all about suture material and suturing technique

1. Good morning

2. Suture materials and techniques

3. What is a Suture ??
 Suturing is the act of bringing tissues
together and holding them in apposition
until healing takes place.

4. What is the Purpose or Goal of
Suturing ??
 Provide adequate tension of wound closure
without dead space…but loose enough to obliviate
tissue ischaemia & necrosis.
 Maintain Haemostasis.
 Healing by primary intension.

5.  Provide support for healing until it is no longer
needed.
 Post operative pain control.
 Prevention of bone exposure.
 Proper flap positioning.

6. Instrumentation

7. A needle holder has a locking handle and a short, stout beak
Needle Holder:

8. The faces of the beaks of the needle holder are cross-hatched to ensure a
positive grip on the needle

9.  To control the locking handles the surgeon must hold the
instrument properly.
 The thumb and ring finger are inserted through the rings.
 The index finger is held along the length of the needle holder
to steady and direct it.
 The second finger aids in controlling the locking mechanism.

10.  The index finger should not be put through the finger ring,
because this will result in a dramatic decrease in control.
The first and second fingers help direct the instrument.

11. Tissue Forceps
 commonly used for this purpose for dentoalveolar suturing
are the Adson forceps.
Adson forceps with teeth.

12. Scissors
 The final instruments necessary for placing sutures are
suture scissors.

13. SUTURE MATERIALS
Ideal properties of Sutures :
 Good handling characteristics.
 Non-reactivity with tissue.
 Knot security.
 Adequate tensile strength.
 Sterile, non-allergenic.
 Favorable absorption profile.
 Resistant to infection.

14. Essential suture characteristics
 Sterility
 Uniform diameter and size.
 Pliability and tensile strength.
 Freedom from irritants and impurities.

15. Classification of suture
materials

16.  Suture Absorbable Non-Absorbable
Materials
 MONO
FILAMENT 1. Surgical Gut 1 . Polyamide
Chromic
2. Collagen Plain 2. Polypropylene
chromic
3. Monocryl 3.Stainless Steel
4. PDS II
5. Polyglactin 910 4. Polyester
(finer sizes) (finer sizes)
 MULTI 1. Polyglycolic 1. Surgical Silk
FILAMENT acid 2. Surgical Linen
2. Polyglactin 910 3. Cotton
3 Polyglactin 910- 4. Polyamide Braided
Rapide 5. Polyester Braided
6. Polyester Braided
Coated
7. Stainless Steel

17. Monofilament
Multifilament

18. COMPARISON OF ...
Multifilament Monofilament
 Has capillary action
 Increased infection risk
 Less smooth passage
 Less tensile strength
 Better handling
 Better knot security
• No capillary action
• Less infection risk
• Smooth tissue passage
• Higher tensile strength
• Has memory
• More throws required

19. Absorbable Sutures
 Plain Gut
 Derived from submucosa of
sheep intestines
 Not a true monofilament
 Less than 10 day life span in
tissue
 100 times the bacterial
adhesion than that of Nylon or
Polypropylene

20. Absorbable Sutures
• Chromic Gut
 Plain gut tanned with chromium
salts
 Improved strength and duration
 Duration is 2-3 weeks
 Knot security greater than plain
gut
 Absorption by proteolytic
enzymes

21. Absorbable Sutures
• Dexon (polyglycolic or PGA)
 Monofilament which is braided
 Un-coated Dexon S and coated
Dexon Plus
 More durable than gut sutures
 Absorbed by hydrolysis of ester bond
 Sutures lost orally is 16-20 days

22. Absorbable Sutures
• Vicryl
 Copolymer of glycolic and lactic
acid in a 9:1 ratio; Polyglactin 910
 Nearly identical properties as
Dexon
 Strength loss after 16-20 days
 Absorbed by hydrolysis of ester
bond
 Braided suture like Dexon

23. Non-absorbable Sutures
 Silk
 70% natural silk, silk worm larvae
 Main advantage is favorable
handling
 Knot security is good
 Tissue response to silk is severe
 Braided material, potential for
infection is great

24. most commonly used sutures for the oral cavity
is 3-0 black silk.
The size 3-0 has the appropriate amount of
strength; the polyfilament (braided) nature of the
silk makes it easy to tie and is well tolerated by the
patient’s tongue.
The color makes the suture easy to see when the
patient returns for suture removal.

25. Non-absorbable Sutures
 Nylon
 Synthetic polyamide polymer
 Available in monofilament or
multifilament
 Poor knot security
 Among the best for minimizing
infection
 Face: 5-0 or 6-0 Nylon
Scalp: 3-0 Nylon

26. Non-absorbable Sutures
 Polypropylene (Prolene)
 Similar to Nylon, synthetic
monofilament polymers
 Breaking strength less than Nylon
 Knot security and ease of tying
greater than Nylon
 Absorption is non-existent, good
for contaminated wounds

27. Suture Needle
Anatomy of the needle :
Point -This portion of the needle extends from the tip to the
maximum cross-section of the body.
 Body -This part of the needle incorporates the majority of the
needle length.
 Swage -The suture attachment end creates a single, continuous
unit of suture and needle.

28. Suture Needle

29. Taper-Point •Suited to soft tissue
•Dilates rather than cuts
Reverse
cutting
•Very sharp
•Ideal for skin
•Cuts rather than dilates
Conventional
Cutting
•Very sharp
•Cuts rather than dilates
•Creates weakness allowing suture
tear out
Taper-cutting
•Ideal in tough or calcified tissues
•Mainly used in Cardiac &
Vascular procedures.
NEEDLE POINT GEOMETRY

30. NEEDLE CURVATURE

31.  The cutting portion of the needle extends about one third
the length of the needle, and the remaining portion of the
needle is rounded.
 Tapered needles are used for more delicate tissues, such
as in ocular or vascular surgery.
 Care must be taken with cutting needles, because they
can cut through tissue lateral to the track of the needle if
not used carefully or correctly.
Suture Needle

32. Available Suture Sizes
 Size: Refers to the diameter of the suture
 The more “0’s” in the number, the smaller the suture
 Microsurgery/repair: 9-0 or 10-0 suture
 Facial skin closure: 5-0 or 6-0 suture
 Trunk or extremities: 4-0 or 5-0 suture
 Scalp: 3-0 suture
 Muscle, deep skin, intraoral mucosa: 3-0 or 4-0 suture

34. principles for placing the needle in tissue:
1. Force should always be applied in the direction that follows the
curvature of the needle.
2. Suturing should always be from a movable to a non movable
tissue.
3. Excessive tissue bites with small needles should be avoided, as it
will be difficult to retrieve them.
4. Only sharp needles with minimal force should be used.
Ethicon (1985)
PLACEMENT OF NEEDLE IN TISSUE

35. 5. The needle should be grasped in the body one-quarter to
one-half of the length from the swaged area.
6. The swaged area should not be held; this may bend or
break the needle.
7. The needle should never be forced through the tissue.
8. Retrieving the needle from the tissue by the tip should
be avoided. This will damage or dull the needle.

36. 9.The body should be grasped as far back as possible.
10. Sutures should be placed in keratinized tissue
whenever possible.
11. An adequate tissue bite is required to prevent the flap
from tearing.

37. KNOTS AND 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 is generally the result of untying owing to
knot slippage or breakage.

38. 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.
A sutured knot has three components
Thacker and colleagues, 1975

39. There are basically three types of knot used for
securing suture;
1. Square knot
2. Surgeons not
3. Granny knot

40. Square knot
 Square knot is formed by wrapping suture around needle holder
once in opposite directions between ties.

41. Surgeon’s knot
 Surgeon’s knot is formed by two throws of suture around
needle holder on first tie and then one throw in opposite
direction on second tie.

42. Surgeons knot: Variations

43. Granny knot
Granny’s knot involves a tie in one direction followed by a tie
in the same direction.

44. Knot tying
1. Knot must be firm ….no slippage.
2. Knot should not be placed on the incision lines to
avoid wicking.
3. Avoid excessive tension…..crimping of suture.
4. Maintain adequate tension …….avoid
excess……..necrosis.

45. Knot tying
5. Knot ends must be 2-3mm.
6. An added throw does not increase the strength of the
knot.
7. After the first loop is tied it is necessary to maintain
traction at one end of the strand to avoid loosening of
the throw.
8. Final tension or final throw should be as nearly
horizontal as possible.

46. THE SUTURE PACKAGING
STRAND
SIZE
MATERIAL
STRAND
LENGTH
PRODUCT
CODE
NEEDLE
CODE
WITH LIFE
SIZE
PICTURE
OF
NEEDLE
NEEDLE
LENGTH
COLOUR
POINT
TYPE
NEEDLE
CIRCLE

47. Classification of Suture Techniques
 Interrupted  Continuous
Direct / Loop
Figure Of 8
Vertical /
Horizontal Mattress
Intra-papillary
Vertical Mattress
Horizontal
Mattress
Independent Sling

48. Interrupted Sutures
 Most commonly used in the oral cavity.
 This suture goes through one side of the wound, comes up through
the other side of the wound, and is tied in a knot.
 When placing multiple adjacent interrupted sutures, they can usually
be spaced about 1 to 1.5 cm apart.

49. indications
 where maximum interproximal coverage is required.
 Edentulous areas- tuberosity & molar areas.
 Partial thickness flaps.
 Incase of vertical incisions.
 Bone regeneration procedures.
 Osseo integrated implants.

50. Interrupted Sutures

51. Steps used to tie an interrupted suture using a needle
holder

54.  Advantages :
1. They are stronger & loosening of any one suture will not
cause the others to loosen.
2. In areas of tension when strong closure is required interrupted
sutures are preferred.
3. Incase of infection….removal of infected sutures is sufficient.

55. Figure of 8 Suture
Indications:
 When flaps are not in close apposition because of
apical flap displacement.
 The major disadvantage being presence of suture
between the 2 flaps.

56. Figure of 8 Suture

57. Horizontal Mattress Suture
1. Used in areas of diastema or wide interdental spaces
to properly adapt the inter-proximal papilla.
2. This technique is also useful when the edges of the papilla
are very fragile, because the suture can enter the tissue
further away from the wound edges.
3. Helps in tissue eversion.

58. The use of this suture decreases the number of individual sutures
that must be placed.

59. Vertical Mattress Suture
1. Recommended for bone regeneration procedures.
2. provides maximum tissue closure.
3. avoids suture contact with implanted material by
avoiding wicking.
4. Particularly suited for papillary management.

60. Vertical Mattress Suture

61. Continuous Sutures
 Advantages:
1. One can include as many teeth as required.
2. Minimizes need for multiple knots.
3. Allows independent placement & tension
of buccal & lingual/ palatal flaps
4. Simple

62. Continuous Locking Suture
 Usually used in long edentulous areas.
 Technique :
1. Initially a single interrupted suture is given.
2. Needle is inserted from outer surface of buccal flap & inner
aspect of the lingual flap.
3. Needle then passed through the remaining loop of the suture
& pulled tight.
4. Procedure continued & final suture tied at the terminal end.

65. Suture removal
Oral mucosa: 5-7 days

66. Recent Advances