sutures and suturing techniques


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sutures and suturing techniques

  2. 2. Dr. M.G.R MEDICAL UNIVERSITY C.S.I COLLEGE OF DENTAL SCIENCES AND RESEARCH Certificate This is to certify that the Library Dissertation entitled “SUTURESAND SUTURING TECHNIQUES” was conducted by the UnderGraduatestudent, VESTA ENID LYDIA.R, under my guidance and supervision inpartial fulfillment of the requirements of the Dr. M.G.R Medical University,for the award of the degree “Bachelor of Dental Surgery”. Dr.JayaPrakash, Professor & H.O.D, Department of Oral & Maxillofacial SurgeryDate:Madurai. 2
  3. 3. ACKNOWLEDGEMENTFirst of all, I would like to thank the almighty , for givingme the strength and health to do this library dissertationwork until it be done Not forgotten to my family forproviding everything, such as money, to buy anything thatare related to this project work and their advice, which isthe most needed for this project. Internet, books, computersand all that as my source to complete this project. They alsosupported me and encouraged me to complete this task sothat I will not procrastinate in doing it.It is with deep satisfaction and gratitude that Iacknowledgenmy guide,DR.JAYAPRAKASH ,MDS, HOD oforal surgery CSICDSR for scholoraly guidance,help andconfidence ,encouragement which enabled me to completethis study.I whole heartedly thank DR.RATHNAKUMAR ourprincipal for providing the necessary infrastructure andenvironment that is conductive for research activities,incollege. 3
  4. 4. And Im greatfull to DR.THANVIR MOHAMMED NIAZI,MDS,DR.ULAGANATHAN,MDS,DR.YOGANATHA,MDS, fortheir mentoring heartfull discusions,continious guidance andadvices. 4
  6. 6. 6
  7. 7. INTRODUCTIONWound repair is a well orchestrated and highly coordinated process that includesa series of overlapping phases: inflammation, cell proliferation, matrix deposition,and tissue remodeling.Sutures play an important role in wound healing aftersurgical interventions and thus the selection of suture material, especially in oralprocedures, must be made carefully. This location differs from other body sitesdue to the constant presence of saliva, specific microbiata, high vascularization,as well as its functions related to speech, mastication and swallowing.The series of pathological changes associated with several diseases ultimatelyleads to severely disturbed wound healing conditions.Systemic diseases whichdelay wound healing is another significant point that ef- fects the choice of suturematerial and represent major clinical importanc.Diabetic wound healingimpairment is one of the most well-known chronic wound situations.The factorsensuring appropriate intercellular communication during wound repair are notcompletely understood.The primary objective of dental suturing is to position and secure surgical flaps topromote optimal healing. When used properly, surgical sutures should hold flapedges in apposition until the wound has healed enough to withstand normalfunc- tional stresses. When the proper suture technique is used with theappropriate thread type and diameter, tension is placed on the wound margins 7
  8. 8. so primary intention healing occurs.1 Accurate apposition of surgical flaps issignificant to patient comfort, hemostasis, reduction of the wound size to berepaired, and prevention of unnecessary bone destruction. If surgical woundedges are not properly approximated and are therefore inadequate,hemostasis is present and blood and serum may accumulate under the flap,delaying the healing process by sep-arating the flap from the underlying bone.Learning how to suture wounds and lacerations requires a thoroughunderstanding of the theory of wound care and the basic principles of suturing.webelive that this work on sutures and suturing techniques will enlighten yourknowledge on patient care with the available source. 8
  9. 9. REVIEW OF LITERATURESometime between 50,000 and 30,000 B.C. eyed needles were invented, and by20,000 B.C., bone needles became the standard that was not improved upon untilthe Renaissance. It is reasonable to assume that these needles were used to sewwounds together, because Neolithic (“of the ‘New’ Stone Age”) skulls have beenfound, showing that trepanning (a form of surgery where a hole is drilled orscraped into the skull) was used successfully. Evidence shows that the woundsmust have been closed up after the procedure because there is bone growthinward from the edges of the hole;this means that the patient was not only alive at the time of the operation, but livedfor a considerable period of time afterward. 9
  10. 10. The primitive men in the beginning of more modern times give examples of howearly surgery was performed. Native Americans used cautery (the burning of thebody to remove or close a part of it) and East African tribes would ligate (tie off)blood vessels with tendons and close wounds with acacia thorns pushed throughthe wound with strips of leaves wound around the two protruding ends in a figureeight.A South African method of wound closure uses large black ants to bite the woundedges together, with their powerful jaws acting as Michel clips. The bodies wouldthen be twisted off, leaving the head in the place to keep the wound closed. Inmore ancient times (1,900 B.C.), the king of Babylon, Hammurabi, engraved hiscountry’s laws on a pillar. Some of these law related to surgical practice; onestated that “If a physician should make a severe wound with an operating knifeand kill a patient or destroy an eye, his hands shall be cut off.” Because of this and similar other laws, the Babylonian practice of medicine 10
  11. 11. declined so far that people with illness and disease were carried into the marketsquare so that they could get recommendations and advice from people who hadalready experienced the illness.The Mesopotamian civilizations are known to have been in regular contact withthe India and one Indian man wrote a surgical text which was a great reservoir ofinformation. Susruta described how to perform, in great detail, a tonsillectomy,caesarean section, amputation, rhinoplasty and the repair of anal fistulae.Rhinoplasty was a popular operation since the punishment for adultery washaving the offender’s nose cut off. There were many different, yet successful,surgical procedures performed, such as the opening of the intestines and removalof any blockage, rinsed with milk, then lubricated with butter and then finallyclosed by the ant head method described before. Instruments were described indetail in this surgical text, including triangular,round-bodied, curved, or straightneedles; sutures were made from hemp, hair, flax, and bark fiber. Training forincisions was very important and they used melons, gourds, and animal bladders 11
  12. 12. to practice suturing and lotus stems for ligating. It is obvious from this and othertexts that Indian surgery was considerably ahead of any other early civilizationand it can be assumed that much of Arabic, Babylonian, Egyptian, and Greeksurgery techniques originated in India.In the seventh century B.C., the Greeks began to found medical schools becauseof the great demand for surgical and medical attention; it was also at thisparticular time that medicine was finally recognized as a science. A Greekphysician by the name of Hippocrates is considered to be one of the mostoutstanding figures in the history of medicine.His main contributions to surgery were his detailed clinical descriptions and thediscarding of treatments founded on tradition or wishful thinking rather than onrationalitySometime around 30 A.D., a medical encyclopedia was written by a Romannamed Aurelius Cornelius Celsus. His work, De Re Medicina, tells the reader thatsutures should be “soft, and not over twisted, so that they may be more easy on 12
  13. 13. the part.” He is also credited with first substantiated mention of ligating byrecommending it as a secondary means of stopping haemmorhageGalen, an ancient Greek physician from A.D. 150, gained a sterling reputationfrom treating and suturing the severed tendons of gladiators, giving them achance at recovery ratherthan the sure fate of paralysis.He was an authority on suture thread materials and has many recommendationson which material would be best for each sort of wound closure in his book DelMethodo Medendi. Also, Galen, along with Hippocrates, recognized two kinds ofwounds: a clean wound and a dirty wound (which required drainage beforehealing could occur).A Muslim scholar named Avicenna became known as the Prince of Physiciansbecause at twenty years old, he had already written extensively on philosophy,natural history, mathematics, law, and medicine (of which he was already anauthority). 13
  14. 14. Another development in suturing was Avicenna’s realization that some traditionalmaterials had a tendency to break down rapidly; because of this, he invented thefirst monofilament suture by using pig’s bristles.Avicenna may have been thePrince of Physicians, but the Prince of Surgeons was undoubtedly Albucasis. Inhis first book, he recommended the indiscriminate use of cautery, but in hissecond book, the use of cutting instruments and sutures were implementedinstead. In this book he described a technique called a “double suture” which isstill used today.The technique of closing wounds by means of needle and thread is severalthousand years old. The history of surgical sutures can be traced back to ancientEgypt, and the literature of the classical period contains a number of descriptionsof surgical techniques involving sutures.Before catgut became the standard surgical suture material towards the end of the19th century, many different paths had been followed to find a suitable material for 14
  15. 15. sutures and ligatures. Materials that had been tried included gold, silver and steelwire, silk, linen, hemp, flax, tree bark, animal and human hair, bowstrings, and gutstrings from sheep and goats.At the beginning of the 19th century metal threads were tested as suture material.At that time inertness of a material with respect to body tissues was considered anadvantage. Nevertheless, metal threads had major disadvantages: their stiffnessrendered knotting more difficult and could easily result in knot breakage; inaddition, suppuration of the wound edges occurred frequently.These negative experiences with metal contributed to the establishment of silk asthe number one suture material. Wounds sewn with silk cicatrised within a fewdays, and the small knot caused no problems. For these reasons most surgeonsat that time chose silk for sutures and vessel ligatures. A fundamental change inthe assessment of suture materials followed the publication in 1867 of Lister’’sresearch on the prevention of wound suppuration. On the basis of work by Kochand Pasteur, Lister concluded that wound suppuration could be prevented bydisinfecting sutures, dressings, and instruments with carbolic acid. Initially Listerused silk as a suture material, on the assumption that it was absorbable andtherefore could also be used for ligatures. Later he searched for a more rapidlyabsorbable material and consequently began to use catgut. 15
  16. 16. Catgut is produced from animal connective tissue, in particular bovine subserosa.Over the years it gradually emerged that animals born and bred in South Americawere most suitable because they had the lowest fat content thanks to their naturalhusbandry conditions.The use of catgut was never called into question until the appearance of BSE atthe beginning of the 21st century. Alternative products had already beendeveloped by this time. These are the synthetically manufactured absorbablesuture materials which have largely superseded catgut in Europe. However,catgut continues to play a major role in woundcare world-wide.A wide variety of sterilization methods have been tested at various times.Nowadays sutures are mostly sterilized by ethylene oxide or gamma irradiation.Inresponse to the requirements of modern surgery and thanks to the efforts of usersand manufacturers over the last few decades, a wide variety of sutures have nowbeen developed have made these sutures available to all Surgeons ARMAMENTARIUM TOOLS FOR SUTURING 16
  17. 17. To obtain the best results, it is important to have good quality instruments that are the correct size for the location and nature of the wounds being closed. The instruments also need to be correctly sterilised and handled carefully.SURGICAL SCISSORSSurgical scissors are classified according to the 2 blade tips - thus: • Sharp–sharp • Sharp–blunt • Blunt–bluntSometimes scissors are classified according to function – for example: • Suture cutting scissors • Dissection scissors In certain operations it is safer to carefully dissect your way towards an area/organ rather than cutting into the tissues with a sharp scalpel blade. 17 1
  18. 18. Use your medium Sharp–blunt scissors for general cutting purposes and to cutoff excess suture material after placing a suture and tying the knot.Use the small Sharp-sharp scissors to cut the suture for removal.SURGICAL PROBES (SEEKERS) • Sharp (straight) • Blunt (slightly curved)Probes are also classified as: • Hollow • Solid 18
  19. 19. A dentist uses a sharp curved probe to examine teethand detect cavities.Anesthetists and radiologistsuse flexible blunt probes to maneuver their way intospecific veins or arteries in the body (for diagnostic or therapeutic purposes)SKIN HOOKA skin hook is used to lift a section of skin, to facilitate the placement of sutureswhile minimizing the amount of injury to the tissues.By placing two skin hooks intothe tissue at the corners on the 2 sides of a laceration, and gently lifting both skinhooks, one can facilitate eversion (having a slightly raised sutured lacerationcompared to the adjacent tissue). 19 1
  20. 20. SCALPELA scalpel is a surgical knife with a fixed or removable blade (cutting area).Removable blades are produced in a variety of patterns and sizes.FORCEPSA forceps is an instrument used in medicine to grab or to hold something.Suture Kit contains a general-purpose tweezer-forceps. The inside of the tips(jaws) are serrated to enhance gripping. This forceps is used for general handlingand gripping of tissue or objects. 20
  21. 21. The other forceps is called a tissue forceps. The tip of this forceps shows asharpish tip (jaws) on the one leg and a v-shaped groove on the other side. It iscommonly referred to as a rat-tooth forceps. Use this forceps to handle tissuewhen placing sutures.NEEDLE HOLDERA Needle Holder is a special type of forceps, designed to securely holdthe surgical suture needle when placing sutures. Artery forceps are somewhatsimilar in appearance, but have longer jaws – some with straight and some withcurved jaws. 21
  22. 22. SUTURE MATERIALSIn addition to proper technique, it is critical to select the appropriate type and size(diameter) of suture material to ensure that wound margins are free of tension, allowing healing by primary intention. Accurate apposition of surgical flapscontributes to patient comfort, hemostasis, reduction of wound size, andprevention of unnecessary bone resorption. If surgical wound edges are notproperly approximated, hemostasis can be compromised and blood/serum mayaccumulate under the flap. This could result in a space between the underlyingsoft tissue and bone, thus delaying the healing process. In addition, when thisoccurs, healing will be by secondary intention, which can lead to irregular soft-tissue contours and the formation of scar tissue.Conventional intraoral surgical treatment concludes with closure of the soft tissue.Proper suturing precisely positions the mucosal and/or mucoperiosteal flaps asrequired by the surgical procedure being performed. Certain periodontal surgical 22
  23. 23. procedures (eg, excisional new attachment procedure [ENAP] and modifiedWidman flap procedure) require the surgical flap margins to be positioned in theiroriginal location, whereas other periodontal procedures may require that thesurgical flaps be placed apically, coronally, or laterally to their original position inorder to achieve the surgical objectives.Suturing technique, the type and diameter of suture material (thread), the type ofsurgical needle, and the design of the surgical knot are essential factors inachieving optimal wound healing. Wound closure variables are different whensuturing over hard versus soft tissue, or suturing over various types of materialsplaced into the surgical site to promote periodontal regeneration (eg, bone graftmaterial or a membrane). The suture material and needle design will changeaccordingly.Tensile strength is an important quality when determining which suture material isappropriate for specific situations. Tissue biocompatibility and ease of handling,with a focus on minimal knot slippage, also influence which thread should beselected. The clinician should select the suture material and diameter based onthe thickness of the tissue to be sutured and whether there is a need for flaptension.Therefore, selection of the suturing technique and material should be based onthe goals of the surgical procedure and the physical/biologic characteristics of the 23
  24. 24. suture material in relationship to the healing process. Adequate strength of thesuture material will prevent breakage during suturing, and proper tying of the knotin consideration of the material being used will prevent untying or knot slippage.The clinician must also understand the nature of the suture material, the woundhealing process, the biologic forces exerted on the healing wound (eg, musclepulls and swelling), and the interaction of the suture and tissue. The suture mustretain its strength until the tissues of the flaps regain sufficient strength to keep thewound edges together. In clinical situations where the tissues will not regain theirpreoperative strength, or tension is exerted on the surgical flaps, considerationshould be given to using a suture material that retains long-term strength (up to 14days) and resorbs in 21 to 28 days, such as conventional polyglycolic acid (PGA)suture material. A clinical example would be a resorbed anterior mandible that hasmuscle attachments close to the crestal ridge; when the flap margins arereapproximated there will be tension on the margins. Should a resorbable suturematerial be used that loses its tensile strength after a few days, the re-adhesion ofthe periosteum to the underlying bone will not have gained enough strength toovercome the muscle pull. Therefore, a longer-lasting suture material should beutilized until the flap has achieved sufficient reattachment to the bone.Resorbable sutures lose tensile strength over a period of time from several daysto several weeks, and the breakdown of the resorbable material should equal thehealing rate of the tissue being coapted by the material. If a suture is to be placed 24
  25. 25. in tissue that heals rapidly, a resorbable suture should be used that will lose itstensile strength at approximately the same rate as the tissue gains strength. Thesuture will be absorbed by the tissue, leaving no foreign material in the woundafter healing. Examples are surgical gut or the rapidly resorbable PGA sutures(PGA-FA).Resorbable sutures re-sorb due to 2 mechanisms. Sutures of biological origin (eg,surgical gut, plain and chromic gut) are gradually digested by enzymes in thetissue, whereas resorbable sutures fabricated from synthetic materials such aspolygycolic acid are hydrolyzed via the Krebs cycle.2 Surgical gut suture materialis made from animal protein (ie, gut), thus it can potentially induce an antigenicreaction.6 When used intraorally, this material loses most of its tensile strength in24 to 48 hours; coating the material with a chromic compound extends resorptionto 7 to 10 days, and extends significant tensile strength to 5 days.An additional consideration with regard to gut su-tures is that breakage of thematerial during the resorption process may occur too rapidly to maintain flapapposition, particularly if used in patients with a very low intraoral pH.4 Manyphysiological events can cause a decrease in intraoral pH, including disorderssuch as epigastric reflux, hiatal hernia, and bulimia. Sjogrens syndrome,chemotherapy, radiation therapy, and certain medications (eg, angiotensin-converting inhibitors, anti-psychotics, diuretics, antihypertensive agents, 25
  26. 26. antipsoriasis medications, and steroid inhalers) can cause xerostomia and a lowintraoral pH.Coaptation of tissue flaps requires a minimum of 5 days.5 Selection of a fast-absorbing PGA suture is indicated in clinical situations where there is a lowintraoral pH (and surgical gut sutures are contraindicated). PGA-FA suturematerial is not affected by low intraoral pH; it is manufactured from syntheticpolymers and is mainly degraded by hydrolysis in tissue fluids (via enzymesinvolved in the Krebs cycle). This requires 7 to 10 days. This material has ahigher tensile strength than surgical gut suture material, but its resorption rate iscomparable to that of surgical gut sutures under normal intraoral physiologicconditions.Nonresorbable sutures are fabricated either from natural or synthetic materials.Silk has been the most widely used material for dental and many other types ofsurgery. Silk is easy to handle, is tied with a slipknot, and costs less than manyother nonresorbable suture materials. However, silk sutures have certaindisadvantages. Being nonresor-bable, silk sutures must be removed by theclinician, usually 1 week following surgery. The patient generally is notanesthetized for this suture removal. Further, being a multifilament thread, silkdemonstrates a "wick effect," which pulls bacteria and fluids into the woundsite.9Therefore, silk is not the suture material of choice when foreign materials 26
  27. 27. such as dental implants, bone grafts, or regenerative barriers are placed under amucoperiosteal flap, or when infection of the surgical site is present at the time ofsurgery (ie, removal of a septic tooth).Nonresorbable sutures that can be used in situations where silk is contraindicatedinclude nylon, polyester, polyethylene, polypropylene, or expandedpolytetrafluoroethylene (e-PTFE). Polyester sutures comprise multiple filaments ofpolyester polymer, which are braided into a single strand that possesses hightensile strength and does not weaken when moistened. A biologically inert,nonresorbable compound of proprietary composition4 is often used to coat thesesutures to aid the suture in passing more easily through tissues. However, thiscoating allows the material to untie easily unless the suture is secured with asurgeons knot. Nonresorbable e-PTFE suture material is a monofilament withhigh tensile strength, good handling properties, and good knot security. It is,however, expensive compared with other nonresorbable suture materials.Inaddition to material composition, surgical threads are also classified by numberingfrom 1 to 10; higher numbers indicate thinner, more delicate thread. 10 Forexample, in implant dentistry a 3-0 thread diameter is generally used to secureflaps when a mattress suturing technique is used, and a 4-0 thread is used closerto the flap edges to coapt tension-free flap edges. A 4-0 thread also is used to 27
  28. 28. secure implant surgical flaps when interrupted sutures, horizontal or verticalmattress sutures (depending on where the tissue is positioned), and mostcontinuous suture techniques are utilized. In periodontal plastic surgeryprocedures a 5-0 thread diameter is most often used to secure soft-tissue graftsand transpositional/sliding pedicle flaps. When securing most other periodontalmucoperiosteal flaps, 4-0 thread is used ABSORBABLE MATERIALSCatgut plain – used to suture mucous membrane of lips, tongues superficiallaceration of the genital area. They are easily absorbed within one week.Catgut chromic – used to suture fascia, muscles, or ligature of bloodvessels.It is usually absorbed within 30 – 45 days.vicryl – same as above. Takes at least 70 days for absorption. Rapid vicryl iseasily absorbed. 28
  29. 29. PDS – expensive, takes at least 5 – 6 months to be absorbed.However, vicryl is the most commonly used suture materials during surgerywhile closing in layers. TENSILE COLOR OF STRENGTH ABSORPTIO SUTURE TYPES RAW MATERIAL MATERIAL RETENTION N RATE in vivo Surgical Gut Plain Yellowish- Collagen derived from Individual Absorbed Suture tan healthy beef and patient by sheep. characteristics proteolytic Blue Dyed can affect rate enzymatic of tensile digestive strength loss. process. Surgical Gut Chromic Brown Collagen derived from Individual Absorbed Suture healthy beef and patient by Blue Dyed sheep. characteristics proteolytic can enzymatic affect rate of digestive tensile process. strength loss. (polyglactin Braided Violet Copolymer of lactide Approximately Essentially 910) Suture and glycolide coated 75% remains atcomplete Monofilament Undyed with polyglactin 370 two weeks.between (Natural) and calcium stearate. Approximately 56-70 days. 50% remains Absorbed at three weeks. by Coated Braided Undyed Copolymer of lactide Approximately hydrolysis. Essentially (polyglactin (Natural) and glycolide coated 50% remains complete by 910) with polyglactin 370 at 5 days. All 42 days. Suture and calcium stearate. tensile Absorbed by strength is lost hydrolysis. at approximately 14 days. 29
  30. 30. (poliglecaprone Monofilament Undyed Copolymer of Approximately Complete25) Suture (Natural) glycolide and epsilon- 50-60% at caprolactone. (violet: 60- 91-119 Violet 70%) remainsdays. at one week.Absorbed Approximately by 20-30% hydrolysis. (violet: 30- 40%) remains at two weeks. Lost within three weeks (violet: four weeks). (polydioxanone Monofilament Violet Polyester polymer. Approximately Minimal until) Suture 70% remains atabout 90th Blue two Approximately Essentially Clear 50% remains atcomplete four weeks.within six Approximately months. 25% remains Absorbed at six weeks. by slowBraided Braided hydrolysis. Copolymer of lactide Approximately Essentially UndyedSynthetic (White) and glycolide coated80% remains atcompleteAbsorbable with caprolactone/3 months.between 18Suture glycolide. Approximately and 60% remains at30 months. 6 months.Absorbed Approximately by slow 20% remains hydrolysis. at 12 months. NON-ABSORBABLE MATERIALSEthilon – most commonly used to close and suture skin after surgery ortrauma to the skin. Cutting needles are usually used. 30
  31. 31. Prolene – used to suture nerve, tendon or blood vessels. Preferable roundbody needles are used.Silk and Linen – have similar properties. They are very strong, but they areadherent to the tissues and can caused reaction or infection. TENSILE COLOR OF STRENGTH ABSORPTIO SUTURE TYPES RAW MATERIAL MATERIAL RETENTION N RATE in vivoSilk Braided Violet Organic Progressive GradualSuture protein called degradation encapsulatio White fibroin. of fiber may n by fibrous result in connective gradual loss tissue. of tensile strength over time.Surgical Stainless Monofilament Silver 316L stainless steel. Indefinite. NonabsorbablSteel Suture metallic e. MultifilamentNylon Monofilament Violet Long-chain Progressive GradualSuture aliphatic polymers hydrolysis encapsulatio Green Nylon 6 or Nylon may result in n by fibrous 6,6. gradual loss connective Undyed of tensile tissue. (Clear) strength over time.Nylon Braided Violet Long-chain Progressive GradualSuture aliphatic polymers hydrolysis encapsulatio Green Nylon 6 or Nylon may result in n by fibrous 6,6. gradual loss connective Undyed of tensile tissue. (Clear) strength over time. 31
  32. 32. Polyester Fiber Braided Green Poly No GradualSuture (ethylene significant encapsulatio Monofilament Undyed terephthalate) change n by fibrous (White) . known to connective occur in vivo. tissue. Braided Green Poly (ethylene No GradualPolyester Fiber terephthalate) significant encapsulatioSuture Undyed coated with change n by fibrous (White) polybutilate. knownto connective occur in vivo. tissue.Polypropylene Monofilament Clear Isotactic Not subject toNonabsorbablSuture crystalline degradation e. Blue stereoisomer of or weakening polypropylene. by action of tissue enzymes. PolyMonofilament Blue Polymer blend ofNot subject toNonabsorbabl(hexafluoropropyle poly (vinylidenedegradation VDF) Suture fluoride) and polyor weakening (vinylidene fluoride-by action of co- tissue hexafluoropropylene) enzymes. . OTHER SUTURE MATERIALS THAT ARE ALSO USED ARE:Staples – to close wound under high tension, like scalp, trunk and extremeties.Strips and tapes – used to close superficial laceration on the face.Dermabond – very expensive, ideal for simple laceration, but fact around theedges have to be removed. 32
  35. 35. The ideal suture has the following characteristics:• Sterile• All-purpose (composed of material that can be used in any surgical procedure)• Causes minimal tissue injury or tissue reaction (ie, nonelectrolytic, noncapillary, nonallergenic, noncarcinogenic)• Easy to handle• Holds securely when knotted (ie, no fraying or cutting)• High tensile strength• Favorable absorption profile• Resistant to infectionUnfortunately, at the present time, no single material can provide all of thesecharacteristics. In different situations and with differences in tissue compositionthroughout the body, the requirements for adequate wound closure requiredifferent suture characteristics. ESSENTIAL SUTURE CHARACTERISTICSAll sutures should be manufactured to assure several fundamental characteristics,as follows: 35
  36. 36. • Sterility• Uniform diameter and size• Pliability for ease of handling and knot security• Uniform tensile strength by suture type and sizeFreedom from irritants or impurities that would elicit tissue reactionOTHER SUTURE CHARACTERISTICSThe following terms describe various characteristics related to suture material:• Absorbable - Progressive loss of mass and/or volume of suture material; does not correlate with initial tensile strength• Breaking strength - Limit of tensile strength at which suture failure occurs• Capillarity - Extent to which absorbed fluid is transferred along the suture• Elasticity - Measure of the ability of the material to regain its original form and length after deformation• Fluid absorption - Ability to take up fluid after immersion• Knot-pull tensile strength - Breaking strength of knotted suture material (10-40% weaker after deformation by knot placement)• Knot strength - Amount of force necessary to cause a knot to slip (related to the coefficient of static friction and plasticity of a given material) 36
  37. 37. • Memory - Inherent capability of suture to return to or maintain its original gross shape (related to elasticity, plasticity, and diameter)• Plasticity - Measure of the ability to deform without breaking and to maintain a new form after relief of the deforming force• Pliability - Ease of handling of suture material; ability to adjust knot tension and to secure knots (related to suture material, filament type, and diameter)• Straight-pull tensile strength - Linear breaking strength of suture material• Suture pullout value - The application of force to a loop of suture located where tissue failure occurs, which measures the strength of a particular tissue; variable depending on anatomic site and histologic composition (fat, 0.2 kg; muscle, 1.27 kg; skin, 1.82 kg; fascia, 3.77 kg)• Tensile strength - Measure of a material or tissues ability to resist deformation and breakageWound breaking strength - Limit of tensile strength of a healing wound at whichseparation of the wound edges occurs 37
  38. 38. 38
  39. 39. POSSIBLE FAILURE MECHANISMS• Soft tissue strength: One possible failure mechanism is suture cutting through the soft tissue to which it is tied. This is something all suture retaining devices have in common. This failure mechanism is dependent only on the suture, soft tissue and surgical technique so the failure mechanisms involving the bone anchor may be evaluated independently of the soft tissue strength.• Suture strength: The suture is a probable point of failure, partly because the suture is usually weaker than the anchor. The suture may fail at the anchor, knot or some unexpected flaw mechanically isolated from the anchor.• Bone or anchor strength:The anchor may fracture and loosen from the bone or the bone may fracture, resulting in anchor displacement from the bone due to inadequate fixation. Bone fractures are more likely to occur at bony sites which contain greater amounts of cancellous or more porous bone.• Suture fatigue resistance: Notching of the suture as the suture rubs against bone or the anchor during cyclic motion may result in suture breakage. This may not be an important issue except in special applications where healing would not be sufficient to bear expected loads by six weeks.• Anchor fatigue resistance: Cyclic stresses in the device may exceed the endurance limit of the anchor design, resulting in device fracture, loosening and loss of fixation. This may not be an important issue if the tissue heals soon (less than six weeks). 39
  40. 40. SUTURE SIZESModern suture diameters range from thick to thin and are represented by theseries of numbers 5, 4, 3, 1, 0,2-0, 3-0, 4-0, 5-0, 6-0, 7-0, 8-0, 9-0, 10-0 and 11-0.Number 5 sutures are heavy braided sutures used by orthopedic surgeons and11-0 sutures are micro-fine monofilament sutures used by ophthalmic surgeonsoperating with the aid of a surgical microscope. Number 5-0 or 6-0 sutures areused to stitch up lacerations in cosmetically sensitive areas like face 40
  41. 41. SUTURE NEEDLEThe surgical needle is composed of the point, the body, and the swaged (press-fit)end. Classification of suture needles is usually based on their curvature, radius,and shape. For intraoral use, three-eighths and one-half circle needles are mostcommonly used.When using the three-eighths needle to close tissue in the oral cavity, the clinicianrotates the needle on a central axis to pass it from the buccal surface to thelingual surface in one motion, whereas the one-half circle needle is traditionallyused in more restricted areas (eg, buccal surface of maxillary molars and facialsurface of maxillary and mandibular incisors). The one-half circle needle isroutinely used for periosteal and mucogingival surgery.Suture needles may also be classified as either conventional cutting or reversecutting. In the oral cavity, reverse-cutting sutures should be used to prevent the 41
  42. 42. suture material from tearing through the papillae or edges of the surgical flap(referred to as "cut out" ). Conventional su-ture needles are generally associatedwith cut out because the inside concave (inner) curvature is sharpened; as theneedle is pulled through the tissue, it cuts the tissue. This is detrimental in dentalsurgery because the tears that are created will complicate healing. In contrast, theinner curvature of a reverse-cutting needle is smooth, with a third cutting edgelocated on the convex (outer) edge.Figure illustrates the inner curvature of a reverse-cutting needle compared to aconventional needle. For suturing of mucoperiosteal flaps in the oral cavity, thethree-eighths reverse-cutting needle with 3-0 or 4-0 thread diameters and the one-half reverse-cutting needle with thinner 5-0 or 6-0 thread diameters are commonlyused combinations. 42
  43. 43. Modern needles are pre-assembled with a suitable suture material attached to theblunt end. These needles are referred to as “atraumatic” meaning they do nothave an eye that may injure the tissue as it traverses the tissues. The needles inyour Kit have a small eye on the side opposite to the tipfor you to attach the sutureto. Atraumatic needles are manufactured in all shapes for most sizes of sutures.ATTACHMENT OF SUTURE MATERIAL TO A NEEDLE 43
  44. 44. In past generations, a medical professional would routinely use a needle with aneye (an “eye” is a small hole on the blunt side of a needle where the thread isheld) for suturing purposes. The eye part of such a needle may cause minimaldamage as it traverses the tissue.Modern suturing materials have pre-attached thread. Pre-attached sutures allowfor a smooth transition from the needle’s body to the swage and then to the suture– and are thus referred to as an “atraumatic design” (won’t cause further injury tothe tissue).The needle-suture attachment is an occasional weak link, and on rare occasionsmay become undone. This attachment occupies about ⅛ inch (3 mm) on thesuture end of the needle (the swage). One should avoid clamping the NeedleHolder to the swage of the needle as one may interfere with the secureattachment of the suture to the needle.STEP 1-Unroll about 12-16 inches (30-40 cm) of silk suture from one of the reels supplied.STEP 2-Remove one no 16 needle from the package using the Needle Holder. Clamp theneedle roughly in the middle of the needle’s body. Secure the Needle Holder byclamping it to the first ratchet. (Be careful when working with sharp objects). 44
  46. 46. STEP 3Fold the last 1½-inch (4 cm) of suture double and pass the double thread throughthe eye of the suture needle.STEP 4open up the double thread slightly to form a loop, and pass the needle through theloop firmly pull the long and short loose ends of the double hread away from theneedle - thus tightening the simple loop knot to attach the thread to the needle.STEP 5Firmly pull the long and short loose ends of the double hread away from theneedle - thus tightening the SImple loop knot to attach the thread to the needle. 4 46
  47. 47. SUTURING TECHNIQUE GRIPThe needle holder should be held with the palm grip as illustrated in Figure 1.This allows superior wrist mobility than if the fingers are placed in the handleloops. The needle should be grasped between 1/3 to 1/2 of the distance betweenthe suture attachment and the needle tipTHE BASIC PRINCIPLES OF WOUND CAREKNOW YOUR PATIENTIf time allows – take a good medical history, if not take a brief medical history –but always take a medical history -Is your patient allergic to certain localanesthetics, antibiotics and pain medication, antiseptic solutions orplasters/strapping? Does he/she suffer from chronic diseases like Diabetes orbleeding disorders? Are they using any chronic medications? Etc 47
  48. 48. .GOOD VISION (GOOD LIGHTING)Fact is that medical schools have trained a number of blind physicians over theyears – but no blind surgeon yet. Scrub sisters have a saying that the goodsurgeons are those who always complain about the light – might be true, becausethe whole success of the surgical procedure depends on good, proper lighting ofthe operative field offering the surgeon with optimal visual sensory input!ANESTHESIAThe surgeon will make decisions regarding local anesthesia / general anesthesiaand/or sedation. You cannot do your best for a patient who is jumping, jerkingscreaming or crying all the time. 48
  49. 49. ASEPTIC TECHNIQUEComplete sterility of the operative field is not attainable. Sterile instruments andsuture material must be used. Excess suture material must be discarded in acontainer purposed for biological waste. The needle must be discarded in asuitable biological sharps waste container). Avoid using strong antisepticpreparations for cleaning the wound. Most antiseptic solutions will cause damageto the friable exposed tissue cells. In most cases a normal saline solution will besufficient to clean an uninfected wound!REMOVE ALL FOREIGN MATERIALThe removal of all foreign material must be ensured. Remove all pieces of glass,soil, plant material etc. Soil remaining in the wound will cause a traumatictattooing (very difficult if not impossible to remove at a later stage!) If necessarybrush the wound with a bristled brush combined with a mild soap solution e.g.Savlon. Leave the least number of sutures buried in the depth of the tissue - within 49
  50. 50. the limits of getting a secure closure. Remember that suturing materials althoughnecessary are considered by the tissue as foreign material.LEAVE MINIMAL DEAD SPACEWhile suturing, the operator will try to suture living tissue to living tissue. Do notleave empty spaces filled with air, blood or tissue fluid. Dead spaces producewonderful opportunities for bacteria to proliferate and to cause infection. Deadspace may fill up with blood clot and will contribute to the formation of excessivescarring.HANDLE TISSUE GENTLYAlways perform surgery - showing respect for living tissue. Careless suturing maycause more unsightly damage compared to the original wound! Use a toothedforceps to handle the skin (gently touch though). A flat forceps slipping all the timewill cause more damage compared to a toothed forceps handled gently.CONTROL BLEEDINGBleeding can be reduced with suctioning and gentle sponging, and controlled byElectro-cautery (electrical burning) and suturing – ligate (tie-off) larger veins andarteries and use tight suturing over bleeding areas (within reasonable limits ofcourse). Excessive bleeding will decrease your ability to see what you are doingand good vision is the first principle of surgery! 50
  51. 51. General bleeding and an inability of blood to clot may be due to a number ofmedications e.g. aspirin (pain-killer), Hemophilia (a hereditary absence of clottingfactors in the blood), Liver disease, a number of blood diseases, anti-cancermedication (chemotherapy may reduce the blood platelets which are essential fornormal blood clotting to occur) and alcohol consumption (not an infrequent findingwith patients reporting to a hospital’s emergency section). Do take a thoroughpatient history before you start treating the injury!THE REPAIR OF WOUNDSGoals For Suturing WoundsOptimal wound care aims at maximizing functional restoration as well asoptimizing the esthetic result. These goals must occur within the limits ofmaximum patient safety and patient comfort (a calm patient experiencingthe minimal amount of pain and discomfort).Suturing a wound may assist the healthcare professional with 3 immediate goals:• Tight sutures will assist in controlling bleeding (securing hemostasis). It is not asubstitute for normal bleeding control measures e.g. ligating arterial bleeds in thedepth of the wound etc.• It reduces the chances of wound infection. A closed wound is much less prone to 51
  52. 52. wound sepsis than an open wound. Further contamination from the outsideenvironment is also reduced considerably!• Reduced pain. An open wound leaves the severed sensory nerve endings open– thus increasing pain.Suturing a wound will optimize the traumatized tissue’s chances of retainingits blood supply, and at the same time minimizing the formation of unsightlyscar tissue.WOUND CLOSURE IS DIVIDED INTO:• Primary closure – closure within the first 24 hours• Secondary closure – wound closure more than 24 hours after the injury.Primary closure of wounds should be the norm in most cases.Exceptions to the rule would be highly compromised tissue where themedical professional anticipates debridement of the wound (cleaningand cutting away dead tissue and-or foreign material) to be necessary.REASONS FOR WOUND BREAKDOWN• Suturing under tension. Suturing should be passive – do not stretch tissue andtry to close the wound under tension – it will break down!• Sepsis. Common reasons for sutured wounds to open up again are woundcontamination by bacteria and/or foreign material.• Poor blood supply to the wound edges due to the extent of the trauma.• Other factors include irradiated tissue, certain systemic diseases like diabetes, 52
  53. 53. AIDS etc. PRINCIPLES OF SUTURING • The needle should be grasped with the help of needle holders at approximately 3/4th of its distance from the tip of the needle • The needle should never be held at the suture end as it is the weakest point of the needle and grasping at this point results in either bending or breakage of the needle • The needle should pierce the tissue perpenidcular to its surface. The curved needles should be passed through the tissues following the curvature of the needle to prevent tearing of the tissue • The suture should be placed equidistant from the incision line • When one side of the incision is fixed and the other end is free, the needle should be passed from the free to the fixed end When one side of the tissue is thinner than the other side, then the needle should pass from the thinner to the thicker side • similarly, when one side is deeper ant the other side is superficial, the needle should The suture should not be tied too tightly that it results in blanching of the tissues • The knot should be placed over the wound margins • Each suture should be placed 3-4 mm apart 53
  54. 54. • Sometimes extra tissue might be present on one side of the incision and suturing it would result in ‘dog-ear’ formation • pass through the deeper to superficial side • The distance from the incision point to the needle penetration should be less than the depth to which the needle penetrates into the tissue SUTURING TECHNIQUES There are many types of suture patterns available to close the incisions and wounds encountered daily in veterinary practice. Selecting the appropriate type of pattern is important to achieve not only uncomplicated wound healing, but also good cosmetic appearance. However, the important factors that assist in the selection of the appropriate pattern are not always clear. This review article provides some helpful hints and suggestions. Suture patterns are typically categorised as: 1. continuous or interrupted 2. inverting, appositional, or everting 3. the effect the suture pattern has on wound tension.The choice of using interrupted versus continuous suture patterns still remainscontroversial. Perhaps the biggest advantage of continuous suture patterns is 54
  55. 55. their speed, allowing faster wound closure, thereby saving anaesthetic andsurgical time in critically ill patients. However, interrupted patterns allow thetension along the wound line to be more precisely controlled, adjusting tensionaccording to the variable spreading forces along the margin.These types of forcesare usually more of a problem with irregular wound edges. How these woundedges look once they are apposed and the suture pattern is applied can bedescr ibed as either inverting, appositional, or everting. For most tissueclosure, appositional suture patterns are preferable, as they allow the bestanatomical approximation of the disrupted tissue planes. Inverting suturepatterns have been traditionally described for the closure of hollow viscera.However, studies have shown no added benefit of using inverting suturepatterns on routine closure of hollow viscera, and have even documented adelay in healing when compared to appositional suture patterns (Radasch1990). An inverting pattern can sometimes be quite useful, for example toinvaginate a section of stomach wall when managing a patient with gastricdilatation and volvulus whose gastr ic mucosal viability is questionable.Otherwise, due to concerns regarding possible stricture formation and delayedhealing, inverting patterns for gastrointestinal surgery have largely fallen intodisfavour. Everting suture patterns are used primarily in areas that requiredispersal of tension forces along the wound closure line. Many of the tensionrelieving suture patterns commonly in use will produce slight eversion. Thebenefit of having slight eversion on skin closure becomes evident after 55
  56. 56. removal of sutures (or staples), as the scar has a tendency to flatten rather thanwiden. More commonly, most skin closures are accomplished using a moretraditional interrupted or continuous appositional type pattern.ADVANTAGES AND DISADVANTAGES OF INTERRUPTED VERSUS CONTINUOUSSUTURE PATTERNS INTERRUPTED SUTURE PATTERNS Advantages • Allows adjustment of tension throughout the suture line • Failure of one knot is often inconsequential Disadvantages • More time needed to tie individual knots • Poor suture economy Increased amount of foreign material in the wound CONTINUOUS SUTURE PATTERNS Advantages • Faster • Less foreign material in wound • Potentially better airtight or watertight seal Disadvantages • Failure of knot may lead to disruption of suture line • Less precise control of wound approximation and tension 56
  57. 57. SURGICAL KNOTSAll suture patterns start with one basic component - the square knot. Also knownas the ‘reef ’ knot, this knot is primarily used to start and finish all suture patterns,whether continuous or interrupted. Each square knot consists of two ‘throws’, andby reversing directions after each throw and applying even pressure as the knotis tightened, the resulting knot leaves the ‘tags’ of the knot coming out on thesame side of the loops. Extra throws are placed over the square knot to producethe final knot, with the number of throws depending on the type of suture material.As a general rule, all square knots should have a minimum of three total throws(Rosin 1989). Extra throws beyond those necessary to produce a secure knot willresult in unnecessary extra bulk.Failing to reverse directions while tying the knot produces a ‘granny’ knot , thusproducing ‘tags’ that exit on opposing sides of the suture loops. This knot isinferior to the square knot because of its tendency to slip (Rosin 1989).A surgeon’s knot , produced by passing one strand through the loop twice on thefirst throw of a square knot, is occasionally used for closure of tissues where 57 5
  58. 58. tension on the tissues makes it difficult to apply a regular square knot.Theincrease in frictional forces obtained from passing the strand through theSurgeon’sHalf-hitch loop twice will allow a second throw to be placed without lossof significant tightening. However, this does produce an asymmetrical knot, andsubsequent regular square knot throws must be utilised to prevent the knot fromslipping or coming undone. The increased bulk and asymmetry of the knotmakes it less suitable for general ligation than the square knot. There shouldnever be a need to routinely use a surgeon’s knot other than in areas wherethe tension is too great to facilitate tying a square knot.In addition, surgeon’s knots should not be utilised with catgut as the increasedfriction has a tendency to make the material fray.An alternative to the surgeon’sknot for utilisation in areas of wound tension is to tie a ‘half-hitch’ knot, slide itdown the suture line towards the pedicle, and by judiciously pulling the correct tag,turning the half-hitch into a true square knot.This is termed a ‘sliding knot’.Thistechnique requires some patience and practice, but can be a very usefuladdition to the surgeon’s ar mamentar ium, particularly when ligatingstructures within deep cavities. It leaves a square knot rather than the more bulky 58 5
  59. 59. and asymmetrical surgeon’s knot. However, it must be tightened correctly in orderto avoid the suture material slipping off the pedicle.Surgeons will often utilise a ‘buried’ knot for subcuticular or intradermalpatterns.This knot is tied using the same knotting technique as a square knot, butthe suture is passed on the near side from deep to superficial and then across tothe far side from superficial to deep. In effect, this produces an ‘upside down’version of the simple interrupted suture, with the knot buried in the deeper layersof the tissues.GENERAL PRINCIPLES OF TYING KNOTSThere are three basic methods for tying knots:1. instrument2. one-handed3. two-handed tying techniquesNumerous methods have been described for each technique, and detaileddescriptions can be found in the recommended reading list at the end of thisarticle. Instrument tying is the most widely used tying technique, and has theadvantage of producing consistent and reliable square knots. This technique canbe difficult to apply in deep cavities, where the one-handed tie may be moreuseful.The two-handed tie produces reliably more consistent square knots thanthe one-handed method, but can be slower and unwieldy in small areas. All threetechniques have their distinct advantages and disadvantages, and mastery of 59
  60. 60. these three methods allows the surgeon to secure ligatures in a wide variety ofsituations.There are several important principles to consider when tying suture material(Toombs and Clarke 2003):● Knot secur ity is inversely proportional to diameter of the suturematerial. As a general rule, use sutures no larger than 3-0 (2M) on individualvessels and 0 (3.5M) on tissue pedicles)● Ensure that adequate and equal tension is applied to each strand duringknot tightening to produce a secure square knot • Completed knots are left with 3 mm long tags for synthetic material and 6 mm long tags for surgical gut. Gut must be cut long due to its tendency to swell and potentially loosen when exposed to tissue fluids.● Do not include frayed or damaged suture material within a knot, andonly use instrumentson the end of the suture material. This tag end will beremoved at the completion of the knot anyway.● Extra knots produce more bulk and potentially more tissue reaction. Onlyuse the recommended number of throws for your particular suture material.EXAMPLES OF USEFUL SUTURING TECHNIQUES IN ORAL SURGERY 60
  61. 61. A simple loop suture used Figure 6. The simple loop to coapt flap margins. suture being tied to coapt the edges of the incision.Two suturing techniques can be used for the interrupted suture: the simple loopand the criss-cross (which is a modification of the horizontal mattress suturetechnique). In dental surgery, the simple loop is used most commonly to coapttension-free, mobile surgical flaps.4 Procedures where the simple loop is usefulinclude surgery of edentulous ridge areas, to coapt vertical releasing incisions, forperiosteal suturing, and to coapt flaps as part of certain periodontal surgicalprocedures (ie, modified Wid-man flap, some periodontal regeneration surgery,and some exploratory flap procedures). A simple loop is created by entering thebuccal flap from the epithelial surface (position 1) and crossing under theperiosteum to exit the epithelial surface of the lingual flap (position 2); a knot istied toward the buccal (Note: This example assumes a simple flap where all thesoft tissue has been elevated off the bone, including the periosteum.). A criss-cross suture placed atan extraction site to close themargins and aid in retention ofgraft material placed in th 61
  62. 62. socket.The criss-cross is similar to the simple loop on the buccal aspect; however, on thelingual aspect, the needle penetrates first through the epithelial surface of thelingual flap, thus interposing additional suture thread between the surgical flaps.The criss-cross technique is useful when suturing on the lingual aspect of theman-dibular molars, especially in a patient with an active gag reflex or a largetongue.4 A criss-cross suture is tied by entering the mesial buccal aspect (position1) and exiting the distal buccal aspect (position 2); the suture is then crossed overthe socket, enters the mesial lingual aspect (position 3), and exits the distal lingualaspect (position 4). The suture at the distal lingual (position 4) is tied to the freeend at the mesial buccal (position 1), and the knot is positioned toward the buccalInterrupted sutures should be used only with tension-free mobile flaps and shouldhave needle penetration ap-proximately 3 mm from the wound edges or at thebase of an interdental papilla. For closing wounds with flaps free of tension, theseinterrupted suture techniques achieve similar results.The mattress technique is a variation of the interrupted suture and is usually usedin areas where tension-free flap closure cannot be accomplished.4 Mattress su-turing techniques generally are used to resist muscle pull, to evert the woundedges (which keeps epithelium away from underlying structures), and to adapt thetissue flaps tightly to underlying structures when a bone graft or regenerativemembrane is used, or during dental implant surgery. A three-eighths reverse-cutting needle with a thicker thread diameter (3-0 or 4-0) is usually used with a 62
  63. 63. mattress suture technique1 Mattress sutures are usually left in place for 14 to 21days before dissolution or removal.There are variations of the mattress suture technique referred to as the horizontalmattress and the apically or coronally repositioned vertical mattress. A horizontal mattress Horizontal mattress suture showing the suture used to closely sutures position in adapt nontension-free relation to the tissue around an implant mucogingival junction. abutment, coupled with simple loop sutures to coapt the tension-free flap margins created by the horizontal mattress suture.When performing a mattress suture, the needle penetration through the surgicalflap should be approximately 8 mm away from the flap edge or just above themuco-gingival junction . A horizontal mattress suture is placed by penetration ofthe needle at the mesial buccal (position 1) apical to the mucogingival junction 63
  64. 64. and is then crossed under the flap to exit at the mesial lingual (position 2). Thesuture then penetrates the tissue at the distal lingual (position 3) and againcrosses under the flap to exit at the distal buccal (position 4) apical to themucogingival junction. The suture at the distal buccal (position 4) is tied to the freeend at the mesial buccal . Sling suture used to . Lingual view reposition the buccal flap demonstrating the margin, independent of direction and position of the position of the palatal/ the suture around the lingual tissues. The teeth neck of the tooth. are utilized to help hold the tissue in position.Another suture technique is the interrupted suspensory suture, commonly referredto as the sling suture. This technique is used when only 1 side (or 1 or morepapillae of a flap) is independently repositioned to its original position or coronallyrepositioned. The sling suture technique is especially useful when performingcoronally repositioned sliding flaps. When tying a sling suture, the needle enters 64
  65. 65. the buccal flap papilla distally (position 1) and is carried lingually around the neckof the tooth or implant to penetrate the papilla mesially (position 2), exitingbuccally. The suture is then looped back around the same tooth or implantlingually and is tied with the free end, positioning the knot buccally. With thistechnique, each suture includes the papilla on the mesial and distal aspects ofevery other tooth, using separate ties.Another variation of the interrupted suture technique is called a continuoussuture. Continuous sutures can be used to attach 2 surgical flap edges or tosecure multiple interproximal papillae of one flap independently of the other flap.This technique offers the advantage of fewer individual suture ties; however, thereare significant disadvantages associated with this technique. If one knot or loopbreaks, the integrity of the entire surgical site will be compromised.12 For thisreason, more control can be gained using individually placed interrupted, sling,criss-cross, or mattress sutures in lieu of placing one large continuous suture. KNOT TYING (SQUARE KNOT)The long end of the suture is wrapped around the tip of the closed needle holdertwice before grasping the short end of the suture with the needle holder. The firstdouble knot is then pulled gently tight. Two (or three) further single throws arethen added in a similar fashion to secure the knot. Each throw is pulled in theopposite direction across the wound edge. 65
  66. 66. SIMPLE INTERRUPTED SUTUREThe wound edge should be gently stabilised with either toothed forceps or askin hook. The needle should enter perpendicular to the skin 3-5mm from thewound edge.Entering perpendicular causes a wider bite of deeper tissue tobe included in the suture than at the surface and consequently causes morewound edge eversion and ultimately a superior cosmetic result with a thinnerscar. A common mistake is to enter the skin at a flatter angle resulting inmuch less wound edge eversion The knot is then tied. 66
  67. 67. CONTINUOUS SUTUREUsing a continuous suture rather than multiple interrupted sutures offers asignificant time saving. However,it is not as strong as interrupted sutures,and can strangulate the blood supply in wounds under more than minimaltension. An interrupted suture is performed, but only the free suture end iscut before the needle is reintroduced and directed diagonally across thewound to exit the skin on the other side. The suture is then broughtacross perpendicular to the wound edge and reintroduced on the first sideagain with each bite. Once the entire wound is closed, a loop is madewith the last pass of suture, and this loop is grasp by the needle holder totie the knot.VERTICAL MATTRESS SUTUREThis suture provides excellent wound support, decreases dead space, 67
  68. 68. and provides superior wound edge eversion. The needle is introduced 5-10mm from the wound edge and a deep bite of tissue is taken before exiting the skin in the same position on the opposite wound edge. The needle position is then reversed in the needle holder, and the needle is reintroduced 1-3mm from the second side of the wound and a smaller bite of tissue is taken before exiting on the first side of the wound. A knot can then be securedHORIZONTAL MATTRESS SUTUREThis suture is especially good for distributing wound tension across largerwounds particularly for the initial sutures. The needle is introduced 5-10mm fromthe wound edge and exited on the opposite side of the wound. The needle isthen reintroduced on the second side of the wound but 3-5mm along the woundedge from the exit point. The suture exits in the same position on the first side ofthe wound and the suture is tied. The disadvantage of this suture is the risk ofstrangulation of the dermal blood supply and subsequent edge necrosis. 68
  69. 69. RUNNING SUBCUTICULAR SUTURE The benefit of this suture is the minimal epidermal puncture points allowing the suture to be left in place longer without suture-track scarring. The needle is introduced 10mm distal to one wound end and brought out inside the apex of the wound within the dermis. The free end of suture can be tied off on itself, or secured with a bead or crimp. Horizontal bites of dermis are then taken from alternating sides of the wound working towards the other wound apex. The second epidermal puncture is made when the needle exits 10mm from the other end of the wound. The second free end can be secured in the same way as the first. Alternatively, absorbable suture material can be used and the ends tied off underneath the skin surface.BURIED SUTURE 69
  70. 70. This suture is extremely important for distributing wound tension to the dermisrather than the epidermis and also for closing dead space. It provides longer-term support to the healing wound and improves the cosmetic result. The woundedge is everted with a skin hook and then an absorbable suture is introduced atthe subcutaneous level and brought back out at dermal level on the same side ofthe wound.. The needle then enters the same dermal level on the opposite sideof the wound and exits the in the same subcutaneous level as it was initiallyentered into on the first side of the wound. The knot is tied deep at thesubcutaneous level and the free ends cut short 70
  71. 71. SUTURE REMOVALThe time to suture removal depends on the location and the degree oftension the wound was closed under. This varies between surgeon andsituation, but as a general rule sutures on the head and neck are usuallyremoved between five and seven days post-operatively, while sutures ontrunk or extremity wounds are typically removed between ten and fourteendays. To remove sutures, one tail of the suture should be grasp withforceps and pulled gently towards one side to the wound, elevating theknot. The opposite side of the suture should then be cut with stitch-cuttersor fine suture scissors immediately under the knot.. The suture can thenbe pulled out of the tissue by pulling towards the opposite side of thewound 71
  72. 72. CONCLUSIONSuturing in essence is a surgical procedure and is governed by the basicprinciples of surgery like aseptic technique etc. At the end of the day weshould be reminded that historically, surgery has been seen as a lastresort. Let us also be reminded of the famous quotation by the famoussurgeon in history, Ambrose Paré (1510–1590), who on occasionremarked, “I dressed the wound, and God healed it!”The body has healing mechanisms of its own. Most wounds if left for asufficient period of time will close completely/significantly on its own by theprocess of wound contraction. Remember – do not suture each and everysingle little wound – some minor cuts and bruises in esthetically unimportantareas will heal perfectly well without suturing. Sometimes cleaning and asmall band-aid strapping is the appropriate way to manage a cut. Somewounds may even heal better if left undisturbed by invasive measures… 72
  73. 73. REFERENCES • Surgery of the skin procedural dermatology. Ed Robinson JK, Hanke CW, Sengelmann RD, Siegel DM. Elsevier Mosby 2005. • Text book of oral and maxillofacial surgery Daniel.m. Laskin • Textbook of oral and maxillofacial surgery Neelima anil malik • Text book of oral and maxillofacial surgery S.M.Balaji 73