This document discusses suture materials and suturing techniques. It begins with definitions of a suture and suturing. It then provides background on the history of sutures. The document outlines different closure types, goals of suturing, and requisites for an ideal suture. It classifies sutures and discusses various natural and synthetic, absorbable and non-absorbable suture materials like silk, catgut, polyglycolic acid, polyglactin 910, polydioxanone, and polyester. It provides details on characteristics, indications, and absorption times for different suture materials.

2. SUTURE MATERIALS ANDSUTURING
TECHNIQUES
Presented by: Guided by:
Dr. Jyothish.k Dr. C.S. Soumithran
MDS 1st year Professor and HOD
Department of OMFS
Govt. dental college, kozhikode

3. Suture is one that approximates the adjacent cut surfaces or
compresses blood vessels to stop bleeding.
Suturing is the act of sewing or bringing tissues or flap
edges together and holding them in apposition until normal
healing takes place.

4. History
 Galen ,in second century A.D,used silk and hempcord for
ligature as well as strands of animal intestine to close the the
wound of Roman gladiators
 John hunter(1728-1793)and philip syng (1768-1837) started of
sutures and their routine use in surgery
 Joseph lister (1827-1912) discovered that bacteria present in
the suture strands and not the suture itself caused wound
infection

5.  Thorns
The thorn, used by African tribes to close tissue,
was passed through the skin on either side of the wound.
A strip of vegetable fibre was then tied
around the wound edge in a figure of eight.

6. Closure Types
 Primary closure (primary intention)
 Wound edges are brought together so that they are adjacent to each other (re-approximated)
.wounds which have been neatly approximad
 Examples: well-repaired lacerations, well reduced bone fractures, healing after flap surgery
 Secondary closure (secondary intention)
 Wound is left open and closes naturally (granulation)
 Examples: gingivectomy, gingivoplasty,tooth extraction sockets, poorly reduced fractures
 Tertiary closure (delayed primary closure)
 Wound is left open for a number of days and then closed if it is found to be clean
 Examples: healing of wounds by use of tissue grafts.

7. Goals of suturing
1- Provide an adequate tension of wound closure without dead space but loose
enough to obviate tissue ischemia and necrosis.
2- Maintain hemostasis.
3- Permit primary intention healing
4- Reduce postoperative pain
5- Provide support for tissue margins until they have healed and the support
no longer needed
6- Prevent bone exposure resulting in delayed healing and unnecessary
resorption
7- Permit proper flap position

8. Requisites for an Ideal Suture
1. Sterile
2. Nonelectrolytic, noncapillary, nonallergenic, and noncarcinogenic.
3. Nonferromagnetic, as is the case with stainless steel sutures.
4. Easy to handle.
5. Minimally reactive in tissue and not predisposed to bacterial growth.
6. Capable of holding tissue layers throughout the critical wound healing period
securely when knotted without fraying or cutting.
7. Resistant to shrinking in tissues.
8. Absorbed completely with minimal tissue reaction after serving its purpose.
“An ideal suture does not exist”

9. Classifications
3 ways of classifying suture material:
 Natural or Synthetic
 Absorbable or Non-Absorbable
 Monofilament or Multifiament (Braided/Twisted)
Pseudomonofilament

10. Silk Catgut
 Natural
 Silk, linen, catgut
 Synthetic polymer
 Polypropylene, polyester,
polyamide
Polypropylene Polyester

11. A monofilament
 suture is made of a single strand.
 Nylon, polypropylene, polydioxanone

12. A multifilament
• Suture consists of several filaments twisted or
braided together
• Twisted
• Braided
• Silk, vicryl

13. Pseudomonofilament
 Actually coated polyfilament threads
 Reduces mechanical trauma during suturing
 When coating breaks then they behaves similar to
polyfilament threads

14. Monofilament & Multifilament
Monofilament Multifilament
simplified structure. Complex structure
they encounter less resistance as they pass
through tissue
Multifilament sutures may be coated to
help them pass relatively smoothly
through tissue and enhance handling
characteristics.
resist harboring organisms which may cause
suture line infection
Wicking effect: This has been
attributed to braided sutures. These
may allow bacteria from the oral cavity
to be drawn through the suture to the
deeper areas of the wound.
These features help them to be used in
vascular surgery.
Crushing or crumping of this suture type
can nick or create a weak spot in the strand.
may result in breakage
affords greater strength, pliability and
flexibility
Extreme care must be taken when handling
and tying these sutures..

15. Suture Size
5..4..3..2..1..0..2/0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/0
Thick Thin
USP (United States Pharmacopoeia)

16.  Absorbable
 catgut, polydioxanone, polyglycolic acid
 Used for deep tissues, membranes, & subcuticular skin closure
 Non-Absorbable
 polyester, nylon, stainless steel
 Used for skin (removed) & some deep structures (tendons, vessels, nerve
repairs – not removed)

17. Absorbable/ Resorbable sutures
 Sutures that are digested by body enzymes or are hydrolyzed
by the tissue fluids
 May be natural or synthetic
 Some are absorbed rapidly while others are treated or
chemically structured to lengthen absorption time
 May be impregnated with agents to improve handling
properties
 Coloured to increase visibility

18. Natural Absorbable/ Resorbable sutures
 Natural absorbable sutures are digested by body
enzymes

19. Surgical Gut
 Oldest known Suture Material
 Natural
 Absorbable
 Fabricated from submucosa of sheep intestines or serosa of beef
intestines
 Contains processed strands of highly purified collagen
 The percentage of collagen in the suture determines its tensile
strength and prevents adverse reaction

20. Gut sutures
 Two type
Plain gut
Chromic gut
 Smallest tensile strength
 As it is highly susceptible to enzymatic degradation it is
packed with isopropyl alcohol
 Gut sutures is absorbed by proteolytic degradation
 Total absorption of suture materials take 40 to 60 days

21. Plain gut
 Plain surgical gut is rapidly absorbed, within 70 days.
 Tensile strength is maintained for only 7 to 10 days post
implantation,
 for use in tissues which heal rapidly and require minimal
support
 (for example, ligating superficial blood vessels and
suturing subcutaneous fatty tissue).

22. Plain gut
 Can also be specially heat-treated to accelerate tensile
strength loss and absorption.
 This fast absorbing surgical gut is used primarily for
epidermal suturing where sutures are required for only 5
to 7 days.
 Have less tensile strength
 Fast absorbing plain gut is not to be used internally
 Plain gut is more difficult to use as it is stiff and has
insecure knot- handling characteristics when wet.

23. Plain gut
Suture
Construction
Suture
Color
Available
Sizes
Suture BSR
Profile
Absorption
complete by:
Monofilament
(virtual)
Dyed &
Undyed
6/0 through 0 7-10 days 70 days

24. Chromic gut
 Plain gut tanned with solution of chromium salts
prior to being spun, ground and polished-
CHROMICIZING
 Chromium salts act as a cross linking agents
increases
 Tensile strength of material
 Resistance to absorption by body
 Lesser stimulation of tissue reaction.

25. Chromic gut .
Suture
Construction
Suture Color
Available
Sizes
Suture BSR*
Profile
Absorption
complete by:
Monofilament
(virtual)
Dyed &
Undyed
7/0 through 3 21-28 days 90 days

26. Synthetic absorbable suture
 Were developed in response to problems encountered with
natural absorbable sutures
 Suture antigenicity, tissue reaction, and unpredictable rates of
absorption
I. Polygycolic acid and polyglactin 910 (vicryl)
II. Poliglecaprone 25
III. Polyglyconate
IV. Polydioxanone
V. Poly (l-lactide/glycolide)

27. Polyglycolic acid
 Differ significantly in that they are resorbed by hydrolysis
 Synthetic polymers produce less of tissue reaction
 Polyglycolic acid is hydroxyacetic acid, which in presence
of heat & catlyst is converted to high molecular weight,
linear chain polymers

28. Polyglycolic acid
DEXON
 Braided and monofilament
 Are composed of the homopolymer of glycolic acid.
 Excellent strength over the critical wound healing period
 Uniform diameter
 Predictable absorption profile

29. DEXON
 Sutures are indicated for use in soft tissue approximation
and/or ligation
 Including use in ophthalmic procedures, but not in
cardiovascular tissue or in neural tissue.
 Monofilament are indicated for use as absorbable sutures in
microsurgery and ophthalmic surgery.
 The use of this suture is contraindicated in patients with known
sensitivities or allergies to its components.
 These sutures, being absorbable, should not be used where
extended approximation of tissue is required.

30. Polyglactin910
 Polyglactin 910 copolymer of glycolide and lactide
derived from hydroxyacetic acid and lactic acid

31. Vicryl
 These two suture material when braided - strongest
suture material (Vicryl)
 Degradation products of polyglycolic acid may
destroy bacteria in wound & minimize tissue reaction
 Polyglactin has quicker dissolution when compared to
polyglycolic acid
 Surgicryl, Polysorb

32. Disadvantages
 Tying with this material is difficult as material does not slide
easily on itself
 Wetting material with saline will facilitate tying
 They are expensive
 Vicryl is slow-absorbing and often braided
 Its use is contraindicated in closure of any cutaneous wound
exposed to the air
 It draws moisture from the healing tissue to the skin
 Allows bacteria and irritants to migrate into the wound.
 Leads to high reactivity to the contaminants
 Poor wound healing
 Eventually infection.

33. Vicryl Rapide
 Vicryl and other polyglycolic-acid sutures may also
be treated for more rapid breakdown ("vicryl
rapide")
 In rapidly healing tissues such as mucous membrane
 Or impregnated with triclosan ("vicryl plus
antibacterial") to provide antimicrobial protection of
the suture line

34. Coated vicryl
 coating is a combination of equal parts of co-polymer
of lactide and glycolide (polyglactin 370), plus calcium
stearate
 outstandingly absorbable, adherent, non flaking
lubricant.
 Complete absorption between 56 -70 days
 may be used in the presence of infection
 Facilitate easy tissue passage,
 precise knot placement,
 smooth tie down

35. Coated vicryl
 Coated VICRYL suture is indicated for use in general
soft tissue approximation and/or ligation
 Including use in ophthalmic procedures
 But not for use in cardiovascular or neurological
tissues
 This suture, being absorbable, should not be used
where extended approximation of tissue is required.
 Absorption of coated vicryl suture occurs by means of
hydrolysis.

36. MONOCRYL (POLIGLECAPRONE 25) SUTURE
 monofilament suture with superior pliability for easy
handling and tying
 copolymer of glycolide and epsilon-caprolactone
 it is virtually inert in tissue and absorbs predictably
 high initial tensile strength diminishing over 2 weeks
postoperatively

37. MONOCRYL (POLIGLECAPRONE 25)
 MONOCRYL Suture is indicated for use
 in general soft tissue approximation and/ or ligation
 but not for use in cardiovascular or neurological tissues,
microsurgery, or ophthalmic surgery
 This suture, being absorbable, should not be used where
extended approximation of tissue under stress is
required, such as in fascia
 hydrolysis

38. MONOCRYL (POLIGLECAPRONE 25)
SUTURE

39. Polyglyconate
 Monofilament Absorbable Sutures
 Maxon
 are prepared from polyglyconate, a copolymer of glycolic
acid and trimethylene carbonate
 monofilament absorbable sutures provide strength and
security for extended wound healing needs of about six
weeks.
 indicated for use in general soft tissue approximation
and/or ligation
 and in peripheral vascular surgery.
 These sutures are colored green to increase visibility and
are also available undyed.

40. Polyglyconate
 The advanced extrusion process of the molecule of
polyglyconate gives the suture:
 Excellent in-vivo strength retention
 Excellent knot tying security
 Excellent handling
 Minimal memory

41. PDS (polydioxanone)
 PDS II sutures are indicated for use in soft tissue
approximation
 Including use in pediatric cardiovascular tissue
 Where growth is expected to occur
 Ophthalmic surgery.
 Pds ii suture is not indicated in adult
cardiovascular tissue, microsurgery and neural
tissue

42. PDS (polydioxanone)
 Not to be used where prolonged (beyond six weeks)
approximation of tissues under stress is required
 And is not to be used in conjunction with prosthetic
devices (i.E. Heart valves or synthetic grafts)
 Pds ii sutures have been formulated to minimize the
variability of tensile strength retention and
absorption rate (loss of mass)
 And to provide wound support through and
extended healing period.

43. PDS

44. SUTURE RAW MATERIAL
Surgical Gut
Plane
Chromic
Fast Absorbing
Submacosa of sheep intestine or serosa
of beef intestine
Polyglactin 910
Uncoated- Vicryl
Coated- Coated Vicryl, Vicryl Rapide
Copolymer of glycolide and lactide with
polyglactin
370 and calcium stearate, if coated
Polyglycolic Acid Homopolymer of glycolid
Poliglecaprone 25
Monocryl
Copolymer of glycolide and epsilon-
caprolactone
Polyglyconate Copolymer of glycolide and
trimethylene carbonate

45. Continuation…
SUTURE RAW MATERIAL
Polydioxanone
PDS II
Polyester of poly (p-dioxanone)
Poly (L-lactide/glycolide)
PANACRYL
Copolymer of lactide and glycode
with caprolactone
and glycolide coating

46. Non absorbable suture
 Strands of material that are suitably resistant to
the action of living mammalian tissue.
 A suture may be composed of a single or multiple
filaments of metal or organic fibers rendered into
a strand by spinning, twisting, or braiding.
 Each strand is substantially uniform in diameter
throughout its length
 The material may be uncolored, naturally
colored, or dyed with an f.D.A

47. Non absorbable sutures
It include
 silk
 nylon
 cotton, linen
 metal like stainless steel
 polyester
 polypropylene
 teflon coated polyester

48. Silk
 It is organic substance
 Natural protein fiber of raw silk treated with silicon
protein or wax
 undergo slow proteolysis
 Most popular for intra oral use

49. Advantages
 Excellent handling characteristics
 Moderate tissue response
 Does not irritate mucous membrane
 Inexpensive
Disadvantages:
 Low tensile strength

50. Silk

51. Silk
PERMA-HAND
 Suture is indicated for use in general soft tissue approximating and/or
ligation including use in cardiovascular, ophthalmic, and neurological
procedures.
 Elicits an acute inflammatory reaction in tissue
 Which is followed by a gradual encapsulation of the suture by fibrous
connective tissue
 Silk sutures are not absorbed
 Progressive degradation of the proteinaceous silk fiber in vivo may
result in gradual loss of all of the suture’s tensile strength over time.
 Due to the gradual loss of tensile strength, silk suture should not be
sued where permanent retention of tensile strength is required.

52. Silk
Suture
Construction
Suture
Color
Availabl
e Sizes
Suture
BSR*
Profile
Absorption
complete
by:
Braided Black
5, 2
through
7/0
Gradual
loss of all
tensile
strength
over time
n/a

53. Cotton and linen
 Made from non continuous natural fibers of cotton,
combined into yarns and twisted into piles
 Strength similar to silk but handling properties are
inferior to it
 Linen somewhat stronger but similar properties

54. Nylon( synthetic)
 Can be obtained in braided or monofilament forms
 Degradation products of nylon causes marked
reduction in counts of staph. Aureus in culture
 Nylon possesses property of “memory”
 monofilament nylon sutures have a tendency to return
to their original straight extruded state (“Memory
Effect)
 So, more throws in the knot are required to securely
hold monofilament nylon sutures.

55. Nylon( synthetic)
 Indicated for use in general soft tissue approximation
and/or ligation
 Including use in cardiovascular, ophthalmic, and
neurological procedures
 Elicits a minimal acute inflammatory reaction in tissue,
which is followed by a gradual encapsulation of the suture
by fibrous connective tissue.
 While nylon is not absorbed, progressive hydrolysis of the
nylon in vivo may result in gradual loss of tensile strength
over time.
 Due to the gradual loss of tensile strength which may
occur over prolonged periods in vivo, nylon suture should
not be used where permanent retention of tensile strength
is required.

56. Polyester
 Untreated fibers of polyester (polyethylene terephthalate
DACRON- ) closely braided into a multifilament strand.
 They are stronger than natural fibers
 Do not weaken when wetted prior to use
 And cause minimal tissue reaction.
 Available white or dyed green
 Polyester fiber sutures are among the most acceptable for
vascular synthetic prostheses

57. Polyester
 MERSILENE sutures are indicated for use
 In general soft tissue approximation and/or ligation
 Including use in cardiovascular, ophthalmic and
neurological procedures.
 The sutures are braided for optimal handling properties,
and for good visibility in the surgical field, are dyed green.
 Mersilene suture provides precise, consistent suture
tension.

58. Polyester
 MERSILENE suture elicits a minimal acute inflammatory
reaction in tissue
 Followed by a gradual encapsulation of the suture by
fibrous connective tissue.
 Implantation studies in animals show no meaningful
decline in polyester suture strength over time.
 The polyester fiber suture material is pharmacologically
inactive.

59. Polyester

60. Polypropylene
 monofilament sutures that are not subject to degradation or weakening
by tissue enzymes.
 They are extremely inert in tissue
 have been found to retain tensile strength for long periods of time
 Become encapsulated in connective tissues
 hold knots better than most other synthetic monofilament materials

61. Polypropylene
 PRONOVA Suture is indicated for use
 in general soft tissue approximation and/or ligation
 including use in cardiovascular, ophthalmic and neurological
procedures.
 PRONOVA Suture elicits a minimal to mild inflammatory
reaction in tissue
 which is followed by gradual encapsulation of the suture by
fibrous connective tissue

62. Polypropylene
 PRONOVA Suture is not absorbed
 nor is it subject to degradation or weakening by the
action of tissue enzymes.
 As a monofilament, PRONOVA Suture, resists
involvement in infection
 has been successfully employed in contaminated and
infected wounds to eliminate or minimize later sinus
formation and suture extrusion.
 Furthermore, the lack of adherence to the tissues has
facilitated the use of PRONOVA Suture as a pull-out
suture.

63. Polypropylene
Suture
Constructi
on
Suture
Color
Available
Sizes
Suture
BSR*
Profile
Absorptio
n
complete
by:
Monofilam
ent
Blue
2/0 through
8/0
Indefinite n/a

64. Polypropylene

65. Metal (stainless steel)
 Monofilament or braided
 Strongest and produce most secure knot
 This can undergo degradation through corrosion,
 process is slow, tissue reaction to ions can occur
 Metallic sutures are stiff and can produce tissue damage and increased
susceptibility to infection

66. SUTURE RAW MATERIAL
Surgical Silk Raw silk spun by silkworm
Stainless Steel Wire Specially Formulated iron
chromium-
nickel-molybdenum alloy
Nylon
ETHILON
NUROLON
Polyamide polymer
Polyester fiber
Uncoated- MERSILENE
Coated- ETHIBOND* EXCEL
Polymer of polyethylene
terephthalate (may be coated)
Polypropylene
PROLENE
Polymer of propylene
Poly(hexafluoropropylene-VDF)
PRONOVA
Polymer blend of poly(vinylidene
fluoride) and poly(vinylidene
fluoride-cohexafluoropropylene

67. Suture Packaging

68. The Suture Packaging
STRAND
SIZE
MATERIAL
STRAND
LENGTH
PRODUCT
CODE
NEEDLE
CODE WITH
LIFE SIZE
PICTURE OF
NEEDLE
NEEDLE
LENGTHCOLOUR
POINT
TYPE
NEEDLE
CIRCLE

69. Suture Selection
Bowel: 2/0 - 3/0
Fascia: 1 - 0
Ligatures: 0 - 3/0
Pedicles: 2 - 0
Skin: 2/0 - 5/0
Arteries: 2/0 - 8/0
Micro surgery 9/0 - 10/0
Corneal closure: 9/0 - 10/0
Intraoral : 3/0

70. ARMAMENTARIUM FOR
SUTURING

71. Instruments
Adson forcep hemostat scissors suture scissors

72. Surgical Needles
 Most of surgical needles are fabricated from heat treated
steel
 The surgical needle has a basic design composed of three
parts
1- The eye which is swaged and permits the suture and needle to
act as a single unit to decrease trauma.shape may be round,
oblong or square

73.  Needle body
body or shaft area is usually referred to as needle
grasping area.
cross-section _round, oval,side flattened
rectangular, triangular,
trepezoidal
longitudinal- straight, half curved, curved
 Needle point
extreme tip
can be cutting,round or blend

75. SUTURING NEEDLE

76. Needle shapes

77. Classification of suturing needles
Based on design
1. straight
2.curved
Based on cross-section
1. round body
2.Cutting conventional cutting
reverse cutting
Based on how material connects to needle
1.eyed needle
2.swaged needle

78. Needle point Geometry
Taper-Point
•Suited to soft tissue
•Dilates rather than cuts
Reverse
cutting
•Very sharp
•Ideal for skin
•Cuts rather than dilates
Convention
al Cutting
•Very sharp
•Cuts rather than dilates
•Creates weakness allowing suture tearout
Taper-
cutting
•Ideal in tough or calcified tissues
•Mainly used in Cardiac & Vascular
procedures.

79. Needle Point Geometry
Blunt
•Also known as “Protect Point”
•Mainly used to prevent needle stick
injuries i.e. for abdominal wall closure.
Premium point
spatula
•Ophthalmic Surgery
Spatula
•Ophthalmic Surgery
DermaX*
•NEW:
•½ The Penetration force
•Superior Cosmetic Effect

80. Conventional cutting needle
 third cutting edge on the inside concave curvature of
the needle.
 This needle type may be prone to cutout of tissue
because the inside cutting edge

81. Reverse cutting needle
 The third cutting edge is located on the outer convex
curvature of the needle.
 were created specifically for tough, difficult-to-penetrate
tissue such as skin, tendon sheath, or oral mucosa.
 minimal trauma, early regeneration of tissue, and little scar
formation.

83. Types of Needles
 Eyed needles
 More Traumatic
 Material threaded in to the
hole
 Can be sterilized
 Tends to unthread itself
easily
 They must be threaded by
assistant
 Adds bulk to suture

84. Needle eye
 closed eye
 French (split or spring) eye
 swaged (eyeless).

85. Types of Needles
 Swaged-on needles
 Much less traumatic
 Manufacturer attaches
material to hollow of the
needle body
 More expensive suture
material
 Sterile
 Single use

86. Advantages of swaged needles
a. Selection of needles is avoided as it is already attached
to suture
b. Handling / preparation is minimized
c. Minimal trauma
d. Repeated use of needles is avoided
e. Unthreading is avoided while in use
f. If a needle is accidently dropped into a body cavity, the
attached suture makes it easier to find
g. Time spent for cleaning, sharpening, handling and
sterilizing needles is eliminated
h. Control release needles allow placement of many
sutures rapidly.

87. The Right Needle Choice
 The appropriate needle choice for any situation
is…………….
……………The needle that will cause least possible trauma
to the tissue being sutured

88. FORCEPS
 Grasp forceps between thumb & middle finger, while index finger
is used for stabilization.
 If possible, use forceps to grasp dermis, rather than epidermis or
skin surface itself. This helps prevent marking & injuring of skin
at wound edge.

89. Follow the needle’s arc
 Rotate your wrist to follow the arc of the needle.
Principle:
 minimize trauma to the skin,
 and don’t bend the needle.
 Follow the path of least resistance.

90. Needle Holder Selection
1- Use an approximate size for the given needle. The
smaller the needle, the smaller the needle holder
required
2- Needle should be grasped one-quarter to one half the
distance from the swaged area
3- The tip of the jaws of the needle holder should meet
before remaining portion of the jaws

91. Needle Holder Selection
4- The needle should be placed securely in the tips of
the jaws and should not rock, twist, or turn
5- Do not over close the needle holder. It should
close only to the first or second ratchet. This will
avoid damaging the needle
6- Pass the needle holder so it is always directed by
the operator thumb

92. Needle Holder
 Remember!!! Thumb & ring finger into needle
holder’s rings (NOT the middle finger!)

93. Index finger stabilizes the
instrument by resting on the shaft.

94. The trick to an instrument tie
 Always place the suture holder parallel to the wound’s
direction.
 Hold the longer side of the suture (with the needle)
and wrap OVER the suture holder.
 With each tie, move your suture-holding hand to the
OTHER side.

95. Wound Preparation
 Most important step for reducing the risk of wound infection.
 Remove all contaminants and devitalized tissue before wound closure.
 IRRIGATE w/ NS or TAP WATER
 CUT OUT DEAD, FRAGMENTED TISSUE
 Remove any sharp bony spicule and smoothen bone margins
 If not, the risk of infection and of a cosmetically poor scar are greatly
increased
 Personal Precautions

96. Langer’s Lines

97. General Principles of Suturing
 The needle holder should grasp the needle at approximately ¾
of the distance from the point.
 The needle should enter the tissue perpendicular to the surface.
 The needle should be passed through the tissue following the
curve of the needle.
 The suture should be placed at an equal distance(2-3mm)from the
incision on both sides and at an equal depth.
 The needle should be passed from free to fixed side.
 The needle should be passed from the thinner to the thicker side.

98. The needle should be passed from the deeper to the
superficial side.
To produce tissue eversion the distance that the needle
is passed in to the tissue should be greater than the
distance from the tissue edge.
the tissue shouldn’t be closed under tension.If tension
is present , tissue layer should be undermined to relieve
it
The suture should be tied so the tissue is merely
approximated, not blanched
The knot should not be placed over the incision line.

99. The tissue shouldn’t be closed under tension.If
tension is present , tissue layer shundermined to
relieve it
The suture should be tied so the tissue is merely
approximated, not blanched
The knot should not be placed over the incision line.

100. • Suture should be placed approximately 3-4mm
apart.Closer spaced sutures are indicated in areas of
underlying muscular activity.
• Occasionally, extra tissue on one side of the incision
produce ‘dog- ear’ formation. To prevent it after
undermining excess tissue, incision is made approx.
30 degrees to parent incision directed towards
undermined side. Extra tissue is pulled over incision
and the appropriate amount is exised .Incision is
closed.

101. Suturing Techniques
 The Choice of technique is generally made on the
basis of a combination of the individual operator’s
preference, educational background, and skill
level, as well as surgical requirement

102. Types
Interrupted Continuous
1. Circumferential direct
loop
2. Figure of eight
3. Mattress suture-
Horizontal, vertical,
Internal and external
4. Sling Suture
5. Anchoring suture
6. Laurell loop
7. Intra papillary
8. Suspensory Suture
1. Papillary sling
2. Mattress
3. Locking

103. Interrupted Sutures
 Indications
1- Vertical incision
2- Tuberosity and retromolar areas
3- Bone regeneration procedures with/without GTR
4- Widman flaps, open flap curettage, repositioned flaps, or
apically positioned flaps where maximum interproximal
coverage is required
5- Edentulous areas
6- Partial or spilt-thickness flap
7- Osseointegrated implants

104. 1. Circumferential Direct loop/simple
 A, The needle penetrates the outer surface of the first flap
 B, The undersurface of the opposite flap is engaged, and
 C, the suture is brought back to the initial side, where
 D, the knot is tied.

105. Advantages
Equal distribution of tension
If one suture get loose,wont affect others
In case of edema or hematoma one or two sutures can be
removed
Disadvantage
Time consuming
Not recommended when the buccal and lingual flaps are
repositioned at different levels

106. 2. Figure Eight Sutures
 thread is placed between the two flaps.
 This suture is used when the flaps are not in close
apposition as a result of apical flap position or
nonscalloped incisions.
 This is simpler to perform than the direct ligation

107. 2. Figure Eight Sutures
 A, The needle penetrates the outer surface of the first flap and
 B, the outer surface of the opposite flap
 C, The suture is brought back to the first flap
 D, the knot is tied.

108. 3. Mattress suture
 Greater flap security and Control
 Precise flap placement
 Periosteal stabilization
 Good papillary stabilization and placement
 Watertight closure
 Types:
 Horizontal / vertical
 Internal / external

109. Mattress sutures
Indication
• In wounds where wound eversion is desirable
• Wounds on abdomen ,hip and sometime neck incision
 Narrow interdental areas and when greater control of papilla
required

110. Horizontal mattress(External)
 Used in wide embrasure area
 Better control over papilla tip
 In anterior area – to prevent compression of papilla
tip
 May constrict the blood supply minimally

111. Horizontal mattress- external
 A, The suture penetrates the facial papilla from the outside-in just above
the mucogingival junction at the distal aspect of the papilla.
 The papilla is stabilized with forceps and the needle is passed from the
inside-out at a point on the mesial aspect of the papilla along a
horizontal plane even with the distal needle puncture. The suture passes
through the embrasure space and the suture needle is passed through
the lingual tissue in a similar fashion.
 B, The suture crisscrosses over the top of the papilla and is secured on
the facial.

112. Horizontal mattress- external
 Used in the anterior area, placing the suture on either side of
the papilla will allow the papillary tissue to stay upright
filling the embrasure space

113. Horizontal Mattress
Good for closing wound edges under high tension,
And for hemostasis.

114. Vertical mattress/(External)
 Used when it is desirable to position the interdental papilla
more upright in the embrasure space
 Suture enters facial tissue apical to base of papilla run
across the alveolar crest, penetrates lingual tissue from
inside out.
 Suture pass back through lingual papilla from outside in, 2-
3 mm coronal and courses back across papilla from inside
out 2 to 3 mm coronal to initial facial entry.

115.  The suture penetrates the facial papilla just above the
mucogingival junction from outside-in. The papilla is stabilized
with tissue forceps and the needle is passed from inside out 2 to
3 mm coronal to the initial suture penetration.
 The needle and suture are passed through the lingual (or
palatal) papilla in a similar fashion as the facial papilla
 The suture is gently tightened bringing the facial and lingual
papilla together. The knot is secured on the facial. Note that the
majority of the suture material lies on top of the flaps.

116. Vertical Mattress
Good for everting wound edges , majority of the suture material
lies on top of the flaps.(neck, forehead creases, concave surfaces)

117. Advantage
• Causes good eversion
• Since it passes at 2 levels ,it provides good wound
support
• As it runs vertical to blood supply ,not likely to
compromise vascularity

118. Intrapapillary suture
 A P-3 needle is inserted buccally 4 to 5 mm from the tip of the
papilla and passed through the tissue, emerging from the very
tip of the papilla.
 This is repeated lingually and tied buccally, thus permitting
exact tip-to-tip placement of the flaps

119. Sling technique
 It is primarily used for a flap that has been
raised on only one side of a tooth involving one
or two adjacent papillae
 Most often used in coronally and laterally
positioned flaps
 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

120. Sling suture
 Suture is passed through facial from outside –in and looped
around the lingual of tooth
 Suture does not enter lingual papilla
 Suture is passed through other facial papilla from inside out and
looped back around lingual of tooth.

123. Anchor suture
 Closing of flap mesial or distal to tooth as in mesial and
distal wedge procedure.
 Suture closes facial and lingual flaps and adapt tightly
against them.
 Needle is placed at line angle area of facial or lingual flap
adjacent to tooth, anchored around the tooth, passed
beneath opposite flap and tied.

124.  A, The suture is passed through the base of the facial papilla from the
outside-in and is looped around the lingual of the tooth, through the
interdental space.
 B, The suture loops completely around the adjacent tooth and
penetrates the lingual papilla from the inside-out
 C, The suture crosses over the top of the papilla. As tension is placed on
the suture, the papillae are drawn together and toward the proximal
surface of the adjacent tooth. This eliminates gaps between the flaps at
the proximal tooth surface.
 D, The suture is secured on the facial.

125. Closed anchor suture
 To close flap located in edentulous area
 mesial or distal to tooth consists of tying a direct suture
that closes proximal flap, carrying one of threads around
tooth.

126. Closed Anchor Suture
 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

127. Laurell Loop suture
 Specialized interrupted suturing techniques for bone
regeneration and retromolar and tùberosity areas.
 Capable of being employed for all regenerative techniques
 Is used when standard interproximal incision is used

128. Laurell Loop suture
 Also known as the vertical sling mattress suture
 Incorporates an internal mattress type suture
 That crosses back over the top of the interproximal papilla,
through a loop on the lingual, then over the papilla again,
and secured on the facial surface
 The laurell loop suture works well to bring the facial and
lingual papillae together when guided tissue regeneration
is performed in interproximal sites.

129.  A, The suture is passed through the facial and lingual papillae as
an internal mattress suture. Instead of being tied on the facial
aspect at this point, a loop in the suture is formed on the lingual
 B, The suture is passed over the top of the papillae toward the
lingual, through the lingual loop and back over the top of the
papilla toward the facial.
 C, Tension is applied to the suture bringing the flaps and the
papillae together and the suture is secured on the facial.

130. Laurell Loop suture

131. Suspensory suture
 The suture enters and exits the flap similarly to a horizontal suture
 And is secured on the coronal aspect of the crown with light cured
composite
 Are best suited to isolated areas where coronal positioning of
the flap is required.

132. Continuous suture
Two types
 With locking(blanket suture)
 Without locking
Indication
large wound

133. Technique
. first place interrupted suture
. cut only free ends leaving suture material with the needle
behind
. needle passed through the flaps of the wound alternately to get
continuous oblique sutures all along the wound
. at the end, knot is placed with the loop of the suture and
the needle end of the suture material

134. Continuous with locking
First a simple suture.then suture passed through both flaps
and through a loop made by the suture material
assistant is made to “follow the suture” by holding it close to
the tissues
at the end knot is made similar to the above technique.

135. Advantages
 Even distribution of tension
 Water tight closure
 Faster technique
 Can include as many teeth as required
 Minimizes the need for multiple knots
 Simplicity
Advantage with locking
Suture will align itself perpendicular to the incision
Locking prevents continuous tightening of the suture as wound closure
progress.
Disadvantage
If one suture get loose,all the other sutures also get loose
Not possible to remove individual sutures

136. Subcuticular Sutures
 Usually a running stitch,
but can be interrupted
 Intradermal horizontal
bites
 Allow suture to remain for
a longer period of time
without development of
crosshatch scarring

138. Periosteal suture
 It requires a high degree of dexterity in both flap
management and suture placement.
 Small needles (P-3), fine sutures (4-O to 6-O), and proper
needle holders are a basic requirement.
 Periosteal suturing permits precise flap placement and
stabilization.
 Five steps are penetration, rotation, glide, rotation , exit

139.  1. Penetration: The needle point is positioned
perpendicular (90°) to the tissue surface and underlying
bone.
 It is then inserted completely through the tissue until the
bone is engaged.
 This is as opposed to the usual 30° needle insertion angle

140.  2. Rotation
 The body of the needle is now rotated about the needle
point in the direction opposite to that in which the needle
is intended to travel.
 The needle point is held tightly against the bone so as
not to damage or dull the needle point.

141.  3. Glide:
 The needle point is now permitted to glide against the
bone for only a short distance
 Care must be taken not to lift or damage the periosteum

142.  4. Rotation:
 As the needle glides against the bone, it is rotated about
the body, following its circumferenced outline
 In this way, the needle will not be pushed through the
tissue,

143.  5. Exit:
 The final stage of gliding and rotation is needle exit.
 The needle is made to exit the tissue through the gentle application of
pressure from above, thus allowing the tip to pierce the tissue.
 If digital pressure is to be used, care must be used to avoid personal
injury

145. Knots & Knot Tying
 “Suture security is the ability of the knot and
material to maintain tissue approximation during
the healing process” (Thacker and colleagues,
1975).
 Failure: generally result of untying owing to knot
slippage or breakage.
 Knot strength is always less than the tensile
strength of the material, the site of disruption is
always the knot on application of force.
(Worsfield, 1961; Thacker and colleagues, 1975).
 This is because shear forces produced in the knot
lead to breakage.

146. Knot and knot typing
 Knot slippage or security is determined by the nature of the material,
suture diameter, and type of knot.
 Monofilament and coated sutures(Teflon, silicon) have a low
coefficient of friction and a high degree of slippage; braided and
twisted sutures such as uncoated Dacron and catgut greater knot
security.
 Suture silk, although extremely user friendly, inferior in terms of
strength and knot security compared with other materials (Hernann,
1971).
 High degree of tissue reaction and the addition of wax or silicon to
reduce the tissue reaction and prevent wicking further diminishes
knot security

147. Parts of Knot
 A sutured knot has three components (Thacker and
colleagues, 1975):

1. The “Loop” created by the knot

2. The knot itself, which is composed of a number of tight
“throws” each throw represents a weave of the two strands

3. The “ears” which are the cut ends of the suture

149. Types of Knots
 Square knot
 Granny Knot
 Surgeon’s Knot
2-1
2-2

150. Square knot
 formed by wrapping suture around needle
holder once in opposite direction between ties.
More ties may be required
 Esp with Nylon, Polypropylene and gut sutures

151. Granny Knot
 knot involves a tie in one direction followed by a single tie
in the same direction as the first.
 This allows the knot to be slipped in place and provide
initial holding similar to surgeons knot.
 However, a third tie squared on the second must be made
to hold the knot permanently
Allows knot to be slipped
into place
 Least secure
(Thacker et al 1975)

152. Surgeon’s Knot
This is formed by 2 throws of suture around needle holder on
first tie and then one throw in opposite direction (2-1) on
second tie.
Because of double throw, the surgeon’s knot offers the
advantage of reducing slippage of first tie, while second tie is
put in place.

153. How many knots?
 With a braided material, such as silk, a 3rd throw
(replicating the first) would be placed to secure the knot.
 If a slippery monofilament material, such as nylon were
being used, one would place 5 or 6 throws of alternating
construction in order to minimize knot slippage.

154. Suturing - finishing
 After sutures placed, clean the site with normal saline.
 Apply a small amount of Bacitracin and cover with a sterile
non-adherent dressing.

155. Principles for Suture Removal
1- The area should be swabbed with hydrogen peroxide for removal of
encrusted necrotic debris, blood, and serum from about the sutures
2- A sharp suture scissors should be used to cut the loops of individual or
continuous sutures
3- It is often helpful to use a No. 23 explorer to help lift the sutures if they are
within the sulcus or in close opposition to the tissue
4- A cotton pliers is used to remove the suture. The location of the knots
should be noted so that they can be removed first. This will prevent
unnecessary entrapment under the flap

156. 5. Cut the suture very close to epithelial surface.Pull
the Suture line through the tissue in the direction
that keeps the wound closed .
6. Once all sutures have been removed ,count the
sutures
7. The numbers of sutures needs to match the
number indicated in patients health record
8. Suture should be removed in 7 to 10 days to
prevent epithelialization or wicking about the
suture

157. Suture Removal
 Average time frame is 6-7 days
 Any suture with pus or signs of infections should
be removed immediately.

158. Approximate time for suture
removal
 Face: 3-4 days
 Intraoral : 5-7 days
 Scalp: 5 days
 Trunk: 7 days
 Arm or leg: 7-10 days
 Foot: 10-14 days

159. Cutting Skin Sutures
 With skin sutures, leave 3-4mm tail.
 Tail = amount of suture left above knot
 Tail is left because it helps prevent loosening or undoing of
sutures.
 REMEMBER: Always ask the surgeon the desired length of
suture tail before cutting!!

160. Cutting Deep Sutures
 Buried sutures are left within the body.
 Cut the suture on the knot, leaving no tail behind.
 REMEMBER: Always ask the surgeon the desired length of
suture tail before cutting!!

161. Contraindications to Suturing
 Redness
 Edema of the wound margins
 Infection
 Fever
 Puncture wounds
 Animal bites
 Tendon, nerve, or vessel involvement
 Wound more than 12 hours old (body) and 24 hrs (face)

162. SURGICAL STAPLES
 They are made up of stainless steel & are placed uniformly
to span the incision line
 Minimal tissue reaction
 Can be used for skin closure &closure of the abdominal
layers
CONTRAINDICATION-
when it is not possible to maintain at least 5 mm distance
from the staples skin to the underlying bone &blood
vessels

163. Staples
 Rapid closure of
wound
 Easy to apply
 Evert tissue when
placed properly

164. TISSSUE ADHESIVE
 After tight closure of the subcutaneous tissues ,the skin layers
can be closed with the help of tissue adhesive like n-butyl
cyanoacrylate
 which on tissue contact polymerizes into a hard substance
that keeps the wound margins togethers

165. Topical Adhesives
 Indications: selection of approximated, superficial, clean wounds
especially face, limbs. May be used in conjunction with deep sutures
 Benefits: Cosmetic, seals out bacteria, apply in 3 min, holds 7 days (5-
10 to slough), seal moisture, faster, clear, convenient, no removal, less
expensive
 Contraindicated with infection, gangrene, mucosal, damp or hairy
areas, allergy to formaldehyde or cryanoacrylate, or high tension
areas.mobile areas of skin such as joints,bony prominences.

166. Dermabond®
 A sterile, liquid topical skin
adhesive
 Reacts with moisture on skin
surface to form a strong, flexible
bond
 Only for easily approximated skin
edges of wounds
 punctures from minimally invasive surgery
 simple, thoroughly cleansed, lacerations

167. Follow Up Care with Adhesives
 No ointments or medications on dressing
 May shower but no swimming or scrubbing
 Sloughs naturally in 5-10 days, but if need to remove use acetone
or petroleum jelly to peel but not pull apart skin edges
 Pt education and documentation

168. Dermabond®
 Standard surgical wound prep and dry
 Crack ampule or applicator tip up; invert
 Hold skin edges approximated horizontally
 Gently and evenly apply at least two thin layers
on the surface of the edges with a brushing
motion with at least 30 s between each layer,
hold for 60 s after last layer until not tacky
 Apply dressing

169. 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

170. Practice! Practice! Practice!

171. REFERENCES
 Text book of oral and maxillofacial surgery by
Daniel.M.Laskin-vol.1
 Text book of oral surgery by peterson-5th edition
 Text book of short practice of surgery by Bailey & love-
24th edition,
 Textbook of oral &maxillofacial surgery by neelima
malik -1st ed
 Textbook of oral &maxillofacial surgery by Chithra
Chakravarthy, 2nd edition

172. Thank you