This document provides information on sutures and suturing techniques used in oral and maxillofacial surgery. It discusses the history of sutures, various suture materials including absorbable and non-absorbable options, suture sizes, needles, knots, and different suturing techniques. The principles of suturing and indications for different suture techniques are also outlined.

1. SUTURES AND SUTURING
TECHNIQUES
Dr . Swapnil Singhai
Oral and Maxillofacial Surgery

2. History
Used in closure of wounds – 50,000 B.C
 Large black ants used
 Made from Flax, Bark, Hemp and Fiber
 Metal clips
 Double suture

3. Contents:-
What is a Suture ??
Purpose of suturing
Ideal properties of Sutures
Suture materials
Tissue Reactions to Sutures
Armamenterium: Needles
Needle holder
Scissors
Knots
Principles of Suturing
Techniques of Suturing
Periodontal Suturing
Other methods of wound closure
Conclusion

4. What is a Suture ??
A surgical suture is one that approximates
the adjacent cut surfaces or compresses blood
vessels.
Suturing is the act of bringing tissues
together and holding them in apposition until
healing takes place.

5. What is the Purpose or Goal of
Suturing ??
Provide adequate tension of wound closure without dead
space…but loose enough to obliviate tissue ischaemia & necrosis.
Maintain Haemostasis.
Healing by primary intension.
Provide support for healing until it is no longer needed.
Post operative pain control.
Prevention of bone exposure.
Proper flap positioning.

6. Ideal properties of Sutures
Good handling characteristics.
Non-reactivity with tissue.
Knot security.
Adequate tensile strength.
Sterile, non-allergenic.
Favorable absorption profile.
Resistant to infection.
Essential suture Characteristics
Sterility.
Uniform diameter and size.
Pliability and tensile strength.
Freedom from irritants and impurities.

7. Available Suture Sizes

8. 
Needle
Size
Order Code
Name
Also:
LENGTH
NEEDLE
SYMBOL
COLOR
Absorbabl
e or Non

9. Classification
Suture Material
Absorbable Non-Absorbable
Natural Natural
Synthetic Synthetic Metals
Monofilament and Polyfilaments

10. Monofilament Vs. Multifilament
memory easy to handle
less tissue drag more tissue drag
doesn’t wick wicks/ bacteria
poor knot security good knot security
- tissue reaction +tissue reaction

11. Absorbabale Sutures - Surgical Gut
•Oldest known absorbable suture material.
•Derived from sheep intestinal mucosa / bovine intestinal serosa.
•Comes from the Arabic word “kitstring” or “kitgut”…..
•Consists of several piles that have been twisted slightly & then
machine ground & polished…
•Most variable in terms of tensile strength & absorbability.

12. •Organic & highly susceptible to enzymatic
degradation….isopropyl alcohol.
•Rapid loss of tensile strength…
•Absorbed by proteolytic action…inflammation and
tissue reaction.
•Absorbed in 3-5 days.
•Stiff and insecure knot holding characteristics.
Disadvantages

13. Chromic Gut
•Plain gut tanned with solution of chromium salts…
•Slightly increased strength, lesser tissue reaction and
prolonged rate of absorption…
•Degraded by 7 days when used intraorally
•Much variability exists.
•Made of submucosa of small intestines
•Multifilament
•Easy handling
•Plain: 3-5 days
•Chromic: 10-15 days
Bacteria love this stuff!

14. Vicryl (Polyglactin 910
•Braided, synthetic, absorbable
•Stronger than gut: retains strength 3 weeks
•Broken down by enzymes, not phagocytosis
•Vicryl degrades by hydrolysis like other synthetic polyesters.
Advantages
•Strongest of absorbable materials.
•Well tolerated by tissues.
•Maintains tensile strength for longer duration.
Disadvantages
•Potential for scar formation
Indication
•Skin
•Perineum
•Oral
•Lacerations

15. Collagen
•Obtained by grinding the native collagen of the deep flexor
tendons of cattle……acidified to form gel……extruded into
neutralizing dehydration bath.
•It undergoes premature absorption
•Handlin g is difficult due to more stiffer then surgical gut
Poly Glycolic Acids (Dexon)
•Polymer of glycolic acids
•Braided, synthetic, absorbable
•Broken down by enzymes
•Both PGA and dexon have increased tissue drag, good knot
security
•Both are stronger than gut

16. Advantages
 Synthetic polymers produce very minimal tissue reaction &
are resorbed by hydrolysis .
 Well tolerated when implanted or placed intraorally.
 4 months intraoral life.
 Degradation products of polyglycolic acid destroy bacteria in the
wound thereby minimizing tissue reaction.
Disadvantages
 Loss of tensile strength extremely rapid.
 Difficulty in tying suture material.
 Expensive.

17. Polydioxanone (PDS)
•Polyester monofilament suture.
•Absorbed in 120-180 days.
•Minimal tissue reaction and maintains breaking
strength for 6 wks.
Polyglyconate ( Maxon)
•Monofilament
•Absorbed in 180 days.
•Maintains breaking strength for 3 weeks.

18. Non Absorbable
Silk
•Organic and undergoes slow proteolysis when
implanted
•Most popular for intra oral use.
Advantage
•Braided…excellent handling.
•Does not irritate adjacent mucous membrane.
•Inexpensive.
Disadvantage
•Moderate tissue reaction.
•One of the lowest tensile strengths …….just above that
of collagen and gut.
•Lowest knot holding ability….

19. NYLON
•Braided or monofilament forms and synthetic. ( most popular skin
suture material )
•Minimal tissue reaction….degradation products cause decreased
bacterial loads.
•“Memory” property…..
•Fairly good tensile strength
•Infrequently used within oral cavity :
Stiffness.
Requirement of large knot.
Tendency to tear through
non-keratinised tissue.

20. •Cotton suture is made up of non-continuous fibers of cotton
…….combined into yarns & twisted into piles.
•Strength is comparable to silk….
•Tissue reaction is similar to that of silk.
•Linen is a little stronger than cotton.
Cotton And Linen

21. Metal
•Stainless steel or tantalum sutures are either monofilament or
braided.
•Strongest & most secure knot of suture materials
•Good tissue tolerance…
•Degradation through corrosion….tissue reaction to released ions.
•Stiff & do not conform to the suture pathway during host
movement.
•Usually used for suspension of splints and revision of keloid scars
…….not intra orally.

23. .
SUTURE INDICATIONS BY LOCATION
A. Scalp, Torso (chest, back, abdomen), Extremities
1. Superficial Nonabsorbable Suture: 4-O or 5-O
2. Deep Absorbable Suture: 3-O or 4-O
B. Face, Eyebrow, Nose, Lip
1. Superficial Nonabsorbable Suture: 6-O
2. Deep Absorbable Suture: 5-O
C. Ear, Eyelid
1. Superficial Nonabsorbable Suture: 6-O
D. Hand
1. Superficial Nonabsorbable Suture: 5-O
2. Deep Absorbable Suture: 5-O
E. Foot or sole
1. Superficial Nonabsorbable Suture: 3-O or 4-O
2. Deep Absorbable Suture: 4-O

24. SUTURE SIZE
A. General
1. Superficial facial lesions: 6-0 nylon
2. Other superficial skin lesions
a. Low skin tension areas: 5-0 nylon
b. Higher skin tension areas: 4-0 nylon
B. Annotation for suture size indications below
1. Skin: Superficial monofilament Nonabsorbable Suture
2. Deep: Dermal Absorbable Sutures
C. Size O: Largest suture
D. Size 2-O: Can be used to suture in Chest Tube
E. Size 3-O
1. Skin: Foot
2. Deep: Chest, Abdomen, Back
F. Size 4-O
1. Skin: Scalp, Chest, Abdomen, Foot, Extremity
2. Deep: Scalp, Extremity, Foot
G. Size 5-O
1. Skin: Scalp, Brow, Oral, Chest, Abdomen, Hand, Penis
2. Deep: Brow, Nose, Lip, Face, Hand
H. Size 6-O
1. Skin: Ear, Lid, Brow, Nose, Lip, Face, Penis
I. Size 7-O: Smallest Suture
1. Skin: Eyelid, Lip, Face

25. Tissue Staples
•Very common in human medicine
•Expensive
•Very easy
•Very secure
•Very little tissue reaction
•Removal =
•Special tool required

26. Tissue Adhasive
• Cyanoacrylates
• n-butyl cyanoacrylate is the active ingredient.
• Advantages :
• Strong bonding to tissues in presence of moisture
• Biodegradable, bacteriostatic & hemostatic.
• Reduced post operative pain & facilitates healing.
• Good shelf life.
• Produces little or no heat during polymerisation.
•Nexaband, Vetbond, and others
•Should not be placed between skin layers or inside body

28. Needles
Wound closure and healing is affected by the initial injury caused by the
needle penetration and subsequent suture passage. Needle selection, surface
characteristics of needle ( co-efficient of friction ) and suture coated materials
selected for wound closure are important factors to be considered by the
surgeon.
•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

29. Ideal Properties of Needle
•High quality stainless steel
•Smallest diameter possible
•Capable of implanting sutures with
minimal trauma to tissues.
•Stable in the needle holder
•Should be sharp.
•Sterile and corrosion resistant.

30. • Classifications of Needle :
• Eye
• eyeless
• needles with eye
• Shape
• straight
• curved
• Cutting edge
• round body
• cutting body
• Tip
• triangular
• round tipped
• blunt point

31. • 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

32. Swaged-on needles
•Much less traumatic
•More expensive suture material
•Sterile

33. • 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

34. •Eye
•Microsurgery
•Dura
•Eye
•Fascia
•Nerve
•Muscle
•Eye
•Skin
•Peritoneum
•Cardiovascular
•Oral
•Pelvis
•Urogenital tract
•Nasal cavity
•Nerve
•Skin
•Tendon
•Eye (Anterior
segment)
•Laparoscopy

35. • Taper
• Atraumatic
• Internal organs
• Cutting
• Cutting edge on inside of circle
• Skin
• Traumatic
• Reverse Cutting
• Cutting edge on outside of circle
• Skin
• Less traumatic than cutting
Points Of Needle

36. Tapered
Cutting Reverse cutting
Suture loop inserted through eye
Loop placed over tip
Loop drawn back
Suture tied on eyed needle

37. Armamentarium

38. Needle Holder
 Needle Holder
 Locking handle + Short stout beak.
 6” long…..Beak is shorter &
stronger than beak of the hemostat.
 Face of the beak is crosshatched.

39. Needle Holder Selection
1. Use an approximate size for the given needle.
2. Needles should be grasped 1/4th to half the distance from
the eye or the swaged area.
3. The tips of the jaws of the needle holder must meet
before the remaining portions of the jaws.
4. The needle should be placed securely in the tips of the
jaws and should not rock, twist or turn.
5. The needle holder must not be overclosed.

40. •Scissors
• They have relatively long handles and
thumb/ finger rings.
• Held similar to the needle holder
• Short cutting edges….blades maybe
curved or angled

41. 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

42. Sutured Knot Components

44. Square knot
 Formed by wrapping ties
around needle holder once in
opposite direction between ties

45. 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 of first tie

46. Granny’s 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

47. Knot tying
1. Knot must be firm ….no slippage.
2. Knot should not be placed on the incision lines to avoid wicking.
3. Avoid excessive tension…..crimping of suture.
4. Maintain adequate tension …….avoid excess……..necrosis.
5. Knot ends must be 2-3mm.
6. An added throw does not increase the strength of the knot.
7. After the first loop is tied it is necessary to maintain traction at one end of the
strand to avoid loosening of the throw.
8. Final tension or final throw should be as nearly horizontal as possible.

48. 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

49. • sutures placed 4mm apart
• sutures should be tied so that edges are everted
• suture should be placed at an equal distance from the
incision on both the sides & at an equal depth

51. Time of Suture Removal
• Skin……..3-5 days
• Intra-oral………7 days
• Areas of tension……….10 days
• Swab the area with hydrogen peroxide .
• Use extremely sharp scissors.
• Grasp the knot with the tweezers & cut very close to
the mucosa….

52. Classification of Suture Techniques
 INTERRUPTED  CONTINUOUS
IDEPENDENT
SLING
VERTICAL
MATTRESS
HORIZONTAL
MATTRESS
DIRECT /
LOOP
FIGURE
OF 8
VERTICAL /
HORIZONTAL
MATTRESS
INTRA-
PAPILLARY

53. Interrupted Sutures
• Each suture is independent of each other.
• Advantages :
• Distance between each suture and between that of the suture
and the incision line can be pre-decided or determined.
• They are stronger & loosening of any one suture will not
cause the others to loosen.
• In areas of tension when strong closure is
required…interrupted sutures are preferred.
• Incase of infection….removal of infected sutures is sufficient.

54. Indications:-
•Widman flaps, open flap curettage, unrepositioned flaps or apically
positioned flaps where maximum interproximal coverage is required.
•Edentulous areas…..tuberosity & molar areas.
•Partial thickness flaps.
•Incase of vertical incisions.
•Bone regeneration procedures.
•Osseointegrated implants.

55. Figure of 8 Suture
Indication. This technique is useful for bringing together
underlying
tissues such as muscle, fascia, or extensor tendons. It is not commonly
used for skin closure.
Technique
1. Usually a tapered needle and absorbable sutures are used.
2. Start on the side opposite from you. Go through the full thickness
of
tissues on that side, then finish the first half of the stitch by going
from bottom to top on the opposite side. Advance just a little farther
(1.0–1.5 cm) along the tissue. The needle should now be back on top
of the tissue.
3. Now enter the first side (going from top to bottom) just across from
the suture on the other side. Again go through the full thickness of
the tissue and come out on the undersurface of the tissue.
4. Now enter the undersurface of the other side even with the first
suture and come out on top.
5. The suture can now be easily tied.

56. 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

57. Continuous Sutures
 Advantages:
1. One can include as many teeth as required.
2. The teeth are used to anchor the flap.
3. Precise flap placement.
4. Minimizes need for multiple knots.
5. Allows independent placement & tension of buccal & lingual/ palatal
flaps….
6. Greater distribution of forces over the flaps.
7. Simple.

58. Mattress suture
Indication. Mattress sutures are a good choice when the skin edges
are difficult to evert. Sometimes you may want to close a wound with a
few scattered mattress sutures and place simple sutures between them.
It is a bit more technically challenging to place mattress sutures, but it
is often worth the effort because good dermis-to-dermis contact is
achieved.
 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

59. • 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

60. Continuous Locking Suture
• Usually used in long edentulous areas.
• Though it avoids multiple knots in suture….breakage at one junction can cause
the entire suture to untie.
• Technique :
• Initially a single interrupted suture is given.
• Needle is inserted from outer surface of buccal flap & inner aspect of the
lingual flap.
• Needle then passed through the remaining loop of the suture & pulled tight.
• Procedure continued & final suture tied at the terminal end.

61. Periosteal Sutures
• Used to hold apically displaced flaps in place
• Mainly consists of 2 sutures
1. Holding sutures
2. Closing sutures

62. 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 wound healing