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Principles of Surgery
SUTURES

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

ww...
• In surgery, the choice of suture materials has
been largely empirical. One learns the art and
craft of surgery from once...
• History
– Used in closure of wounds – 50,000 B.C
– Large black ants used
– Made from Flax, Bark, Hemp and Fiber
– Metal ...
• SUTURE :
Any thread or strand which
brings into opposition two
surfaces or tissues
• LIGATURE :
Any thread or strand whi...
Properties :
• Absorbable materials
– digested by tissue enzymes
• Eg. Catgut

– hydrolysis
• Eg. Polyglactin (Vicryl)

• ...
• Tensile strength
– Straight pull – to break the filaments
– Knot pull – to break the knot

• Smoothness
– Smooth materia...
• Monofilament :

• Polyfilament :

– single filament

– Multiple filaments

– Eg. Prolene

– Eg. Cotton, Silk

– smooth

...
Classification :
SUTURE MATERIALS
Absorbable
Natural

Synthetic

Non-absorbable
Natural Synthetic Metals

www.indiandental...
Absorbable
• Natural :
– Catgut
• Plain
• Chromic

– Fascia lata
– Kangaroo tendon
– Cargile membrane

• Synthetic :
– Pol...
Non-absorbable
Natural :
Silk
Cotton
Linen

Synthetic :
Polyamide
Polyester
Polypropelene
Polybutester

Others :
Tapes
Tis...
Catgut :
•
•
•
•
•
•
•
•
•

Kitgut
Sub-mucosa of sheep’s intestine
Monofilament
Plain – tensile strength 15 days
Chromic ...
• Uses :
• Plain Catgut
–
–
–
–

Subcutaneous suturing
For wounds in lip and oral cavity
Ligation of smoother blood vessel...
• Fascia lata :
– Thigh muscles of beef cattle
– Was used to repair hernia

• Kangaroo tendon :
– Tail tendon of small kan...
Synthetic absorbable sutures :
•
•
•
•

Polyglycolic acid – Dexon
Non-protein polymer of glycolic acid
Absorption – estera...
• Polyglactin 910 :
–
–
–
–
–

Co-polymer of Glycolin and Lactide
Violet colour
Coated with Calcium stearate
Absorption – ...
• Vicryl Rapide – Irradiated polyglactin 910
• Absorption – 35- 40 days  Gamma
radiation
• Supports wound upto 12 days
• ...
•
•
•
•
•

Polyglecaprone 25 – Monocryl
co-polymer of Glycolide and Caprolactone
tensile strength double of chromic
Absorp...
Non-absorbable suture materials :
• Silk :
–
–

Natural – obtained from cocoon
Advantages –
•
•
•

natural elasticity
does...
• Types
–
–

Prema hand surgical silk
Virgin silk suture

• Uses
–
–
–
–

ligate blood vessels & pedicles
suture nerves, t...
• Cotton
– vegetable origin ; polyfilament
 disadvantage
– advantage
•
•
•

economical
secure knotting
easily handled

ab...
•

• Polyamide :

–
–
–

– Nylon
– thickness – 1-8N
– advantage
• less irritant
• high tensile strength
• economical
• smo...
• Polypropylene :
–
–

Prolene
advantage
• inert
• monofilament
• smooth
• easily handled
• knot secure
• least thrombogen...
• Stainless steel wire :
– advantage
• very little tissue reaction
– disadvantage
• tear of tissue
• necrosis if tight
• c...
Principles of suture selection :
• knowldege of the tissues

•
•
•

physical and biological properties of suture
condition...
• C.V.S – prolene and polyester are used
• Microvascular surgery – 10-0 polyamide
monofialment used
• Irradiated patients ...
Needle holder:

www.indiandentalacademy.com
Needles :
• sharp, pointed instruments are used for puncturing
the tissue and guiding the thread to suture or pass a
ligat...
• Classifications :
– Eye
• eyeless
• needles with eye

– Shape
•
•

straight
curved

– Cutting edge
• round body
• cuttin...
• Eyeless needle :
– suture material is attached to the swage of the needle
during manufacture
– advantages
•
•
•
•
•

les...
• Straight
– Eye
– Eyeless
– round body
– blunt tip
– suturing with hand
– for fascia & skin
– for passage of
• Circum-zyg...
• Round body needles : used to separate tissue fibers & for
soft tissues
• Mayo’s needle : to penetrate periosteum
• Blunt...
• Slim blade needle : plastic and cosmetic
surgery
• Trocar point needle : in dense tissues
• Taper cut needle : Cardiovas...
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
Principles of suturing :
• grasp the needle at apporximately 3/4th the
distance from the point
• enter the tissue perpendi...
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
• sutures placed 4mm apart
• sutures should be tied so that edges are everted
• dog ear should be eliminated
• suture shou...
Tapes :

• Advantage

& Adhesives :

• Cyanoacrylates
• Advantage
– excellent cosmetic
– quick to use
results
– do not del...
www.indiandentalacademy.com
Staples

& Tissue Glues

• Types –
– Linear

• Indications –
– for hemostasis of liver

– Side by side
– End to end

& spl...
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
Knots :
• A knot, is an interwining of threads for purpose
of joining them
• Knot tying
– one hand / two hand
– instrument...
www.indiandentalacademy.com
Square knot
• formed by wrapping

ties around needle
holder once in
opposite direction
between ties
www.indiandentalacadem...
Surgeon’s knot
• formed by two

throws of suture
around needle on first
tie & one throw in
opposite direction on
second ti...
Granny knot
• involves a tie in one

direction followed by
single tie in same
direction as first
• a third tie is then
squ...
Suture method
•

Interrupted
– used in areas of
tension
– Advantage
• strong
• independent
• infection –
selected sutures ...
• Continuous –
simple interrupted
suture is placed, a needle
is then re-inserted in
continuous fashion
The suture passes
p...
•

Advantage
– rapid technique
– even distribution of
tension
– water tight closure

• Disadvantage
– infection – whole su...
• Locking continuous
suture Degree of locking is
provided by withdrawing
the suture through its own
loop
• Advantage
– sut...
•

Figure of 8 –
–

used in extraction sites

– provides protection to
socket
– as well as adaptation of
gingival papilla ...
• Sub-cuticular suture :
– absorbable 4-0 suture

materials used
– knot should be inverted
– a continuous suture can
be us...
www.indiandentalacademy.com
• Tension suture
– to prevent wound
dehiscence
– non-absorbable nylon
prolene used with
plastic tubing
– to reduce tension...
• Mattress suture
– Vertical
– Horizontal

• Vertical
– needle is passed close to
the incision line on both
sides & then e...
• Horizontal :
– passes perpendicular to
incision line underneath
tissue & parallel to it on
the surface & then again
perp...
• Dog ear elimination :
– excess tissue is
undermined & incision is
made at 30° to the
parent incision directed
towards un...
Suture removal :
• Suture should be grasped with an instrument &
elevated above epithelial surface

• Scissors should be u...
Conclusion :
• Every surgeon should be in a position to make
a logical decision regarding which suture
material / techniqu...
Thank you
For more details please visit
www.indiandentalacademy.com

www.indiandentalacademy.com
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Suture materials /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
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Suture materials /certified fixed orthodontic courses by Indian dental academy

  1. 1. Principles of Surgery SUTURES INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. • In surgery, the choice of suture materials has been largely empirical. One learns the art and craft of surgery from once chief and the tendency is to follow the suture materials used by him or her. Thus the choice of suture material has not always been scientific. www.indiandentalacademy.com
  3. 3. • History – Used in closure of wounds – 50,000 B.C – Large black ants used – Made from Flax, Bark, Hemp and Fiber – Metal clips www.indiandentalacademy.com
  4. 4. • SUTURE : Any thread or strand which brings into opposition two surfaces or tissues • LIGATURE : Any thread or strand which obliterates lumen of ductular structures www.indiandentalacademy.com
  5. 5. Properties : • Absorbable materials – digested by tissue enzymes • Eg. Catgut – hydrolysis • Eg. Polyglactin (Vicryl) • Non-absorbable materials – Eg. Silk, Nylon etc… www.indiandentalacademy.com
  6. 6. • Tensile strength – Straight pull – to break the filaments – Knot pull – to break the knot • Smoothness – Smooth material  Easy passage  Least trauma • Eg. Monofilament www.indiandentalacademy.com
  7. 7. • Monofilament : • Polyfilament : – single filament – Multiple filaments – Eg. Prolene – Eg. Cotton, Silk – smooth – rough – open up – knot secure – not easy to handle – easy to handle – impede bacterial harbour – promotes bacterial harbour – no fraying – fraying www.indiandentalacademy.com
  8. 8. Classification : SUTURE MATERIALS Absorbable Natural Synthetic Non-absorbable Natural Synthetic Metals www.indiandentalacademy.com
  9. 9. Absorbable • Natural : – Catgut • Plain • Chromic – Fascia lata – Kangaroo tendon – Cargile membrane • Synthetic : – Polyglactin 910 – Polyglycolic acid – Monocryl – Polydioxanone – Collagen www.indiandentalacademy.com
  10. 10. Non-absorbable Natural : Silk Cotton Linen Synthetic : Polyamide Polyester Polypropelene Polybutester Others : Tapes Tissue adhesives Staples www.indiandentalacademy.com Metals : Stainless steel Platinum Tantalum Silver wire
  11. 11. Catgut : • • • • • • • • • Kitgut Sub-mucosa of sheep’s intestine Monofilament Plain – tensile strength 15 days Chromic  30 days Kept in preservative solution – Ethicion fluid Hygroscopic Absorption by proteolytic digestive enzymes In infection  rapidly absorbed www.indiandentalacademy.com
  12. 12. • Uses : • Plain Catgut – – – – Subcutaneous suturing For wounds in lip and oral cavity Ligation of smoother blood vessels Not used in tissues deeper to subcutaneous • Chromic – – – 1-0 / 2-0 : ligation of medium sized vessels 3-0 / 4-0 : for cleft lip muscle layer closure 5-0 / 6-0 : plastic surgery www.indiandentalacademy.com
  13. 13. • Fascia lata : – Thigh muscles of beef cattle – Was used to repair hernia • Kangaroo tendon : – Tail tendon of small kangaroos – High tensile strength www.indiandentalacademy.com
  14. 14. Synthetic absorbable sutures : • • • • Polyglycolic acid – Dexon Non-protein polymer of glycolic acid Absorption – esterase enzyme system (100 days) Characteristics – – White, polyfilament, braided • Advantages – – – – – – Minimum tissue reaction Uniform absorption Used even in presence of infection Knot security better Fraying is less www.indiandentalacademy.com
  15. 15. • Polyglactin 910 : – – – – – Co-polymer of Glycolin and Lactide Violet colour Coated with Calcium stearate Absorption – hydrolysis Advantages – • Unique molecular structure – retain strength for long • Minimum tissue reaction • Excellent handling characters – Not used under the areas of stress www.indiandentalacademy.com
  16. 16. • Vicryl Rapide – Irradiated polyglactin 910 • Absorption – 35- 40 days  Gamma radiation • Supports wound upto 12 days • Less force is used for tying knots • Ideal for intra-oral use • • • • Polydioxanone Unique feature of Flexibility Support wound beyond 4 week period Recommended in orthopedic surgery www.indiandentalacademy.com
  17. 17. • • • • • Polyglecaprone 25 – Monocryl co-polymer of Glycolide and Caprolactone tensile strength double of chromic Absorption – Hydrolysis Advantages – – – – – inert, used in infection, memory free, smooth surface • Indications – – subcutaneous www.indiandentalacademy.com
  18. 18. Non-absorbable suture materials : • Silk : – – Natural – obtained from cocoon Advantages – • • • natural elasticity does not soak up fluids ties smoothly & securely – Disadvantages • stitch granuloma • infection - high • tissue reaction - high www.indiandentalacademy.com
  19. 19. • Types – – Prema hand surgical silk Virgin silk suture • Uses – – – – ligate blood vessels & pedicles suture nerves, tendons skin & grafts wound over the face www.indiandentalacademy.com
  20. 20. • Cotton – vegetable origin ; polyfilament  disadvantage – advantage • • • economical secure knotting easily handled absorbs fluid  more tissue reaction  low tensile strength  • Linen – obtained from flax ; polyfilament – advantage • easily handled • tie is secure – uses • tying pedicles • ligatures www.indiandentalacademy.com
  21. 21. • • Polyamide : – – – – Nylon – thickness – 1-8N – advantage • less irritant • high tensile strength • economical • smooth passage through tissues – disadvantage • has memory Polyester : Terylene Dacron advantage • high tensile strength • low tissue reactivity • retained longer – C.V.S – disadvantage • cut through tissue – Teflon coat – better handling properties but diameter of suture increased – Polybutylate coated • infection www.indiandentalacademy.com
  22. 22. • Polypropylene : – – Prolene advantage • inert • monofilament • smooth • easily handled • knot secure • least thrombogenic • more tensile strength • unwetted by blood & tissue enzymes • elastic – indications • vascular surgery • chest & abdominal www.indiandentalacademy.com wall defects
  23. 23. • Stainless steel wire : – advantage • very little tissue reaction – disadvantage • tear of tissue • necrosis if tight • cutaneous discomfort • breaking sterile technique www.indiandentalacademy.com
  24. 24. Principles of suture selection : • knowldege of the tissues • • • physical and biological properties of suture condition of the wound post-operative course of the patient • skin, fascia & tendon – healing slow • peritoneum, liver & muscle – healing rapid • multifilament sutures avoided in contaminated wounds www.indiandentalacademy.com
  25. 25. • C.V.S – prolene and polyester are used • Microvascular surgery – 10-0 polyamide monofialment used • Irradiated patients – closure in layers • Cancer patients – non-absorbable sutures used • Intra-oral – silk, PGA used but absorbable preferred www.indiandentalacademy.com
  26. 26. Needle holder: www.indiandentalacademy.com
  27. 27. Needles : • sharp, pointed instruments are used for puncturing the tissue and guiding the thread to suture or pass a ligature around vessels • carbon steel or stainless steel www.indiandentalacademy.com
  28. 28. • Classifications : – Eye • eyeless • needles with eye – Shape • • straight curved – Cutting edge • round body • cutting body – Tip • tirangular • round tipped • blunt point www.indiandentalacademy.com
  29. 29. • Eyeless needle : – suture material is attached to the swage of the needle during manufacture – advantages • • • • • less trauma new sterile needle for each patient faster time saving no chance of needle loosing • Needles with eye : – can be reused – economical www.indiandentalacademy.com
  30. 30. • Straight – Eye – Eyeless – round body – blunt tip – suturing with hand – for fascia & skin – for passage of • Circum-zygomatic • Circum-mandibular wires • Curved – Eye – Eyeless – round body – cutting needle – facilitates working in depth – more confined operated site – greater curvature required www.indiandentalacademy.com
  31. 31. • Round body needles : used to separate tissue fibers & for soft tissues • Mayo’s needle : to penetrate periosteum • Blunt point suture needle : for friable tissues • Conventional cutting needle : keratinized mucosa & skin • Reverse cutting needle : triangular in cross-section; apex cutting edge on outside of needle curvature www.indiandentalacademy.com
  32. 32. • Slim blade needle : plastic and cosmetic surgery • Trocar point needle : in dense tissues • Taper cut needle : Cardiovascular surgery • Micropoint : for Opthalmic www.indiandentalacademy.com
  33. 33. www.indiandentalacademy.com
  34. 34. www.indiandentalacademy.com
  35. 35. www.indiandentalacademy.com
  36. 36. Principles of suturing : • grasp the needle at apporximately 3/4th the distance from the point • enter the tissue perpendicular to the surface • should follow the curvature of the needle • from free to the fixed tissue • thinner to the thicker • deeper to superficial • tissues should not close under tension • knot should not be placed on incision line www.indiandentalacademy.com
  37. 37. www.indiandentalacademy.com
  38. 38. www.indiandentalacademy.com
  39. 39. www.indiandentalacademy.com
  40. 40. • sutures placed 4mm apart • sutures should be tied so that edges are everted • dog ear should be eliminated • suture should be placed at an equal distance from the incision on both the sides & at an equal depth www.indiandentalacademy.com
  41. 41. Tapes : • Advantage & Adhesives : • Cyanoacrylates • Advantage – excellent cosmetic – quick to use results – do not delay wound – low infection rate healing – can be used in • Disadvantage – perfect hemostasis contaminated wounds required – easy & quick – expensive • Disadvantage – not used in contaminated wounds – perfect hemostasis – blistering of skin should be ensured www.indiandentalacademy.com
  42. 42. www.indiandentalacademy.com
  43. 43. Staples & Tissue Glues • Types – – Linear • Indications – – for hemostasis of liver – Side by side – End to end & spleen • Advantages – quick – dural tears – accurate closure – easy to remove – E.N.T surgeries – acceptable scars – access to difficult areas – to attach skin grafts www.indiandentalacademy.com
  44. 44. www.indiandentalacademy.com
  45. 45. www.indiandentalacademy.com
  46. 46. www.indiandentalacademy.com
  47. 47. Knots : • A knot, is an interwining of threads for purpose of joining them • Knot tying – one hand / two hand – instrument tie • Instrument tie is more convenient in closed areas www.indiandentalacademy.com
  48. 48. www.indiandentalacademy.com
  49. 49. Square knot • formed by wrapping ties around needle holder once in opposite direction between ties www.indiandentalacademy.com
  50. 50. Surgeon’s knot • formed by two throws of suture around needle on first tie & one throw in opposite direction on second tie • Advantage – reduced slippage ofwww.indiandentalacademy.com first
  51. 51. Granny knot • involves a tie in one direction followed by single tie in same direction as first • a third tie is then squared on the second to hold the knot permanently www.indiandentalacademy.com
  52. 52. Suture method • Interrupted – used in areas of tension – Advantage • strong • independent • infection – selected sutures can be removed www.indiandentalacademy.com
  53. 53. • Continuous – simple interrupted suture is placed, a needle is then re-inserted in continuous fashion The suture passes perpendiuclar to incision line underneath tissue & diagonally on surface & ended tying www.indiandentalacademy.com
  54. 54. • Advantage – rapid technique – even distribution of tension – water tight closure • Disadvantage – infection – whole suture should be removed – impedes blood supply to wound edges www.indiandentalacademy.com
  55. 55. • Locking continuous suture Degree of locking is provided by withdrawing the suture through its own loop • Advantage – suture will align perpendicular to its incision – prevents continuous tightening of suture as wound closure progresses www.indiandentalacademy.com
  56. 56. • Figure of 8 – – used in extraction sites – provides protection to socket – as well as adaptation of gingival papilla around adjacent tooth www.indiandentalacademy.com
  57. 57. • Sub-cuticular suture : – absorbable 4-0 suture materials used – knot should be inverted – a continuous suture can be used with no knots by having the ends exit at a short distance from wound www.indiandentalacademy.com
  58. 58. www.indiandentalacademy.com
  59. 59. • Tension suture – to prevent wound dehiscence – non-absorbable nylon prolene used with plastic tubing – to reduce tension www.indiandentalacademy.com
  60. 60. • Mattress suture – Vertical – Horizontal • Vertical – needle is passed close to the incision line on both sides & then engages tissue deep to the first pass when returning to the original site – Advantage • run parallel to the blood supply of the flap – not interfere with healing www.indiandentalacademy.com
  61. 61. • Horizontal : – passes perpendicular to incision line underneath tissue & parallel to it on the surface & then again perpendicular to incision line underneath tissue to be knotted on that side – Interrupted – produces broad contact of wound margins – Continuous – intra-oral bone grafting www.indiandentalacademy.com
  62. 62. • Dog ear elimination : – excess tissue is undermined & incision is made at 30° to the parent incision directed towards undermined side – excising the excess tissue with elliptical incision followed by closure www.indiandentalacademy.com
  63. 63. Suture removal : • Suture should be grasped with an instrument & elevated above epithelial surface • Scissors should be used to transect one side of the loop as close to the epithelial surface as possible www.indiandentalacademy.com
  64. 64. Conclusion : • Every surgeon should be in a position to make a logical decision regarding which suture material / technique to use in a given clinical situation, because the choice of wound closure material & technique may make a difference in www.indiandentalacademy.com
  65. 65. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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