SUTURING MATERIALS AND TECHNIQUE

SUTURING MATERIALS AND TECHNIQUE

HISTORY 1650 BC – 2000’s AD

The origins of surgery can be traced back many centuries. Through
the ages, practitioners have used a wide range of materials and
techniques for closing tissue……..

ANTS-

In the tenth century BC, the ant was held over the wound until it
seized the wound edges in its jaws. It was then decapitated and the
ant's death grip kept the wound closed.

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 wound around the edge in a figure eight.

STERLISED CATGUT-

The tough membrane of sheep intestine was provided to the surgeon

pre-sterilised and required threading through the eye of the needle
before use.

THE IDEAL SUTURE

• Minimal tissue reaction
• Smoothness - minimum tissue drag
• Low Capillarity
• Max tensile strength
• Ease of handling - Minimum memory
• Knot security
• Consistency of performance
• Predictable performance
 • Cost effectiveness

Classification of Suture Material

• Natural vs. Synthetic (last 30 years)
• Absorbable vs. Nonabsorbable
• Braided vs. Monofilament

Basic Suture Materials

Absorbable
• Natural:
– Catgut
– Plain
– Chromic
• Synthetic:
– Polygolic acid (Dexon)
– Polyglactic acid (Vicryl)
– Poly-para-dioxanone (PDS)
– Modified polyglycolic acid (Maxon )

Non-absorbable
• Natural
– Silk
– Cotton
– Metals (stainless steel)
• Synthetic
– Dacron (Tevdek, Ethibond, Tycron)
– Nylon (Ethilon, Dermalon, Braided Nurolon)
• Polyprolene (Prolene, Surgilene)

Braided vs Monofilament Suture

Braided

• Absorbable:
– Dexon
– Vicryl
• Nonabsorbable
– Silk
– Dacron (Ethibond, Tevdek)
– Braided nylon (Nurolon)
Monofilament
• Absorbable:
 – PDS
– Maxon
• Nonabsorbable:
– Nylon (Ethilon, Dermalon)
– Polyprolene (Prolene, Surgilene)

Natural vs Synthetic Suture

Natural
Advantages-

• Natural material
• Absorbs quickly
• Strength retention
Disadvantages-

• More reactive
• Material inconsistency
• Increased tissue trauma

Synthetic
Advantages-

• Pliability and strength

• Strength retention
• Absorption (hydrolysis)
• Patient reactivity
Disadvantages-

• Stays in body longer

NEEDLES
The appropriate needle choice for any situation is…………….
……………The needle that will cause least possible trauma to the
tissue being sutured.
Needles are made of steel alloy (Surgalloy) with a Nucoat coating so
they stay sharp for multiple passes through tissue.

NEEDLE CURVATURE
NEEDLE GEOMETRY
• Suited to soft
tissue
Taper-Point
• Dilates rather
than cuts
• Very sharp
Reverse • Ideal for skin
cutting • Cuts rather
than dilates
• Very sharp
• Cuts rather
than dilates
Conventional • Creates
Cutting weakness
allowing
suture
tearout
• Ideal in tough
or calcified
tissues
Taper- • Mainly used
cutting in Cardiac &
Vascular
procedures.
 • Also known as
“Protect Point”
• Mainly used to
Blunt prevent needle
stick injuries i.e.
for abdominal
wall closure.
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SUTURING TECHNIQUES

BASIC PRINCIPLES
1) The needle is held with a needle holder and should enter the
tissues at right angles and no less than 2-3 mm from the
incision. The needle should be grasped about 1/3 -1/2 the
distance between the suture attachment and needle tip.
2) The needle is then carries through the tissue following the
needles curvature.
3) The suture should be passed at an equal depth and distance from
the incision on both sides.
4) The needle always passes from movable tissue to fixed tissue,
5) The needle always passes through the thinner tissues to the
thicker tissues.
6) The knot should not be places over the incision.
7) Sutures of any type placed in the interdental papillae should
enter and exit at a point located below the imaginary that forms
the base of the triangle.
8) Sutures are normally removed in 5-7 days.

KNOT TYPING

A knot can be tied using an instrument like the needle holder or with
the hand.

SQUARE KNOT

A square knot is formed by wrapping the suture around the the needle
holder once in opposite directions between the ties.At least 3 ties are
recommended,

SURGEONS KNOT

A surgeons knot is formed by two throws of the suture around the

needle holder on the first tie and one throw in the opposite direction
in the second tie.
GRANNY’S KNOT

Grannys knot involves tie in one direction followed by tie in the same
direction and a third tie in the opposite direction to square the knot and
hold it permanently.

LIGATION

INTERDENTAL LIGATION

Two types of interdental ligation can be used.

a) the direct loop suture

b) the figure of eight suture.

Simple loop suture-

This type of suture is used to approximate the buccal and lingual
flaps.The needle penetrated the outer surface of the first flap.The
undersurface of the opposite flap is engaged and the suture is
bought to the initial side were the know is tied.

The figure of eight-

In the figure – eight suture, there is thread between two flaps.This
suture is used when the flaps are not used in closed apposition
because of a apical flap position or non sealloped incisions. It is
simpler to perform then the direct ligation. The direct suture
permits a better closure of the inter dental papilla and should be
performed when bone grafts are used or when close apposition of
the scalloped incision is required.

TYPES OF SUTURES

CONTINOUS SUTURES-

Initially a simple interrupted suture is places and the needle is then

re-inserted in a continuous fashion such that the suture passes
perpendicular to the incision line below and obliquely. The above
suture is ended by passing a knot over the untightened end of the
suture. It provides a rapid technique for closure and distributes the
tension uniformly over the suture line. It also offers a more water
tight closure.
CONTINOUS LOCKING

This technique is similar to the continous suture,but locking is

provided by withdrawing the suture through its own loop. The
suture then passes perpendicular to the incision line. The locking
prevents excessive tightening of the suture over as the wound
closure progresses.

SLING SUTURES

The sling ligation can be used for a flap on one surface of a tooth
that involves two inter dental spaces.

MATTRESS SUTURES
They may be vertical or horizontal

Horizontal mattress sutures

The needle is passes from the edge of the incision to another and
again from the later edge to the first edge and then the knot is
tied.The distance of the needle penetration from the incision line
and the depth of penetration of the needle is the same for each
entry point but the horizontal distance of the points of penetration
of the same side of th flap iffers.The suture provides a broad
contact of the wwound margins.

Vertical mattress sutures.

It is similar to the horizontal mattress sutures except that all the
factors remain constant. Depth of penetration varies,i.e when the
needle is bought back from the second flap to the first, the depth of
penetration is more superficial. It is used for closing deep wounds.

SUBCUTICULAR SUTURES
The subcuticular layer of tough connective if sutured will hold the
skin edges in close approximation when the cosmetic results are
desired.Continous short lateral stitches are taken beneath the
epithelial layer of the skin. The ends of the suture come out at the
end of each incision and are knotted. This type of suturing leaves a
cosmetic scar.
REFERENCES:-

1.Jan Lindhe 4th edition Clinical Periodontology and Implant Dentistry.

2. Carranza’s Clinical Periodontology 10th edition

3. Laskin Textbook for oral surgery.

4.Oral and maxillofacial surgery by Neelima Malik