PDF , Sutures , Classification , Properties , Biocompatability & Biodegradation.

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SUTURESSUTURESSUTURESSUTURES
Presented by Dr. Hashmat Gul,
Demonstrator, NUST,
Army Medical College.
Rawalpindi Cantt.
INTRODUCTION
Successful wound closure is essential in any invasive
surgical procedure
The most common approach is tissue approximation
with sutures
Sutures can be defined as filamentous materials used
to approximated wound edges after surgery or trauma
or to hold tissues in place following surgical
transposition of soft tissues

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In Dentistry Sutures Are Used In
Periodontology
Oral And Maxillofacial Surgery
The selection criteria for sutures include:
Required in vivo longevity
Anatomic location
Natures & characteristics of the tissue being sutured
CLASSIFICATION OF SUTURES
According to No. of
filaments
Mono-filament Multi-filament
Twisted Braided
According to Source
Natural Synthetic
According to
Nature
Absorbable
Non-
absorbable
See detail on pages 246-48
CLASSIFICATIONCLASSIFICATIONCLASSIFICATIONCLASSIFICATION

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MONOMONOMONOMONO----FILAMENT SUTURESFILAMENT SUTURESFILAMENT SUTURESFILAMENT SUTURES
MULTIMULTIMULTIMULTI----FILAMENT SUTURESFILAMENT SUTURESFILAMENT SUTURESFILAMENT SUTURES

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SUTURE MATERIALSSUTURE MATERIALSSUTURE MATERIALSSUTURE MATERIALS
BIOLOGICAL MATERIALS
Silk (Non-absorbable)
Catgut Suture (Absorbable)
Plain
Chromic
SYNTHETIC MATERIALS
The Absorbable
Polyglycolic Acid,
Polylactic Acid,
Monocryl
Polydioxanone
The Non- absorbable
Nylon
Polyester
PVDF
Polypropylene
SS wire
Sutures differ in
Diameter
Physical Configuration &
Chemical Composition
All these factors affect the properties and in vivo
behavior of sutures
Sutures are coated to improve behavior and
handling properties
PROPERTIESPROPERTIESPROPERTIESPROPERTIES

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CODING SYSTEMS USED FOR SUTURESCODING SYSTEMS USED FOR SUTURESCODING SYSTEMS USED FOR SUTURESCODING SYSTEMS USED FOR SUTURES
Two coding systems used to categorize sutures
according to their diameter
US Pharmacopeia (USP)
European Pharmacopeia (EP)
BIOCOMPATIBILITY &BIOCOMPATIBILITY &BIOCOMPATIBILITY &BIOCOMPATIBILITY &
BIODEGRADATIONBIODEGRADATIONBIODEGRADATIONBIODEGRADATION
Micrograph of a H&E stained tissue section
showing a non-absorbable multi-filament
surgical suture with a surrounding foreign-
body giant cell reaction
Sutures are foreign body so they can affect the
surrounding tissues and the surrounding tissues
affect the properties of sutures

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The Type And Extent Of Tissue Reactions
to a suture are determined by the
Chemical Formulations
The Physical Form Of The Suture,
The Degradation Products
Sutures fabricated from natural material
provoke more intense tissue reactions than
synthetic ones because of the availability of
enzymes that can react with them
Sutures with smaller diameter are preferred,
provided they adequately support the healing
wound and add no risk of cutting through wound
tissue

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Sutures with poor pliability when knotted
may leave stiff ears projecting from the knot,
which can mechanically irritate the surrounding
tissues
The problem is less common in braided
multifilament sutures
The Biocompatibility Of A Suture can be
evaluated by
Cellular Response,
Enzyme Histochemistry Or
Both

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Cellular Response
Most commonly used
Provides information about the density and type of
inflammatory cells at the suture site
Histological evaluation of sectioned tissue is
needed to rate the cellular response, which requires
skilled and experienced evaluator
Enzyme Histochemistry
Evaluating suture biocompatibility through
enzyme histochemistry is a reproducible,
consistent and quantifiable approach
It is more time consuming and requires more
sophisticated facilities
However, it is useful for studying the
biodegradation of absorbable sutures

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The normal tissue reaction to sutures proceeds
through 3 stages, which are differentiated according
to the appearance & activity of various inflammatory
cells
STAGE TIME (DAYS) REACTION
Phase 1 0-4 Acute response: infiltration of
polymorphonuclear leukocytes,
lymphocytes and monocytes
Phase 2 4-7 Macrophagic and fibroblastic acivity
Phase 3 7-10 Chronic inflammation and start of
fibrous connective tissue maturation
Generally, there are virtually no differences in the
tissue and cellular responses to synthetic absorbable
and nonabsorbable sutures over the first 7 days after
implantation
Synthetic Absorbable Sutures Synthetic Non-absorbable
Sutures
May elicit a slightly greater
inflammatory reaction that
persist until the suture is
completely absorbed and
metabolized
Elicit minimal chronic
inflammation reactions and by
28 days they are often
surrounded by a thin, fibrous
connective tissue

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ABSORBABLE SUTURES
Do not elicit long term inflammatory reactions.
Progressively lose both strength and mass, with the rate of strength
loss always exceeding rate of mass loss.
Consequently, as the wound healing progress, the suture may no
longer maintain wound closure but a significant amount of material
may remain in the wound area.
This is more important for treating infected or contaminated
wounds.
The degradation rate depend on suture type, tissue involved,
temperature, pH, applied stress & microorganisms within the
wound area.
The accumulation rate and metabolization of the degradation
product in the surrounding tissue is important.
Degradation products are rapidly metabolized in well vascularized
tissues
Multi-filament Suture Mono-filament Suture
A consequence of the normal tissue
reaction is the
Ingrowth of fibrous tissue into
multifilament sutures,
Ingrowth of epidermis with
sutures that pass through the
cutaneous surface.
Such tissue ingrowth may hamper
easy removal of sutures from the
healing wound.
Where multifilament exhibit
capillaries, microorganisms may
migrate throughout the wound area
Monofilament sutures are preferred
for closing contaminated wounds,
as multifilament sutures elicit more
tissue reaction due to penetration of
inflammatory cells into the
interstitial spaces within the suture,
which can adversely affect the
healing of infected wounds
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