Suture presentation by Dr. Nabeel ur Rehman and Dr. Suneel Maghnani


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Suture Material and Suture Techniques, by Dr. Nabeel ur Rehman and Dr. Suneel kumar Maghnani, Dental Officers of Sir Syed Dental Hospital, Karachi, Pakistan.

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Suture presentation by Dr. Nabeel ur Rehman and Dr. Suneel Maghnani

  1. 1. Made by: Dr Nabeel ur Rehman Dr Suneel Kumar Maghnani Sir Syed Dental Hospital, Karachi, Pakistan
  2. 2. 2
  3. 3. Suturing <ul><li>The term “Suture” describes any strand of material utilized to ligate blood vessels or approximate tissues. </li></ul><ul><li>The primary objective of dental suturing is to position and secure surgical flaps in order to promote optimal healing. </li></ul>3 .3
  4. 4. Suturing <ul><li>The goals of suturing are as follows: </li></ul><ul><li>Provide adequate tension for wound closure, but loose enough to prevent tissue ischemia and necrosis. </li></ul><ul><li>Preventing postoperative hemorrhage </li></ul><ul><li>Protecting underlying tissues from infection or other irritating factors. </li></ul><ul><li>Reduce postoperative pain </li></ul>4
  5. 5. Suturing <ul><li>Maintain hemostasis </li></ul><ul><li>Permit healing by primary intention </li></ul><ul><li>Prevent bone exposure resulting in delayed healing and bone resorption </li></ul><ul><li>Permit proper flap position </li></ul>5
  6. 6. Needles 6
  7. 7. Needle Design <ul><li>Vary in degree of needle curvature </li></ul><ul><li>¼ circle: </li></ul><ul><li>3/8 circle: </li></ul><ul><li>½ circle </li></ul><ul><li>¾ circle </li></ul><ul><li>Curve ended straight </li></ul><ul><li>Straight </li></ul>7
  8. 8. Needle Design 8
  9. 9. Tip: Needle Point Geometry 9
  10. 10. Conventional Cutting Suture Needle 10
  11. 11. Reverse Cutting Suture Needle 11
  12. 12. Tapercut Suture Needle 12
  13. 13. Suturing Instruments <ul><li>A. Corn suture pliers </li></ul><ul><li>B. Adson tissue pliers </li></ul><ul><li>C. Needle holder </li></ul><ul><li>D. Scissors </li></ul>13
  14. 14. Suturing Instruments 14
  15. 15. Suture Material: Definition <ul><li>A suture is a thread used for uniting wound edges. </li></ul><ul><li>E.g. Suture Material </li></ul><ul><li>Silk </li></ul><ul><li>Catgut </li></ul><ul><li>Nylon </li></ul><ul><li>Stainless Steel Suture </li></ul>15
  16. 16. Qualities of a Suture Material <ul><li>Adequate tensile strength </li></ul><ul><li>Functional Strength </li></ul><ul><li>Easy to handle </li></ul><ul><li>Flexibility & Elasticity </li></ul><ul><li>Knotable </li></ul><ul><li>Easily sterlisable </li></ul><ul><li>Uniformity </li></ul><ul><li>Non reactivity </li></ul><ul><li>Absorbility </li></ul><ul><li>Smooth surface </li></ul>16
  17. 17. Types of Suture Material <ul><li>According to their behavior in tissue: Absorbable and Nonabsorbable </li></ul><ul><li>According to their structure: Monofilament and Multifilament </li></ul><ul><li>According to their origin: Natural or Synthetic </li></ul>17
  18. 18. Suture Materials: Behavior <ul><li>ABSORBABLE </li></ul><ul><li>Those that are absorbed or digested by the body cells and tissue fluids in which they are embedded during & after the healing processes. </li></ul><ul><li>Catgut </li></ul><ul><li>Collagen </li></ul><ul><li>Polyglycolic acid suture material </li></ul><ul><li>Polyglactin 910 </li></ul><ul><li>Fascia lata </li></ul><ul><li>Polydioxanone </li></ul>18
  19. 19. Vicryl (Polyglactin 910) <ul><li>Vicryl (Polyglactin 910) is an absorbable, synthetic, and braided suture </li></ul><ul><li>It is indicated for soft tissue approximation and ligation </li></ul><ul><li>The suture hold its tensile strength for approximately three to four weeks in tissue, and is completely absorbed by hydrolysis within 60 days. </li></ul><ul><li>Vicryl and other polyglycolic acid sutures may also be treated for more rapid breakdown in rapidly healing tissue such as mucous membrane or impregnated with triclosan to provide antimicrobial protection of the suture line. </li></ul>19
  20. 20. Vicryl (Polyglactin 910) <ul><li>Broken down by enzymes, not phagocytosis </li></ul><ul><li>Break-down products inhibit bacterial growth </li></ul><ul><li>Can use in contaminated wounds, unlike other multifilament. </li></ul>20
  21. 21. Suture Materials: Behavior <ul><li>NON-ABSORBABLE </li></ul><ul><li>Those suture materials that can not be absorbed by the body cells or fluids, they are removed after healing is complete. </li></ul><ul><li>Silk </li></ul><ul><li>Nylon </li></ul><ul><li>Prolene </li></ul><ul><li>Silkworm Gut </li></ul><ul><li>Stainless Steel </li></ul><ul><li>Linen </li></ul>21
  22. 22. Prolene (Polypropylene) Suture <ul><li>Synthetic, monofilament, non-absorbable polypropylene suture </li></ul><ul><li>Indicated for skin closure & general soft tissue approximation and ligation </li></ul><ul><li>Advantages include minimal tissue reactivity & durability </li></ul><ul><li>Disadvantages include fragility, high plasticity, high expense and difficulty of use compared to standard nylon sutures. </li></ul><ul><li>Prolene sutures are intended to be double & long lasting </li></ul>22
  23. 23. Prolene (Polypropylene) Suture <ul><li>They are dyed blue </li></ul><ul><li>Allowing for easy visibility against skin and when operating </li></ul><ul><li>It is composed of a single filament </li></ul><ul><li>Prolene commonly used in both human and veterinary medicine for skin closure. </li></ul><ul><li>In human medicine, it is used in cardiovascular, ophthalmic and neurological procedures. </li></ul><ul><li>Won’t lose tensile strength over time </li></ul><ul><li>Good knot security </li></ul><ul><li>Very little tissue reaction </li></ul>23
  24. 24. Nylon <ul><li>Synthetic </li></ul><ul><li>Mono or Multifilament </li></ul><ul><li>Memory </li></ul><ul><li>Very little tissue reaction </li></ul><ul><li>Poor knot security </li></ul>24
  25. 25. Stainless Steel <ul><li>Monofilament </li></ul><ul><li>Strongest ! </li></ul><ul><li>Great knot security </li></ul><ul><li>Difficult handling </li></ul><ul><li>Can cut through tissues </li></ul><ul><li>Very little tissue reaction, won’t harbor bacteria </li></ul>25
  26. 26. Suture Materials: Structure 27
  27. 27. Comparison 28
  28. 28. Comparison <ul><li>Monofilament </li></ul><ul><li>Multifilament (braided) </li></ul><ul><li>Single strand of suture material </li></ul><ul><li>Minimal tissue trauma </li></ul><ul><li>Smooth tying but more knots needed </li></ul><ul><li>Harder to handle due to memory </li></ul><ul><li>Examples: nylon, monocryl, prolene, PDS </li></ul><ul><li>Fibers are braided or twisted together </li></ul><ul><li>More tissue resistance </li></ul><ul><li>Easier to handle </li></ul><ul><li>Fewer knots needed </li></ul><ul><li>Examples: vicryl, silk, chromic </li></ul>29
  29. 29. Suture Materials: Origin <ul><li>Natural Suture </li></ul><ul><li>Synthetic </li></ul><ul><li>Biological </li></ul><ul><li>Cause inflammatory reaction </li></ul><ul><ul><li>Catgut (connective from cow or sheep) </li></ul></ul><ul><ul><li>Silk (from silkworm fibers) </li></ul></ul><ul><ul><li>Chromic catgut </li></ul></ul><ul><li>Synthetic polymers </li></ul><ul><li>Do not cause inflammatory response </li></ul><ul><ul><li>Nylon </li></ul></ul><ul><ul><li>Vicryl </li></ul></ul><ul><ul><li>Monocryl </li></ul></ul><ul><ul><li>PDS </li></ul></ul><ul><ul><li>Prolene </li></ul></ul>30
  30. 30. Suture Size <ul><li>Largest size 7 to fine 11-0 suture </li></ul><ul><li>Increasing # of zero correlates with dec. suture dm and strength </li></ul><ul><li>E.g.: size 1-0 is larger in dm then 2-0, 3-0 is larger than 7-0 </li></ul><ul><li>Smallest dm keep wound closed properly </li></ul><ul><li>Most oral & maxillofacial surgery----3-0 or 4-0 is used </li></ul>31
  31. 31. The Suture Packaging 32
  32. 32. 33
  33. 33. Suturing Techniques: Tools Manipulation 34
  34. 34. Suturing Techniques: Tools Manipulation 35
  35. 35. Suturing Techniques: Tools Manipulation 36
  36. 36. Basic Suturing Techniques <ul><li>Needle should be grasped with needle holder approx 1/3rd distance from the eye and 2/3rd from the point </li></ul><ul><li>Needle should be placed perpendicular to surface being entered and pushed through tissues following curvature of needle , rotating wrist </li></ul><ul><li>Should not force through tissue may bend or break the needle </li></ul><ul><li>Suture end should be pulled together and tied to approximate wound edges </li></ul><ul><li>Never closed under tension </li></ul><ul><li>Knot should never lie on incision line </li></ul>37
  37. 37. Basic Suturing Techniques <ul><li>The needle enters 2-3 mm away from the margin of the flap (mobile tissue) and exists at the same distance on the opposite side. </li></ul><ul><li>The two ends of the suture are then tied in a knot and are cut 0.8 cm above the knot. </li></ul><ul><li>To avoid tearing the flap, the needle must pass through the wound margins one at a time, and be at least 0.5 cm away from the edges. </li></ul><ul><li>Over tightening of the suture must also be avoided (risk of tissue necrosis), as well as overlapping of wound edges when positioning the knot. </li></ul>38
  38. 38. Basic Suturing Techniques <ul><li>Tightly tied sutures can cause ischemia & wound edge necrosis </li></ul><ul><li>Gentle but firm knots & minimal wound tension will minimize these factors. </li></ul><ul><li>If wound becomes infected or there is an hematoma formation, removal of few sutures may offer satisfactory treatment </li></ul>39
  39. 39. Surgical Knotting Techniques 40
  40. 40. Types of Knots 41
  41. 41. Square Knot or Reef Knot <ul><li>Square knot formed by wrapping the suture around needle holder once in opposite directions b/w ties. 3 ties are recommended </li></ul>42
  42. 42. Granny’s Knot or Slip Knot <ul><li>Granny’s knot involves a tie in one direction followed by tie in same direction and third tie in opposite direction to square the knot and hold it permanently </li></ul>43
  43. 43. Surgeon’s Knot <ul><li>Surgeon’s knots is formed by 2 throws of suture around the needle holder on the first tie and one throw opposite direction in 2nd tie </li></ul>44
  44. 44. How to tie a Knot: 45
  45. 45. How to tie a Knot: 46
  46. 46. How to tie a Knot: 47
  47. 47. How to tie a Knot: 48
  48. 48. Suturing Techniques <ul><li>The main sutures techniques used in oral surgery are: </li></ul><ul><li>Interrupted </li></ul><ul><li>Continuous </li></ul><ul><li>Mattress Sutures </li></ul>49
  49. 49. Simple Interrupted Suture 50
  50. 50. Simple Interrupted Suture <ul><li>Suture is passed through both edges at an equal depth and distance from the incision and knot is tied </li></ul><ul><li>Common </li></ul><ul><li>Stronger </li></ul><ul><li>Used in areas of stress </li></ul><ul><li>Each suture is independent and loosening of one suture will not produce loosening of other </li></ul>51
  51. 51. Simple Interrupted Suture 52
  52. 52. Simple Interrupted Suture 53
  53. 53. Figure 8 (Modification of Interrupted Suture) <ul><li>The needle is first inserted into the outer surface of the buccal flap and then either through the outer epithelialized surface under the surface. </li></ul><ul><li>The needle is then returned through the embrasure and tied buccally. </li></ul>54
  54. 54. Sling (Modification of Interrupted Suture) <ul><li>Its is primarily used for a flap that has been raised on only one side of tooth involving one or two adjacent papillae. </li></ul><ul><li>Most often used in coronally and laterally positioned flaps. </li></ul><ul><li>The technique involves use of one of the interrupted sutures, which either anchored about the adjacent tooth or slung around the tooth to hold both papilla. </li></ul>55
  55. 55. Simple Continuous Suture <ul><li>Initially, simple interrupted suture is placed and needle is reinserted in a continuous fashion such that suture passes perpendicular to incision line below and obliquely above </li></ul><ul><li>Suture is ended by passing a knot over the untightened end of suture </li></ul><ul><li>Rapid technique for wound closure </li></ul><ul><li>Distributes tension uniformly </li></ul>56
  56. 56. Continuous Suture 57
  57. 57. Continuous Locking (Modification of Continuous Suture) <ul><li>It is indicated primarily for long edentulous areas, tuberosities, or retromolar areas. </li></ul><ul><li>It has the advantage of avoiding the multiple knots of interrupted sutures. </li></ul>58
  58. 58. Continuous Locking <ul><li>A single interrupted suture is used to make the initial tie. </li></ul><ul><li>The needle is next inserted through the underlying surface of the flap and the underlying surface of the lingual flap. </li></ul><ul><li>The needle is then passed through the remaining loop of the suture, and the suture is pulled tightly, thus locking it </li></ul><ul><li>This procedure is continued until the final suture is tied off at the terminal end, </li></ul>59
  59. 59. Continuous Locking 60
  60. 60. Independent Sling (Modification of Continuous Suture) <ul><li>When flap position is not critical. </li></ul><ul><li>When buccal periosteal sutures are used for buccal flap position and stabilization. </li></ul><ul><li>When maximum closure is desired. </li></ul>61
  61. 61. Independent Sling <ul><li>After the initial buccal and lingual tie, the suture is passed about the neck of the tooth interdentally and through the lingual flap . </li></ul>62
  62. 62. <ul><li>Then again brought interdentally through the buccal papilla and back interdentally about the lingual surface of the tooth to the buccal papilla. </li></ul>63
  63. 63. <ul><li>Then it is brought about the lingual papilla and then about the buccal surface of the tooth. </li></ul>64
  64. 64. <ul><li>This alternating buccal- lingual suturing is continued until the suture is tied off with a terminal end loop. </li></ul>65
  65. 65. Mattress Suture <ul><li>This is a special type of suture and is described as Horizontal and Vertical. </li></ul><ul><li>It is indicated in cases where strong & secure reapproximation of wound margins is required. </li></ul><ul><li>They also allows for good papillary stabilization and placement. </li></ul>66
  66. 66. Horizontal Interrupted Mattress <ul><li>Horizontal mattress is used for high-tension wounds or wounds with fragile skin. </li></ul><ul><li>The knot is parallel adjacent to the wound edge. </li></ul>67
  67. 67. Horizontal Interrupted Mattress 68
  68. 68. Horizontal Continuous Mattress 69
  69. 69. Vertical Mattress Suture <ul><li>Vertical Mattress is a suture technique most commonly used in anatomic locations which tend to evert, such as the posterior aspect of the neck, deeper wounds </li></ul>70
  70. 70. Vertical Mattress Suture <ul><li>It has a far-far-near-near order of bites </li></ul><ul><li>The knot will is perpendicular adjacent to the wound edge. </li></ul><ul><li>This type of suture is good for deep lacerations. </li></ul>71
  71. 71. Vertical Mattress 72
  72. 72. Suture Removal <ul><li>Average time frame is 7 – 10 days </li></ul><ul><li>FACE: 3 – 5 days </li></ul><ul><li>ORAL MUCOSA: 3-5 Days </li></ul><ul><li>NECK: 5 – 7 days </li></ul><ul><li>SCALP: 7 – 12 days </li></ul><ul><li>UPPER EXTREMITY, TRUNK: 10 – 14 days </li></ul><ul><li>LOWER EXTREMITY: 14 – 28 days </li></ul><ul><li>SOLES, PALMS, BACK OR OVER JOINTS: 10 days </li></ul><ul><li>Any suture with pus or signs of infections should be removed immediately. </li></ul>73
  73. 73. Suture Removal <ul><li>Use a disinfecting mouthwash to clean the wound of all debris </li></ul><ul><li>The suture knot is elevated off the tissue utilizing cotton pliers </li></ul><ul><li>The suture is cut as close to the tissue as possible in order to avoid dragging bacteria through the wound </li></ul><ul><li>When removing continuous sutures, each section should be cut & pulled out individually </li></ul>74
  74. 74. Suture Removal 75
  75. 75. !