2. INTRODUCTION
The primary purpose for suturing -to hold tissue
layers and wound edges in close approximation
until the healing process provides the wound with
sufficient strength to withstand stress without the
need for mechanical support.
Sutures may be used to either assist healing by
first intention or to minimize wound
contamination or to control haemorrhage.
3. SUTURE MATERIALS
Ideal suture materials have following
properties:
Adequate strength
Good handling and knot tying
characteristics
Sterilizable
Evoke little tissue reaction
8. ABSORBABLE SUTURE MATERIALS
® degraded in vivo by enzymatic and
phagocytic mechanisms and / or hydrolysis
and thus over time diminish in strength and
disappear from the tissue.
® The speed of absorption of a suture is
roughly proportional to the vascularity of
the surrounding tissues.
9. ® In general, absorbable sutures are made to be
buried in deep subsurface layers of tissues where
they will be slowly absorbed over several days while
holding the sutured tissues together.
® Examples:
• Plain surgical gut (catgut)
Biologically derived
Chromic catgut (tanned gut)
Polyglycolic acid (Dexon)
Synthetic
Polyglactin 910 (Vicryl)
10. • Gut
–Derived from sheep intestinal
submucosa or bovine intestinal serosa
–Smallest tensile strength
–Packaged in isopropyl alcohol as a
preservative (since highly susceptible
to enzymatic degradation).
11. – Absorbed by proteolytic degradation and
phagocytosis. This is accompanied by
considerable inflammation and tissue
reaction.
– Plain gut – more difficult to use than other
suture materials as it is stiff and has
insecure knot holding characteristics when
wet.
12. • Chromic gut – is plain gut that has been tanned
with a solution of chromium salts prior to being
spun, ground and polished. Chromium salts act as
a cross-linking agent and increase the tensile
strength of the material and its resistance to
absorption by the body.
• Advantages of chromic gut over plain gut:
• Slightly increased strength
• Prolonged rate of absorption
• Lesser stimulation of tissue reaction
13. • Polyglycolic acid and polyglactin 910
–Resorbed by hydrolysis
–Since they are synthetic polymer, they
produce very little tissue reactions.
14. NON-ABSORBABLE SUTURE MATERIAL
• Primarily used on surface layers .
• Require surgical removal after fulfilling their
mission.
• Can be natural or synthetic
• Example – Natural – silk, cotton, linen
Synthetic – Dacron, nylon, polyester
polypropylene
15. • Silk
Most popular suture material for intraoral
use
braided which gives it excellent handling
characteristics
produces a moderate tissue response
does not irritate adjacent mucous
membrane
Inexpensive
16. • Nylon
Braided or monofilament forms
Because of its stiffness, the large knot
required and a tendency to tear
through non-keratinized tissue, nylon
is not frequently used intraorally.
18. Synthetic
– superior tensile strength
– minimal capillary action within the wound
– induces less inflammatory reaction.
– Example: polyglycolic acid sutures, Dacron,
nylon, polyester, polypropylene.
19. MONOFILAMENT / POLYFILAMENT
SUTURE MATERIALS
Monofilament: contains single strand
– Example : Polyamide, polypropylene, catgut.
Polyfilament: made up of multiple fibres –
either braided or twisted
– Example: polyglycolide, silk, cotton, linen,
steel.
20. • The size of suture material is with reference to its
diameter.
• The smallest size that will provide the desired
wound tension must be chosen.
• The higher the number, the smaller the suture.
• Sutures are sized such that No3 is the largest and
7-0 is the smallest in general use.
• The more zeroes in the number the smaller the
diameter of the strand.
• Sutures of 5-0 or 6-0 are generally used for skin
closure in the head and neck, while 3-0 and 4-0 are
used intraorally.
21. INSTRUMENTATION
• Instruments and materials needed during
suturing techniques are as follows:
– A needle holder
– A pair of tissue forceps
– Suturing needles
– Suture material
– A pair of scissors
22. NEEDLE HOLDERS
– Resemble artery forceps, but it is characterized by
the presence of short and stout beaks with serrated
surfaces to prevent the needle from slipping during
the usage. However handles are sufficiently long.
– Ideally the needle is held clamped by the beaks of
the needle holder of a position, nearly two-thirds of
the distance from the tip of the needle.
• While the needle is passed through the tissues, the flap
is gripped with a pair of tissue forceps, with the free
margin of flap held everted.
23. SUTURING NEEDLE
• The needle for suturing vary in size,
Curvature, profile of their cutting point.
• Needles are made of either stainless steel or
carbon steel.
• Two basic shapes :
Straight
Curved
24. • Straight needle
tapered configuration (circular / oblong in cross section)
cutting configuration (triangular in cross section)
• Straight cutting needle
• -used for skin closure in places with adequate
access, such as abdominal, thoracic or iliac regions.
-In oral and maxillofacial surgery -used for the
passage of circumzygomatic or circummandibular
wires.
25. Curved Needles
• used for both skin and mucous membrane surgery
• Manufactured with varying curvatures such as
1/4 , 3/8, ½, 5/8 circle.
Needles:
A - ¼ circle,
B - 3/8 circle,
C – ½ circle
D – ¾ circle,
E – straight with curved end
F – straight
26. Needles in cross section
A – Tapered, B – Cutting, C – Reverse cutting
27. • Tapered or cutting types:
• Cutting needles are further categorized as :
– Conventional – has one of its three cutting edges
along the internal curvature of the needle.
– Reverse cutting – has a flat internal surface.
• Tapered needle is generally used for closing
mesenchymal layer such as muscle /fascia
that are soft & easily penetrable.
28. • Cutting needle – is used for
keratinized mucosa, skin or
subcuticular layers where the tissue
is difficult to penetrate.
• The cutting edge needle make a
lateral cut as it is perforating. It
makes suturing easier through
ligamentous tissue.
29. Needles also vary in their attachment for the suture
material
In swaged needle the suture material is inserted into
the hollow end during manufacture and metal is
compressed around it. The needle is not reusable. It
is atraumatic.
Eyed needle is designed to be reused and suture
material is tied to the needle. These produce slightly
larger holes in the tissue.
30. PRINCIPLES OF SUTURING TECHNIQUES
• The needle holder should grasp the needle at
approximately ¾ of the distance from the needle tip.
• The needle should enter the tissue perpendicular to
the surface.
• The needle should be passed through the tissue
following the curve of the needle.
31. • The suture should be placed at an equal distance (2
to 3 mm) from the incision on both sides and at an
equal depth.
• It one tissue side is free (as with a flap) and the other
fixed the needle should be passed from the free to
the fixed side.
• If one tissue side is thinner than the other then the
needle should be passed from the thinner to the
thicker side.
32. • The distance that the needle is passed into the tissue
should be greater than the distance from the tissue
edge. This will ensure a degree of tissue eversion.
Some degree of tissue eversion is desirable in
anticipation of scar contracture.
• The tissues should not be closed under tension, since
they will either tear or necrose around the suture. If
tension is present the tissue layer should be
undermined to relieve it.
33. • The suture should be tied so that tissue is merely
approximated not blanched.
• The knot should not be placed over the incision line.
• Sutures should be placed approximately 3 to 4 mm
apart. The closeness of the sutures depends on the
anticipated tension across the suture line. Closer
spaced sutures are indicated in areas of underlying
muscular activity such as the tongue or in other
areas of increased tension.
35. Factors that determine the type of suture are:
• type of the tissue
• condition of the wound
• healing process
• anticipated post operative course.
36. INTERRUPTED SUTURES
• Most commonly used
• Each suture is independent of the next
offering strength and flexibility in placement.
Simple interrupted suture
37. • Advantage:
• It is strong
• Successive sutures can be placed in a manner
to fit the individual requirements of the
situation.
• The integrity of the suture remains intact even
if one suture is disturbed or lost.
• Only Disadvantage – is the time required when
compared to other techniques.
38. • Needle enters the mucous membrane from the external
to the tissue surface of the mobile flap.
• Then needle passes from the tissue surface through the
fixed flap and comes out on the surface. Hence both the
points of entry and exit are on the outer surface of the
flaps respectively.
• Both these points should be equidistant from free
margins of the flaps.
39. • Both the ends of the suture materials are tied either by
hand or with instruments.
• At the time of tightening the knot wound margins must
be everted.
• Tension must be distributed equally.
• The suture material is adjusted in such as way that the
knot lie over the needle puncture point in any one side
of the wound and not on the suture line.
• The suturing is done at regular intervals.
40. CONTINUOUS SUTURE
• Used to suture a wide area
• It should not be used in areas of existing
tension
• Advantage:
– Ease and conserving the time of suturing
– Even distribution of tension over the
entire suture line
– Provides a water tight closure of the
wound.
42. • Disadvantage :
– If the wound gives way in any one place it
disrupts the entire wound.
• This is very similar to interrupted sutures. But
instead of tying the knot, the needle is passed again
through the mobile flap and the process continued
till the entire wound is sutured. The knot is placed
at the end only.
43. LOCKING CONTINUOUS SUTURE
• 2 Advantages over simple continuous technique :
suture will align itself perpendicularly to the incision
locking feature prevents continuous tightening of the
suture as wound closure progresses.
Continuous locking
technique
44. • Suture is passed perpendicular to incision line and
degree of locking is provided by withdrawing suture
through its own loop. This suture technique is begun
and ended identically to continuous technique.
• Care must be exercised not to tighten the individual
lock excessively since this can produce tissue necrosis.
• Locking feature may prevent adjustment of tension
over the suture line as tissue swelling occurs
45. MATTRESS SUTURE
• Main purpose of mattress suture is to
provide more tissue eversion than
occurs with simple interrupted suture.
• Mattress suture can be horizontal and
vertical type.
46. • Point of entry and exit are located in the same flap.
• Point of entry is similar to the interrupted suture.
• The needle passes through the mobile flap and
then through the fixed flap. Instead of placing a
knot the needle is passed in the reverse direction
from the fixed flap through the mobile flap so that
ultimately needle returns back near the point of
first entry.
47. • In horizontal mattress type, point of entry
and point of exit are situated equidistant
from the free margins of the mobile flap.
That means wider areas of the flap are
sutured.
Horizontal mattress
technique
48. • In vertical mattress type, point of entry is situated
away from the wound margin deep into the tissues
while the point of exit is near the wound margin.
Both these points are one above the other.
• Horizontal mattress suture if improperly used
compromise blood supply to the flap edge on both
sides of incision causing necrosis and dehiscence.
Vertical mattress
technique
49. FIGURE OF 8 SUTURE
• Used over extraction sites where it provides some
protection to the surgical area as well as adaptation
of the gingival papillae around the adjacent teeth.
50. TYPES OF KNOTS
SQUARE KNOT
• Formed by wrapping suture around needle holder once in
opposite directions between ties.
• It is prudent to provide at least 3 ties for surface knots.
• Certain types of suture material such as nylon,
polypropylene, polyglycolic acid, and gut may require more
ties
Square Knot
51. SURGEON’S KNOT
• Formed by two throws of suture around needle
holder on first tie and then one throw in opposite
direction on second tie.
• Because of the double throw, the surgeon’s knot offer
the advantage of reducing slippage of the first tie,
while second tie is put in place.
• useful in confined or difficult to reach places where
the first tie would ordinarily be loosened in the
process of producing the second tie.
• A third tie squared on the surgeon’s knot is usually
made for security.
53. GRANNY KNOT
• This knot involves a tie in one direction followed
by a single tie in the same direction as the first.
• This will allow the knot to be slipped to place and
provide initial holding similar to the surgeon’s
knot.
• Moreover a 3rd tie squared on the second must be
made to hold the knot permanently.
54. SUTURE REMOVAL
• Usually the wound margins are cleaned with
antiseptics. The sutures are removed between 5th and
7th post-operative day.
• When sutures are removed, the suture (the knot)
should be grasped with an instrument (forceps) and
elevated above the epithelial surface. A scissors
should be used to transect or cut off one side of the
loop as close to the epithelial surface as possible.
55. • The portion of suture which is exposed to the outside
environment becomes laden with debris and
bacteria.
• So that the minimal portion of this exposed suture to
be dragged through the tissue the loop is cut as close
to the epithelial surface as possible.
• If the suture is cut midway the contaminated
external loop is pulled through the wound that
predisposes to wound infection.
56. A. An intra-oral suture is loose and impregnated with food detritus after being
in situ for 1 week.
B. If suture is cut just below the knot as in B the wound is contaminated as
infected silk is pulled through the tissues.
C. if the suture is cut just as it enters the tissues the above complication is
avoided.
