of knots

Tissue reaction to sutures

Suture removal

Suture sterilization

Other Supplements / Adjuncts To Wound Closure

Conclusion

References

INTRODUCTION

Any break in the continuity of the tissue is called as a wound

It may be caused by

Trauma

Voluntary event

Surgery

Burn

In all these cases, the wounded tissues react with a repair or regeneration process known as healing

Correct approximation of the Flaps of the wound is desirable since it makes it possible to accelerate the healing process

Wound healing involves 2 fundamental mechanisms namely,

Primary intention- is defined as healing of wound which are clean and

unifected, surgically incised, without much loss of cells and tissue and

edges of wound are approximated by surgical suture

Healing by secondary intention- where it is impossible to achieve

primary approximation of tissues owing to extensive loss of tissue or

secondary dehiscence of the surgical wound or the onset of super

infection.

It is said that 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

seep in and prevent direct apposition of tissues providing an

environment favourable for bacterial growth.

The importance of soft tissue management is an absolute priority in any

intra and extra oral surgical procedure if a correct esthetic and

functional result is to be achieved .

DEFINITION OF SUTURE

A sutures is any thread or strand which brings into apposition

surfaces or tissues.

Surgical sutures, or stitches, are used to sew an incision. Much

like sewing fabric, a strand of material is used to connect the

edges of a wound, pulling them closer together so that they

may heal.

In endodontic surgery, the most common method of wound

closure uses sutures. The primary objectives of suturing are

to stabilize and to secure tissues in their desired locations.

Somewhere between 50,000 and 30,000 B.C. eyed needles

were invented and by 20,000 B.C. bone needles became the

standard that was not improved until the Renaissance.

HISTORY OF SUTURES

East African tribes ligate blood vessels with tendons and close

wounds with acacia thorns pushed through the wound with

strips of vegetation wound round the protruding ends in a

figure-of-eight.

South American method of wound closure uses large black ants

which bite the wound edges together, their powerful jaws acting

in a similar manner to Michel clips. The ant's body is then twisted

off leaving the head in place.

Indian surgery was considerably ahead of any other early

civilization and we must assume that much of Egyptian,

Babylonian, Greek and Arabic surgery originated in India. (The

Scottish Society of the History of Medicine 1971)

The first written description of sutures used in operative

procedures is recorded in the Edwin Smith Papyrus dated to the

4000 B.C.

(130-200 AD)- Gold metallic sutures were used by Greece –

Galen

15 Centuries later- Hicronymus-used the same material.

1816-Philip Syug Physick – used lead wire

1860-Lord Joseph Lister’s –introduced catgut

1881-Lord Joseph Lister’s –chromic catgut

The development of scientific principles started only in

1931

1931-Poly Entero Phthalate Ester

1950-Polyester

1970-Poly Glycolic Acid

1975-Khubchandini-mono filament stainless

1978-Dr.Joseph Quill-described mono filament stainless

steel

GOALS:

• Provide an adequate tension of wound closure without dead

space but loose enough to obviate tissue ischemia and

necrosis.

• Maintain hemostasis.

• Permit primary intention healing.

• Provide support for tissue margins until they have healed and the

support is no longer needed.

• Reduce postoperative pain.

• Prevent bone exposure resulting in delayed healing and

unnecessary resorption.

REQUISITES FOR SUTURE MATERIALS:

Ethicon (1985)

• High uniform tensile strength, permitting use of finer sizes.

• High tensile strength retention in vivo, holding the wound

securely throughout the critical healing period, followed by rapid

absorption.

• Sterile.

• Pliable for ease of handling and

knot security.

• Freedom from irritating

substances or impurities for

optimum tissue acceptance.

• Predictable performance.

Prevent or limit bacterial adhesion and proliferation

Uniform diameter

Noncarcinogenic

Biologically inactive

With the possible exception of coated Vicryl, none of the sutures

available today meet these criteria.

PRINCIPLES OF SUTURE SELECTION

The selection of a suture material by a surgeon must be based

on a sound knowledge of the

healing characteristics of the tissues which are to be

approximated,

the physical and biological properties of the suture materials,

the condition of the wound to be closed and

probable post-operative course of the patient.

• When a wound has reached maximal strength, sutures

are no longer needed.

• Multifilament sutures should be avoided in contaminated

wounds as bacteria can linger within them and may

convert it into an infected one.

• Where cosmetic results are important, close and

prolonged apposition of wounds and avoidance of

irritants will produce the best results.

• So, the smallest inert monofilament suture materials such

as polyamide or prolene should be used.

• Skin sutures should be avoided and subcuticular closure

should be performed wherever possible.

PRINCIPLES OF SUTURING

The needle holder should grasp the needle at approximately 1/4

of the distance from the end.

The needle should enter the tissue perpendicular to the surface.

If the needle pierces the tissue obliquely, a tear may develop.

The needle should be passed through the tissue following the

curve of the needle.

The suture should be placed at an equal distance from the incision

on both the sides and at an equal depth.

• The needle should pass from the free tissue to the fixed side.

• If one tissue side is thinner than the other the needle should

pass from the thinner tissue to the thicker one.

If one tissue plane is deeper than the other, then the needle should

pass from the deeper to the superficial side.

The distance that the needle is passed into the tissue should be

greater than the distance from the tissue edge.

The tissues should not be closed under tension, since they will tear

or necrose around the suture. If tension is present the tissues

should be undermined to relieve it.

The suture should be tied so that the tissue is merely

approximated and the edges are everted.

The knot should not be placed over the incision line.

Sutures should be placed approximately 3-4mm apart. Closer

spaced sutures are indicated in areas of tension.

SURGICAL NEEDLES:

Proper suturing begins with an understanding of the physical

and biologic properties of both the needle and suture

material.

The surgical needles are sharp, pointed instruments used for

puncturing the tissue for guiding the thread. They are

available in a wide range of types, shapes, lengths and

thickness.

Needles are either made of stainless steel or carbon steel.

Most surgical needles are fabricated from heat treated steel

and possess a micro-silicon finish to diminish tissue drag and

a tip that is extremely sharp and has undergone

electropolishing (Ethicon 1985).IDEAL SURGICAL NEEDLE CHARACTERISTICS

High quality stainless steel.

Smallest diameter possible.

Stable in grasp of the needle holder.

Sharp enough to penetrate tissue with minimal resistance.

Sterile and corrosion resistant .

Classification of Surgical Needles:

According to its eye:

Eyeless needles.

Needles with eye.

According to shape:

Straight needles.

Curved needles.

Semi curved needles

According to cutting edge:

Conventional cutting needles.

Reverse cutting needles.

  According to its tip.

Triangular tipped needles.

Round tipped needles.

Blunt point needles.

THE ANATOMY OF THE NEEDLE

THREE DISTINCT PARTS:

1.The attachment

end

2.The body

3.The point

TERMINOLOGIES

1.Chord length

2.Needle length

3.Radius

4.Diameter(gauge)

THE ATTACHMENT ENDMay be

1.Swaged ( eyeless ) / atraumatic needles

2.Closed eye / traumatic needles

3.French eye ( split or spring )

CLOSED EYE /TRAUMATIC NEEDLES

Similar to house hold needle. It consists of a hole / eye

through which the suture material can be threaded.

As the eye of the needle necessarily larger than the diameter

of the needle , they produce larger hole in the tissue than the

diameter of their own .

These eyes have a slit from inside the eye to the end of the needle

with ridges that catch and hold the suture in place.

FRENCH EYE

SWAGED / ATRAUMATIC NEEDLES

The suture material is inserted into

the hollow end during manufacture

& the metal is compressed around

it.

This doesn’t cause injury to the

tissues as much as eyed needle ,

hence termed as atraumatic

needles. But they are not reusable.

NEEDLE BODY

The body is the widest portion of the needle and is also

referred to as the grasping area which is grasped by the

needle holder during the surgical procedure.

The body comes in a number of shapes:

Curved , semicurved ,straight, compound curvature.

STRAIGHT NEEDLE

Preferred in suturing easily accessible areas

Keith needle –used primarily for skin closure of

abdominal wounds

Bunnell (BN) needle- used in tendon repairs.

HALF CURVED (SKI) NEEDLE

Used for skin closure

Its use is rare Because of its poor handling property

They allow predictable needle turn out from tissue and are therefore used most often

The curvatures are ¼ ,3/8 ,½ or 3/4

CURVED NEEDLE

Radius of curvature of the body

Clinical uses

STRAIGHT NEEDLE Skin surgeriesLimited use in oral surgery

¼ CIRCLE Needle of choice in microsurgery associated with very fine sutures; ophthalmology

3/8 CIRCLE Oral surgeryMay be used in almost all surgical wounds

½ CIRCLE Needle of choice in oral surgery

Variable radius (Fishermen’s needle)

Oral surgeryOphthalmology

The point runs from the tip to

the maximum cross-sectional

area of the body.

Depending upon shape of tip-

cutting needle and blunt

needles

Cutting can be further

subdivided into- classical

cutting, reverse cutting,

lateral cutting, taper cut and

bevelled needles

NEEDLE POINT

CONVENTIONAL CUTTING NEEDLE:

The point of this needle is triangular in cross-section with the

apex cutting edge on the inside of the needle curvature. It is

used for keratinized mucosa, skin or subcuticular layers where

the tissue is difficult to penetrate. Cuts more tissue than

necessary. Risk of accidental cutting from a depth upwards is

maximum

REVERSE CUTTING NEEDLE:

The body of this needle is triangular in cross-section with the

apex cutting edge on the outside of the needle curvature. This

improves the strength of the needle and particularly increases

resistance to bending. The tissue is protected in case of

accidental traction

TROCAR POINT NEEDLE:

This needle has a strong cutting head, which

merges into a robust round body. The design

of the cutting head is such that it ensures

powerful penetration even when deep in the

dense tissue.

SPATULA TIPS• Tips with only 2 lateral cutting edges.

• Never used in oral surgery.

• Used only in ophthalmic surgeries .

TAPER-CUT NEEDLES

• Combine characteristics of reverse cutting and bevelled

needles. Used in oral surgeries

BEVELLED NEEDLES

• Used occasionally in oral surgery

• Mainly indicated for suturing on more than one plane

BLUNT TIPSNeedles without cutting tips completely lost their importance

in our fields of surgery some years ago.

Their capability to penetrate tissue is very low but the

appearance of high-risk patients (HIV,HCV,etc.) has caused

their use in oral surgery to be revaluated

SELECTION CRITERIA OF SUTURING NEEDLES :

DEPENDING UPON ITS CURVATURE:

3/8 & ½ circle needles are the most commonly used

The 3/8th needle allows the clinician to pass the needle from

buccal surface to the lingual surface in one motion.

The ¼ & ½ circle needles are more appropriate to be used in

restricted areas such as buccal aspect of maxillary 2nd & 3rd

molar area

The 3/4th circle needle , when used at the mandibular incisors

because of its curvature prevents injury to the tongue

The ½ circle needle is routinely used for periosteal &

mucogingival surgery.

SUTURE MATERIALS

Absorbable

Non-absorbabl

e

Monofilamentous

Multifilamentous

Natural Syntheti

c

CLASSIFICATION

ABSORBABLECatgutCollagenHomopolymer of glycolide (PGA)Copolymer of glycolide and lactide (PGA910)PolydiaxononePolyglecaprone 25

NON ABSORBABLESilkCotton and linenPolyesterPolyamidePolyproplenePolyethyleneSteel

CLASSIFICATION

MULTI FILAMENTPolyesterPolyamidePolyglycolidePolylactideSilkCotton, linen

MONOFILAMENTPolyamidePolypropylenePolyethylenePolydiaxononePolyglecaprone 25Catgut

CLASSIFICATION

COATEDPolyesterPolyglycolidePolylactideCottonLinenPolyetheleneCatgut

UNCOATED

PolyamidePolypropylene

CLASSIFICATION

BRAIDEDPolyesterPolyamidePolyglycolidePolylactideSilk

TWISTEDCotton Linen

CHARACTERISTICS OF SUTURE MATERIAL

1. Handling ability

2. Elastic memory

3. Knot security

4. Capillarity

5. Tensile strength

6. Size

7. Atraumatic behaviour

8. Colonization of bacteria

1. Handling ability Easy to handle and glide easily through the tissues.

Excellent handling - silk

2. Elastic memory This memory is actually built in orientation of the polymer

produced by extruding and stretching during manufacture of

the filament.

When tied, suture tends to remember that it was originally a

straight fiber and knot slips and untie.

High for nylon,

Lower for silk,

minimum for Gore tex

3. Knot security Is as a rule inversely proportional to the thread’ ability to

glide.

The better the thread glides, the more probable will it be that

knots accidentally come undone.

Drawback resolved by increasing number of clockwise and

anti-clockwise half knots.

But hinders healing of the wound

Knot made of high elastic memory- Ex: nylon

4. Capillarity

Is the phenomenon whereby a liquid diffuses

inside a capillary.

The 3 ‘D’ structure and technological

characteristics of a thread act directly on

it capillarity.

Ideally, should limit c.

• Lower the c, the less the suture will absorb liquids.

• If suture absorbed liquids, its removal is inevitably more

laborious.

• Neutralizing capacity to absorb liquids also reduce

inflammatory response, advantage of wound healing.

• C is lower with monofilaments and with synthetic.

5. Tensile strength

Knot tensile strength is the force which the

suture strand can withstand before it breaks when knotted.

The tensile strength of the tissue to be mended determines the

size and tensile strength.

The accepted rule is that the tensile strength of the suture

should never exceed the tensile strength of the tissue.

6. Size Size denotes the diameter of the suture material.

The more zeroes in the number, the smaller the diameter.

Smaller the section, less damage produced to the tissues, less

the foreign material dispersed.

The accepted surgical practice is to use the smallest diameter

The smaller the size, the less tensile strength the suture will

have.

7. Atraumatic behaviour

Given by 3D structure.

When the thread glides inside the tissue , if it move with

some speed, the friction between thread and tissue may

be converted to heat and create micro-burns along the

line of suture. This may leave small openings along the

line and facilitate bacterial colonization.

It should move slowly.

Friction minimum for monofilaments and maximum for

non coated multifilaments.

8. Colonization of bacteria

Also known as bacterial wicking.

Suture material draws bacteria and fluids into the wound

site.

Eg: silk

MONOFILAMENT VS.MULTIFILAMENT STRANDS

Monofilament sutures

Are made of a single strand of material. simplified structure, less resistance as they pass through tissue Better ability to slide Less frictionIncreases their ability to glide Less traumatic

smooth, closed surface and completely closed interior, have no capillarity.

3D Structure of single fiber

No cavities that could be colonized by

microorganisms

Reduces the risk of contamination

Disadvantage Knot more likely to come undone. Detriorates more easily, stretched or folded by the

needle holder, never be employed in crucial position.

Multifilament sutures

Consist of several filaments, or strands, twisted or braided together. Greater tensile strength, pliability, and

flexibility. Have higher friction, reduction in smoothness, increased overheating of the wound

Better knot holding security

Coated multifilament threads – silicone or polybutilite

Coated to help them pass relatively smoothly through tissue

and enhance handling characteristics.

Are less stiff and wiry than monofilament threads.

The coating also reduces capillarity.

In 3D structure, some area unreachable by the immune

system, allows greater colonization of bacteria.

Greater risk for infection.

Wicking effect.

TwistedTheir surface is mostly rough.The longitudinal orientation of the individual filaments within the thread results in relatively high capillarity.

Braided The individual filaments lie more or less obliquely to the longitudinal axis of the thread. This tends to impede the passage of fluid.The capillarity therefore less than that of twisted threads.

Braided vs Monofilament

Has capillary action Increased infection

risk Less smooth

passage Higher tensile

strength Better handling Better knot security

No capillary action Less infection risk Smooth tissue

passage Less tensile

strength Has memory More throws

required

ABSORBABLE SUTURE MATERIALS

Sutures that undergo rapid degradation in tissues, losing their

tensile strength within 60 days, are considered absorbable

sutures.

Prepared either from the collagen of healthy mammals or from

synthetic polymers.

Some are absorbed rapidly, while others are treated or

chemically structured to lengthen absorption time.

Absorption time or half life, which is defined as the time

required for the tensile strength of a material to be reduced to

half its original value.

Dissolution time is the time that elapses before a thread is

completely dissolved.

These times are influenced by a large number of factors

including thread thickness, type of tissue, age, gender and

general condition of the patient.

ABSORBABLE SUTURE MATERIALS

Natural SyntheticDigested by body enzymes

Endocellular degradation

Hydrolyzation

Cleavage by water molecules

• Hydrolyzation results in a lesser degree of tissue reaction following implantation.

• Choice- in oral surgery

Limitations

If a patient has a fever or infection….

If the sutures become wet or moist during handling…

Patients with impaired healing…

Resorbable suture are highly reactive,.

Advantages

Avoid recalling of the patient.

In complex suturing technique, involving more than one

plane.

It is the oldest known absorbable suture material.

According to Katz and Turner (1970), Galen referred to

gut suture as early as 175 A.D.

It is derived from sheep or bovine intestine and is

classified as natural, monofilament and absorbable suture.

Gut is the most variable suture material in

terms of tensile strength and absorbability.

GUT

GUT SUTURE

Gut has the smallest strength of any of the commonly used

suture materials (Herrmann 1971).

The percentage of collagen in the suture determines its tensile

strength and its ability to be absorbed by the body without

adverse reaction.

When placed intraorally through mucosal surfaces, the

sutures resorb in 3-5 days.

GUT SUTURE

Because it is organic material and highly susceptible to

enzymatic degradation, it is packaged in isopropyl alcohol as

a preservative.

The suture should not be soaked in saline - loses from 20% to

30% of its tensile strength. (Katz and Turner)

Gut suture is absorbed by proteolytic degradation and

phagocytosis.

PLAIN SURGICAL GUT Rapidly absorbed.

Tensile strength is maintained for only 7 to 10 days and

absorption is complete within 70 days.

Can also be specially heat-treated to accelerate tensile

strength loss and absorption.

Used primarily for epidermal suturing where sutures are

required for only 5 to 7 days.

CHROMIC GUT

It is plain gut that has been treated with a solution of

buffered chrome tanning solution to resist body enzymes,

prior to being spin, ground and polished.

It prolongs the absorption time over 90 days.

The chromic salt acts as a cross-linking agent and increases

the tensile strength and its resistance to absorption of the

body (Edlich et al 1973).

Chromic gut sutures minimize tissue irritation, causing less

reaction than plain surgical gut during the early stages of

wound healing.

Tensile strength may be retained for 10 to 14 days, with some

measurable strength remaining for up to 21 days.Contraindications:

Being absorbable should not be used when prolonged

approximation of tissues under stress is required.

In intraoral Surgery

PLAIN GUT Used occasionally, manipulation difficult

Knot holding property- poor

Becomes hard, can traumatize – mucosa

CHROMIC GUT Not particularly good choice

Stiff, difficult to handle and tie

Does not rapidly resorb.

It is natural, monofilament, absorbable.

Reconstituted collagen sutures are obtained by grinding the native

collagen of deep flexor tendons of cattle, which is then acidified to

form gel and extruded into a neutralizing dehydration bath.

It takes 5-6 days to get absorbed.

After 10 days only 10% of the tensile strength

remains, hence cannot be used where tissue

healing is slow.

Tissue reaction is minimal.

COLLAGEN

POLYGLYCOLIC ACID Is a homopolymer of glycolic acid (Polyhydroxyacetic

acid) coated with polaxamer 188.

Is manufactured by orienting these filaments by means of

stretching and braiding.

It is a multifilament suture , which is braided and coated.

Trade name “Dexon”

Absorbed by hydrolysis in 60-90 days.

POLYGLACTIN 910

They come under trade name “Vicryl”

Synthetic absorbable sterile surgical suture composed of a

copolymer made from 90% glycolide and 10% L-lactide.

Coated vicryl suture is prepared by coating vicryl suture

material with a mixture composed of equal parts of

copolymer of glycolide and lactide (polyglactin 370) and

calcium stearate.

Dexon and Vicryl, when braided are the strongest of the

absorbable suture materials.

According to Dardik, and Lanfman (1971), metabolites of

polyglycolic acid are metabolised via the citric acid cycle and

produce energy, Co2 and water.

Available as braided dyed violet or undyed natural strands in a

variety of lengths with or without needles.

COATED VICRYL PLUS ANTIBACTERIAL (POLYGLACTIN 910) SUTURE

Coated VICRYL Plus Antibacterial suture contains one of the

purest forms of the broad-spectrum antibacterial agent

triclosan .

Coated VICRYL Plus Antibacterial suture offers protection

against bacterial colonization of the suture.

Degree of inflammation is less as

seen in plain/chromic catgut sutures.

In vivo studies demonstrate that

Coated VICRYL Plus Antibacterial suture has a zone of

inhibition that is effective against the pathogens that most

often cause surgical site infection (SSI)

Staphylococcus aureus, methicillin-resistant Staphy aureus

(MRSA),

Staphy epidermidis, methicillin-resistant Staphy epidermidis

(MRSE)

(Rothenburger S et al 2002)

VICRYL Plus Antibacterial suture has no adverse effect on

normal wound healing. (Gilbert P et al 2002)

POLYGLECAPRONE 25 Trade name – “Monocryl”

It is a synthetic, monofilament, absorbable suture material

made up of co-polymer of 75% glycolide and 25% epsilon-

caprolactone.

It undergoes hydrolysis and absorption by 90-120 days.

Tissue reaction is minimal.

It has good knot strength.

It is the most pliable and is used in soft tissue closure.

Biologic behaviour similar to that of PGA 910.

Narry Filho 2002 - Because of its favorable characteristics it

can be used not only deep in tissues, but also in superficial

tissues of oral mucosa.

Tremendous tensile strength (highest) but is very stiff.

POLYDIOXANONE (PDS)

It is a synthetic, monofilament, absorbable suture.

It is comprised of the polyester poly(p-dioxanone).

It combines the features of soft, pliable, monofilament

construction with absorbability and extended wound support

for up to 6 weeks.

It undergoes slow hydrolysis and takes 110-210 days to get

absorbed.

It has good tensile strength and moderate knot tensile

strength. PDS sutures are available clear or dyed violet to

enhance visibility.Uses:

Absorbable suture with extended wound support.

  Contraindication:

Being absorbable should not be used when prolonged

approximation of tissues under stress is required.

NON RESORBABLE SUTURE MATERIALS

SURGICAL SILK It is a natural, multifilament, non-absorbable suture.

Silk is an organic substance that undergoes slow

proteolysis when implanted (Douglas, 1949)

It is a natural protein fiber of raw silk,

which is treated with silicon protein or wax.

Silk loses most of the tensile strength after 1 year of

implantation and usually disappears after 2 years.

It is the most popular inexpensive suture material for intraoral

use.

It is braided, which gives it excellent handling characteristics.

Types: According to preparation.

Perma hand surgical silk.

Virgin silk suture which is prepared from the glands of silk

worm before their pupae stage.

According to fiber pattern:

Braided.

Twisted.

Floss.

Postlethwait (1970) and Van Winkle and Co-workers

(1975)- Silk initially produces more tissue reaction

(inflammation) than synthetic non-absorbable sutures.

According to Herrmann (1971), silk has one of the lowest

tensile strengths among suture materials, ranking just above

gut and collagen and in terms of knot-holding ability it ranks

the lowest of all the commonly used suture materials.

Therefore, at least three ties should be used for each knot.

Addition of wax or silicon to reduce the tissue reaction and

prevent wicking further diminishes knot security (Hermann,

1971).

It has the “ wicking effect ” i.e, it pulls the bacteria & fluid

into the wound site .

COTTON

Natural, multifilament and non-absorbable.

Made from non-continuous natural fibers of Egyptian cotton.

Following the report by Mead and Oshsner (1940) cotton

became popular during World War II when silk was relatively

unavailable.

strength is similar to silk, their handling characteristics are

inferior.

Tissue reaction is moderate.

LINEN

It is also natural, multifilament and non-absorbable suture.

It is derived from staple flax fibers.

somewhat stronger than cotton but otherwise has similar

characteristics of cotton.

Tissue reaction is minimal.

Because of its poor tensile strength, cannot be used for

suturing under tension.

NYLON

It is synthetic, non-absorbable suture material available in

braided (or) monofilament forms.

Comprises of polymers of hexamethylene diamine and

adipic acid.

The monofilament form - Duralon and Ethilon.

The multifilament form is - Nurolon and Surgilon.

Nylon possesses the property of “memory”

Generally, multiple square knots are necessary to maintain

the tie.

It degrades at a rate of 15-20% per year.

Herrmann (1971) has shown that nylon has good tensile

strength but ranks below that of steel.

Limitations

Because of its stiffness, the large knot is required.

Since it has a tendency to tear through non-keratinsed tissue,

nylon is not frequently used intraorally.

METAL

316 L Stainless steel or tantalum sutures are either

monofilament or braided.

They are the strongest and produce the most secure knot of

any suture materials (Herrmann 1971).

Tissue tolerance is good but is less than that found with nylon.

Metallic materials may undergo degradation through

corrosion, resulting in transfer of ions from the suture to the

tissue.

Tissue reaction to these ions can occur.

Metallic sutures are stiff and do not conform to the suture

pathway during host movement.

The resultant irritation may produce tissue damage and

increased susceptibility to infection.

In oral and maxillofacial surgery used for suspension of splints

(or) arch bars not as suture material.

POLYESTER

“Dacron, Mersilene, Ethibond” (polyester) are braided

suture materials.

Composed of polymers of polyethylene terephthalate.

exhibits the greatest tensile strength and knot holding ability

of the non-metallic suture materials (Herrmann, 1971).

The tissue reaction is minimal and is unaffected by the

presence of an inert coating or impregnation with silicon or

Teflon (Edlich et al 1973).

POLYPROPYLENE

Trade name – “Prolene”

It is synthetic, monofilament and non-absorbable.

Composed of an isotactic crystalline stereoisomer of

polypropylene.

It exhibits good tensile strength, minimal and transient tissue

reaction.

It is used in all types of soft tissue approximation.

It shows excellent handling characteristics.

Advantage of plasticity of prolene

When swelling occurs , prolene will stretch to

accommodate the wound ,thus there will be little cutting

through the tissue.

When swelling recedes , the suture will remain loose &

keep the edges properly approximated

EXPANDED POLYTETRAFLUROETHYLENE

(E-PTFE) GORE-TEX It is the most recent material to be used as suture material.

It is monofilament strand obtained by polymerization of

Tetrafluroethylene & is expanded mechanically to increase

its flexibility.

• It is easy to handle , sterilize, tie knot & has good tensile

strength.

• It can be used for closure of flaps where the same material

used as barrier membrane.

NEWER MATERIALS

Monofilament synthetic nonabsorbable Butylene terephthalate (84%) and polytetramethylene

ether glycol terephthalate (16%). strength, lack of package memory, elasticity, and

flexibility which made suturing quicker and easier. can be used safely on skin and mucosal wounds

THE POLYBUTESTER SUTURE (NOVAFIL™)

2. POLYSORB- MONOFILAMENT, ABORBABLE

Copolymers of glycolide and lactide were then

synthesized to produce a Lactomer™ copolymer).

Glycolide provides for high initial tensile strength, but

hydrolyses rapidly in tissue. Lactide has a slower and

controlled rate of hydrolysis, and provides for prolonged

tensile strength in tissue.

The Lactomer™ copolymer consists of glycolide and lactide

in a 9:1 ratio.

The handling characteristics were found to be superior to

those of the Polyglactin 910™ suture.

3. MAXON- MONOFILAMENT ABSORBABLE

A suture (Maxon™) has been developed

using trimethylene carbonate.

The strength is better than the braided

synthetic absorbable suture

4. BIOSYN-MONOFILAMENT SYNTHETIC ABSORBABLE

Production of Glycomer 631, a terpolymer composed of

glycolide (60%), trimethylene carbonate (26%), and dioxanone

(14%) advantages over the braided synthetic absorbable.

First, is significantly stronger over four weeks of

implantation potentiates less bacterial infection.

The handling characteristic of this monofilament

suture is superior to the braided suture because

it encounters lower drag forces in the tissue

5. CAPROSYN- MONOFILAMENT ABSORBABLE

Rapidly absorbing

Are prepared from Polyglytone™ 6211 synthetic polyester

which is composed of glycolide, caprolactone, trimethylene

carbonate, and lactide.

Compared to chromic gut it has:

Significantly greater mean breaking strength, handling

properties were far superior, The smooth surface of the

Caprosyn™ sutures encountered lower drag forces, it was

much easier to reposition the Caprosyn™ knotted sutures.

Are an excellent alternative to Chromic Gut sutures.

Suturing is defined as a process of holding severed tissue in close approximation until the healing process provides wound with sufficient strength to withstand stress without the need for support.

Armamenterium SUTURE MATERIAL

SUTURING NEEDLE

NEEDLE HOLDER

TISSUE HOLDING FORCEP

SUTURE CUTTING SCISSOR

NEEDLE HOLDERS

Must be made of non corrosive,

high strength good quality

steel alloy with jaws designed

for holding the suture needle

securely.

It may be short or long ,broad

or narrow, slotted or flat,

concave or convex.

Jaws with tungsten carbide particles embedded in them offer

two distinct advantages.

Good holding power

Less damage to suture material

How to hold needle with needle holder ?

Grasp the needle with the tip of the needle holder jaws in an approximately 1/3rd to ½ of the distance from the attachment end to point.

Do not grasp the needle too tight.

SUTURING TECHNIQUE

CONTINUOUS

Sling suture

Vertical mattress

Horizontal mattress

Locking suture

INTERRUPTED

Circumferential direct loop

Figure of eight

Mattress - Horizontal,

vertical

Sling sutures

Closed Anchor suture

Distal wedge suture

INTERRUPTED SUTURES

They are also called “ solitary sutures ” .They have shorter span & close only a shorter distance of flap.

Indications:• Vertical incision• Tuberosity and retromolar areas• Bone regeneration procedures with or without guided tissue

regeneration• Widman flaps, open flap curettage, unrepositioned flaps, or

apically positioned flaps where maximum interproximal coverage is required

• Edentulous areas, osseointegrated implants• Partial or split-thickness flaps

Advantages: Successive sutures can be placed to fit individual

requirement

The loosening of one suture will not produce loosening of other suture.

When required , selected sutures may be removed without interfering other.Disadvantages:

• Time consuming as many individual sutures has to be placed to close the entire flap.

• Many knots have to be placed.

They have a long span & close the entire distance of the flap

Advantages : Time saving

In case of continuous sling, buccal and lingual flaps are independent of each other preventing tension in the flap.

Can include as many teeth as required.

The teeth are used to anchor the flap.

CONTINUOUS SUTURE

Disadvantages : If the suture breaks, the flap may become loose or the suture may come untied from multiple teeth.

SIMPLE LOOP SUTURE

It is the most commonly used suture because of its simplicity.

Simple loop suture is used to approximate the buccal and lingual

flaps.

The suture forms a simple circular loop uniting the two edges of

surgical incision.

TECHNIQUENeedle penetrates the outer surface of the first flap , then undersurface of the opposite flap is engaged , and the suture is brought back to the initial side where the knot is tied.

FIGURE OF EIGHT

Bite is taken from the buccal flap and needle is passed

through the interdental space and again bite is taken from

the epithelial surface of lingual flap.

The needle is then returned through the embrasure and

tied buccally.

SLING SUTURE

This is primarily used for a flap that has been raised on only one

side of the tooth, involving one or two adjacent papillae

• Coronally and laterally positioned flaps

• The technique involves use of interrupted sutures, which is

either anchored about the adjacent tooth or slung around the

tooth to hold both papillae.

MATTRESS SUTURES

They are used for greater flap security and control.

They permit more precise flap placement.

They allow for good papillary stabilization and placement.

• Vertical mattress sutures are used in narrower interdental

areas when greater control of the papilla tip is required.

• A P-3 needle is inserted 7 to 10mm apical to the tip of papilla.

It is then passed to emerge again from the epithelial surface of

the flap 2 to 3 mm from the tip of the papilla. The needle is

brought through the embrassure, where the technique is again

repeated lingually. The suture is then tied buccally.

HORIZONTAL MATTRESS SUTURE

A P-3 needle is inserted 7 to 8 mm apical to and to one side

of the midline of the papilla, emerging again 4 to 5 mm

through the epithelialized surface on the opposite side of the

midline

The needle is then passed through the embrasure and after

being repeated lingually, the knot is tied buccally.

Internal mattress suture The internal mattress suture allows both the facial and

lingual or palatal papillae to stay upright, filling the

embrasure space in an esthetic area.

The suture enters the facial tissue just apical to the base of

the papilla, runs across the top of the alveolar crest, and

penetrates the lingual tissue from the inside-out apical to

the base of the lingual papilla.

The suture passes back through the lingual papilla from the

outside-in, 2 to 3 mm coronal to the previous point of suture

penetration, and courses back across the alveolar crest exiting

through the facial papilla from the inside-out at a point 2 to 3

mm coronal to the initial facial entry point.

The facial and lingual papillae are positioned together and

the suture is tied on the facial. The majority of the suture

material lies under the flap in the interdental area.

ANCHOR SUTURE

The closing of flap mesial

or distal to a tooth, as in

mesial or distal wedge

procedures, is best

accomplished by the

anchor suture.

The needle is placed at the line-angle area of the facial or

lingual flap adjacent to the tooth , anchored around the

tooth , passed beneath the opposite flap, and tied.

CLOSED ANCHOR SUTURE

Another technique to close a

flap located in an edentulous

area mesial or distal to a tooth

consists of tying a direct

suture that closes the

proximal flap, carrying one of

the threads around the tooth

to anchor the tissue against

the tooth, and then tying the

two threads .

CONTINUOUS SLING SUTURE

The two flaps are completely independent of each other.

The suture is initiated as a loop suture

The needle engages the outer surface of flap and encircles

the tooth and outer surface of the same flap of adjacent

interdental area is engaged and the procedure is continued

upto the last tooth and it is encircled to the last tooth and

same procedure follows on the lingual or palatal side of flap

upto the starting point of suture and tied buccally.

PERIOSTEAL SUTURE This type of suture is used to hold in place apically displaced

partial-thickness flaps.

Two types : Holding suture and Closing suture

The holding suture is a horizontal mattress suture placed at the base of the displaced flap to secure it into the new position.

Closing sutures are used to secure the flap edges to the periosteum.

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.

Chaiken 1977

LOCKING SUTURE

The procedure is simple and

repetitive.

A single interrupted suture is

used to make the initial tie.

The needle is next inserted

through the outer surface of

the buccal flap and the

underlying surface of the

lingual flap.

• The needle is then passed through the remaining loop of the

suture, and the suture is pulled tightly, thus locking it.

• This procedure is continued until the final suture is tied off at

the terminal end .

SUTURING TECHNIQUE IN ENDODONTIC MICROSURGERY

Suturing tech in microsurgery enhances the surgeon’s ability to view inaccuracies in wound closure

AIM

Accomplish passive and primary wound closure.

The execution of proper surgical tech with smaller and sharper instruments limits collateral tissue damage.

Gentle coaptation of the wound following the geometric principles of suturing prevents overlapping or incomplete closure of the wound.

It circumvents dead space and shear forces.

MICROSURGICAL KNOT TYING

The art of tying good surgeon’s knot, or cinching knot can only be mastered through repeated laboratory practice under the microscope.

Geometry of microsurgical suturing

Needle angle: slightly less than 90 degreesBite size: 1.5 times the tissue thicknessSymmetry: equal bite sizes on both sides of the woundDirection of needle passage: perpendicular to the wound

KNOTS

“Everyone knows how to tie a knot but few knows how to tie a knot well”

The purpose of knots is to join the two ends of the suture in a

secure but gentle way. Knots must be placed tightly enough

to prevent slippage and loosening of the flap but not to blanch

the tissues. They are generally placed on buccal aspects of

flaps.

A sutured knot has three components (Thacker et al , 1975).

The “LOOP” created by the knot.

The knot itself, which is composed of a number of tight “throws”:

each throw represents a weave of the two strands.

The “EARS” which are the cut ends of the suture.

The knot may be tied in 2 techniques

INSTRUMENT TIE Using needle holder

ONE- HANDED & TWO-HANDED TIE Using fingers

As periradicular surgeries are involved in inaccessible areas of mouth, the instrument tie is the most appropriate & extensively used technique.

Types of knots

Overhang knot

Square knot

Surgeon’s knot

Slip (or) Granny knot

OVERHANG KNOT

It is the basic knot which is simple loop made by crossing the free end of the suture over the standing part one time.

SQUARE KNOT

It is made by tying two overhang knots each done in opposite directions.

This knot is easy to tie but loosen when synthetic/ monofilament sutures are used.

SLIP/GRANNY KNOT It is similar to square knot , in

it both the overhang knots are

placed in same direction.

The advantage of this knot is

even after placing the second

knot it can be further

tightened with one or two

additional overhang knots.

SURGEONS KNOT It is the most commonly

used knot as it reduces slippage of the first tie , while the 2nd tie is placed.

It is formed by tying 2 ties. The first tie is formed by 2 throws of suture around needle holder in one direction & the 2nd tie by throwing the suture in opposite direction.

METHOD OF KNOT TYING

1 2

3

4

5

Ethicon (1985) recommends the following principles for knot tying:

Suture should be placed in the interdental space below the base of the imaginary triangle in the papilla .

The completed knot must be tight, firm, and tied so that slippage will not occur.

To avoid wicking of bacteria, knots should not be placed in incision lines.• Knots should be small and the ends cut short (2 to 3 mm).

• Avoid excessive tension to finer gauge materials as breakage may occur.

• Avoid using a jerking motion, which may break the suture.

• Avoid crushing or crimping of suture materials by not using hemostats or needle holders on them except on the free end for tying.

Do not tie suture too tightly as tissue necrosis may occur. Knot tension should not produce tissue blanching.

Maintain adequate traction on one end while tying to avoid loosening the first loop.

The surgeons and square knot strength, although generally not needing more than two throws, will have increased strength with an additional throw.

Granny knots and coated and monofilament sutures do require additional throws for knot security and to prevent slippage. Coated vicryl will hold with four throws-two full square knots.

Ethicon (1985) recommends the following principles of suture removal.

1. Area should be swabbed with H2O2 for removal of encroached necrotic debris and serum from sutures.

2. A sharp pair of suture scissors should be used to cut the loops of individual continuous sutures about the teeth. It is often helpful to use a No.23 explorer to help lift the sutures if they are within the sulcus or in close apposition to tissue. This will avoid tissue damage and unnecessary pain.

3. A cotton plier is now used to remove the sutures. The location of knots Should be noted so that they can be removed first. This will prevent unnecessary entrapment the flap.

ALTERNATIVES TO SUTURE MATERIALS

GLUSTITCH PERIACRYL®

Tissue Adhesive - considered by many specialists to be

essential for oral microsurgeries.

Fast-setting cyanoacrylate (CA) formula adheres to moist,

living tissues with no toxic or foreign body reaction.

Violet color ensures visibility.

Eye protection required.

Two-year shelf life.

SURGICAL STAPLES

Staples are formed from high-quality stainless steel and are

available in regular and wide sizes.

STERI-STRIPS

Sterile adhesive tapes

Available in different widths.

Frequently used with subcuticular sutures.

Used following staple or suture removal.

Can be used for delayed closure.

USED TO:

Secure sutures, or in lieu of sutures in specific periradicular

surgeries.

Protect and stabilize membranes, or as a sealing and

supporting agent for socket preservation.

Cover collagen plugs post-extraction.

Dress donor and/or recipient sites.

Mussel Adhesive Protein (MAP):

This is obtained from the blue mussel, Mussel Adhesive protein is in

experimental phase.

One of the unique structural features of mussel adhesive proteins

(MAPs) is the presence of L-3,4-dihydroxyphenylalanine (DOPA), an amino

acid that is believed to be responsible for both adhesive and crosslinking

characteristics of MAPs. DOPA is formed in these proteins by post-

translational hydroxylation of tyrosine residues.

TISSUE REACTION TO SUTURES

INITIAL RESPONSEAlmost identical in the first 4-7 days, regardless of the suture material The damage done to the tissues by the needle evoke a significant inflammatory response even without the presence of suture materialThe early response is a generalized acute aseptic inflammation, involving primarily PMN, Leucocytes.

After a few days, mononuclear cells, fibroblast and histiocytes (tissue macrophages) become evident.

Capillary formation occurs at the end of this initial phase.

AFTER 4-7 DAYS

The response is related more to the type of suture material.

For eg. Plain gut elicits an intense reaction with macrophages

and polymorphonuclear leucocytes predominating, while non-

absorbable materials show a less intense relatively acellular

histological pattern.

In human study conducted by Elen and Conen the presence of

the suture increased the susceptibility to infection by a factor

of 10,000 times.

Generally sutures should be removed after 3-5 days in

skin of head & neck, 5-7 days intraorally 5-10 days in

other sites.

STERILIZATION OF SUTURES

Sterilization differs according to the suture material and are usually done by the manufacturer.

Some sutures are sterilized with gamma radiation like silk, nylon, e-PTFE.

Some suture material cannot withstand gamma

radiation like plain catgut, chromic catgut, PGA 910. Ethylene oxide gas.

The component layers of packaging materials do not permit

exposure to high temperatures or extremes of pressure

without affecting package and product integrity. For this

reason, all sterile products manufactured are clearly labeled

"DO NOT RESTERILIZE."

The practice of resterilization is not recommended, except for

pre-cut steel sutures and spools or cardreels of nonabsorbable

materials supplied nonsterile.

PACKAGING…

Expiry dateBatch NumberDo Not Re-use

Product (re-order) CodeImperial GaugeMetric Gauge

Needle size & curvature

Needle type

Needle point

See Instructions for use

Needle profile

SterilisedEthylene Oxide

Suture length

boxes have specific indications, likeF S ……….. for skinP S ……….. for plastic skinP ……….. for precision pointP C…….…. Precision cosmetic

CONCLUSION “The success of surgery starts

with a good incision , but becomes

perfectly complete only with good

suturing”

Great Teacher of Surgery

Dr. Hamilton Bailey (1894-

1961)

REFERENCES

Atlas of cosmetic and reconstructive periodontal surgery.

Edward S Cohen, 2nd Edition

Oral and maxillofacial surgery. Daniel M Laskin

Suture material techniques and knots. Serag wieesner

Ethicon, Wound closure manual. Somerville, New Jersey,

Ethicon, Inc, 1985

Surgical Knot tying- Ethicon manual.

• Oral tissue reaction to suture materials: A review.

Periodontal Abstracts 2004:52;2,37-44.

• Wound healing and surgery. Postlethwait, R.W.: Somerville,

New Jersey, Ethicon, Inc., 1971

• Suturing technique – Sandro Sievro

• Textbook of clinical periodontology - Carranza 10th Ed.

• Text book of Periodontics. Louis f rose brian l mealey.