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SUTURE MATERIALS

&
SUTURING TECHNIQUES
DEFINITIONS

• DEFINITION: suture material is an artificial fibre used


to keep wound together until they hold sufficiently
well by themselves by natural fibre (collagen) which is
synthesized and woven into a stronger scar

• Suture is a Stitch/Series of Stiches made to secure


apposition of the edges of a Surgical/Traumatic
wound (Wilkins)

• Any Strand of Material utilised to ligate blood vessels


or approximate Tissues (Silverstein L.H 1999)
GOALS OF SUTURING
Suturing is performed to
§ Provide adequate tension
§ Maintain hemostasis
§ Provide support for tissue margins
§ Reduce post-op pain
§ Prevent bone exposure
§ Permit proper flap position
SUTURE
MATERIALS
CLASSIFICATION OF SUTURE MATERIALS

According to source:
1. Natural
2. Synthetic
3. Metallic
1. Monofilament
According to structure
2. Multifilament

According to fate:
1. Absorbable (undergo degradation and lose
T.S. < 60 days)
2. Non absorbable ( maintain T.S > 60 days)

According to coating: 1. Coated


2. Uncoated
NATURAL
u Absorbable Non Absorbable

u Catgut Silk
Chromic catgut Silk worm gut
Collagen Linen
Cotton
u Fascialata Ramie
kangaroo tendon Horse hair
Beef tendon Cargile
membrane
SYNTHETIC
u Non Absorbable
Absorbable
§ Nylon/ polyamide
§ Polyglycolic Acid
§ PolyPropylene
§ Polyglactic Acid
§ Polyesters
§ Polyglactin 910(Vicryl)
§ Polyethelene
§ Polydioxanone(PDS)
§ Polybutester
§ Polyglecaprone 25
§ Polyvinylidene
fluoride / PVDF
Sutures
Monofilament

Multifilament
MONOFILAMENT

Advantages Disadvantages
• Smooth surface • Handling and
• Less tissue trauma knotting
• No bacterial • Stretch
harbours • Any nick or crimp in
• No capillarity the material leads to
breakage.
MONOFILAMENT

Absorbable Non Absorbable

§ Surgical Gut- Plain, § Polypropylene


Chromic § Polyester
§ Polydiaxanone § Nylon/polyamide
§ Polyglactin 910 § Polyvinylidene fluoride /
PVDF Sutures
MULTI FILAMENT

Advantages Disadvantages
• Strength • Bacterial harbours
• Soft and pliable • Capillary action
• Good handling • Tissue trauma
• Good knotting
MULTIFILAMENT

Absorbable Non Absorbable

§ Polyglactin 910 § Silk


§ Polyglycolic Acid § Cotton
§ Linen
MONOFILAMENT MULTIFILAMENT
Ø Handling Difficult Ø Handling easy

Ø Smooth & strong Ø Low Strength

Ø No Wicking Ø Wicking is a Problem

Ø Thinner Ø Thicker
SELECTION OF SUTURE MATERIAL

A variety of suture materials and suture/needle


combinations is available. The choice of suture for a
particular procedure is based on the known physical and
biologic characteristics of the suture material and the
healing properties of the sutured tissues.
ABSORPTION OF SUTURE
MATERIALS
Degraded either by enzymatic process as in gut sutures,
or by hydrolysis, as in many of the synthetic materials
like glycolic acid, ployglactin910 or polydioxanone.
Non absorbable sutures are walled off or
encapsulated.
ü In infected tissues or in a patient who is febrile or
protein deficient, suture breakdown may be accelerated.
ü If the loss of TS outpaces the healing phase, failure of
the wound results.
ü Absorbable sutures must be placed well into the dermis.
ABSORBABLE -NATURAL
Gut / cat gut
Oldest known absorbable suture.
Galen referred to gut suture as early as 175 A.D.
Derived from sheep intestinal sub mucosa orbovine
intestinal serosa.
Submucosa of sheep has a rich elastic tissue content
which accounts for high tensile strength of the catgut. It is
monofilament and is available in the plain form as well as
“tanned” in chromic acid. The tanning process delays the
digestion by white blood cell lysozymes.
• Catgut should not be boiled or autoclaved as heat
destroys its tensile strength.

• Catgut is sterilized during preparation and kept in a


preservative solution (isopropyl alcohol) inside spools or
foils. Unused and reusable catgut is hygroscopic so, catgut
will swell due to water absorption and its tensile strength
will be reduced .

• Absorption :40-60 days

• When placed intra orally sutures are digested in 3- 5days.


• It is available pre-sterilized in aluminium- coated
sterile foil overwrap pack with ethicon fluid as a
preservative.

• Colour: Plain catgut is yellow, while


chromic catgut is tan

• Absorbtion: Catgut is absorbed by proteolytic


digestive enzymes released from inflammatory
cells collected around the catgut. So, in the
presence of infection catgut is rapidly
absorbed.
CHROMIC CATGUT
Coated with thin layer of chromium salt
solution to minimize tissue reaction, increase
TS, slow the absorption rate, better knot
security, and ease of handling.
TS – 10-14 days
Absorbed in 90 days
Uses:Opthalmic surgery (6-0)
Oral surgery
Suture subcutaneous tissues
As it is an organic material and
susceptible to enzymatic degradation,
packed in isopropyl alcohol as a
preservative. Also condition or soften
it.

Suture absorbs alcohol and swells. It is


combustible and is also irritating to
tissues. It is removed by a quick rise
in saline prior to use.
COLLAGEN SUTURE
qNatural, absorbable, monofilament
qObtained by homogenous dispersion of
pure collagen fibrils from the flexor
tendons of cattle.
qAbsorption – 56 days
qTS - < 10% after 10 days.
qUsed in opthalmic surgery
qDisadvantage of premature absorption.
SYNTHETIC ABSORBABLE

POLYGLACTIN 910 (VICRYL) Polyglactic


acid

Ø Coated and uncoated

Ø Synthetic suture

Ø Monofilament/multifilament
Ø Lactide has hydrophobic qualities→delaying loss of
TS

Ø TS - 14 – 21 days.

Ø Absorption – 56-70 days.


Ø Minimal tissue reactivity and can be used in
infected tissues

Ø Available in purple and undyed. Undyed used on


face.

Ø Coated with polyglactin 370 and calcium stearate


which allows easy passage through tissues as well
as easier knot placement.

Ø On skin wounds, associated with delayed


absorption as well as increased inflammation.
VICRYL –RAPIDE

• It is braided synthetic absorbable suture material.


• Colour: White.

• It has a similar initial high tensile strength as that of


the normal vicryl suture.

• It gives wound support upto 12 days. It shows 50% of


the original tensile strength after 5 days and all of its
tensile strength is lost after 14 days.

• Its absorption is associated with minimal tissue reaction


facilitating improved cosmetics and reduction of
postoperative pain.
• The absorption is essentially complete
within 35-42 days.

• Uses: Low tensile strength and Rapid


absorption rate --Ideal for intra-oral
use (dental surgeries).
VICRYL plus ANTIBACTERIAL SUTURE

• Handles and
performs same as
normal vicryl.
• In vitro studies
shown that triclosan
on VICRYL plus
creates a zone of
inhibition around
the suture.
GLYCOLIC ACID HOMOPOLYMER
(DEXON) POLYGLYCOLIC ACID

q Polymer of glycolic acid with greater knot pull


and TS than gut.
q Synthetic, absorbable, braided
q Absorption- hydrolysis, which results in
minimal tissue reactivity.
q Braided and so catches on itself, and knot
tying and passage through tissues difficult.
q Does not tolerate wound infection and not
percutaneous suture.
GLYCOLIC ACID (MAXON) POLYGLYCONATE
-Synthetic, absorbable, monofilament.
-Polyglycolic acid and trimethylene carbonate
-TS – 14-21 days (>Dexon)
Absorption – Hydrolysis in 180 days
In vitro studies by Edlich and co-workers (1973)
have suggested that the degradation products of
polyglycolic acid and nylon sutures - glycolic acid,
1,6-hexane diamine and adipic acid are
antibacterial agents.
POLYDIOXANONE (PDS II)
q Synthetic,absorbable,monofilament.

q Polyester derivative poly P dioxanone.

q TS -14-42 days

q Absorption – Hydrolysis in 6 months.

q Passes through tissues easily.


qSignificant memory – compromises the
ease of knot-tying and knot security.

qMinimal tissue reaction

qFor wounds under tension and


contaminated wounds.

qMay extrude through the wound over


time. So used only in tissues deeper
than subcuticular layer. Or if in face 6-
0 used.
NON ABSORBABLE SUTURES
• Natural – silk, silk worm gut, cotton ,
ramie,linen
• Synthetic-polyester, polyamide, poly
propylene, polybutester,polyethelene
• Metals : SS
Tantalum
platinum
silver wires
gold
aluminium
NATURAL NON-ABSORBABLE

SURGICAL SILK
-Braided or twisted
-Made from the filament spun by silkworm larva
to form its cocoon. Each filament is
processed to remove the natural waxes and
sericin gum. After braiding, the strands are
dyed, stretched and impregnated with a
mixture of waxes and silicone. Dry silk suture
is stronger than wet silk suture.
Advantage:

ü Ease of handling – more for braided


ü Good knot security
ü made non capillary in order to withstand action
of body fluids & moisture.(wax or silicon coated)
ü Cost effective

Contraindications:
Should not be used in presence of infection
Uses:
Plastic surgery, ophthalmic and general
surgeries, ligating body tissues.

Although characterized as non-absorbable,


studies show that it loses most of their
TS after 1 yr. and cannot be detected
in tissues after 2 yrs.
SURGICAL COTTON
qNatural, multifilament, non absorbable
qFrom stable Egyptian cotton fibers
qgood knot security
qNot good in presence of contaminated
wounds or infection
qRarely used nowadays
Uses:
Most body tissues for ligating and
suturing
LINEN

qNatural, multifilament, non absorbable


qMade from stable flax fibers
qPoor TS and so not for suturing under
tension
Uses:
Ligation of superficial vessels
Mucosal suturing without stress
SYNTHETIC NON-ABSORBABLE

POLYPROPYLENE (PROLENE)
-Polymer of propylene.
-Inert and TS for 2 yrs
-Holds knots better than other synthetic
sutures.

Advantages
-Minimal suture reaction and so used in infected
and contaminated wounds.
-Do not adhere to tissues and is flexible. So
used for „pull-out‟ type of sutures.
Uses:
General, plastic, cardiovascular surgery, skin
closure, ophthalmology.
NYLON – BRAIDED
(SURGILON, NURILON)
qSynthetic, non absorbable
qInert polyamide polymer
qBraided and sealed with silicon coating
qLook, handle and feel like silk, but
more stronger
qMultifilament nylon is weaker and less
secure when knotted, offering little
advantage over monofilament nylon.
NYLON MONOFILAMENT (DERMALON,
ETHILON)
qUncoated, but inert and non irritating to
the tissues.
qHigh TS and low tissue reactivity
qSome memory and return to original
linear shape over time. Because of this
more throws (4 throws) indicated.
qMoistened nylon monofilament are more
easily handled and are packaged wet.
Uses:
Skin closure, retention, plastic, ophthalmic
and microsurgery.
POLYESTER – BRAIDED
Tycron, Mersilene -Uncoated
Dacron, Ethibond - Coated (with polybutilate)
q Multifilament fibers of polyester
q Excellent TS which is maintained indefinitely
q Uncoated is rougher and stiffer than coated form
q Coated provides -low infection rate
-secure knotting
-smooth removal
-low reactivity
-easy passage through
tissues
q More expensive
q In deeper layers, may last indefinitely.
GOR-TEX
qNonabsorbable,synthetic,Monofilament
qFrom,expanded polytetrafluoroethylene
(ePTFE)
qExtremely low tissue reaction, good knot
tensile strenghtand ease of handling.
Uses
All type of soft tissue approximation and
cardiovascular surgeries.
MONOCRYL
qAbsorbable, synthetic, monofilament
qPoliglecaprone 25; copolymer of glycolide
and caprolactone
qHydrolysis 90-120 days
qTissue reaction – minimal
qGood knot strength
qUsed for soft tissue closure
qMost pliable material ever made
POLYBUTESTER (NOVOFIL)

-New, monofilament, nonabsorbable, synthetic

-Made of polyglycol trephthate and polybutylene


terephthalate and is considered as a modified polyester
suture.

-No significant memory compared to polypropylene and


nylon. Easier to manipulate and greater knot security.

-Unique feature is their ability to elongate or stretch


with increasing wound edema. When edema subsides,
suture resumes original shape; so it is an ideal suture
for lacerations secondary to blunt trauma.
-TS high and lasts longer
-Minimal tissue reactivity.
-Popularity in cutaneous surgery is gradually
increasing.
SURGICAL STEEL

q Natural, monofilament/multifilament, non


absorbable
q Alloy of iron, nickel and chromium
q Good TS even in infection
q Difficult to handle and tendency to cut
through tissues. Very hard to tie, and knot
ends require special handling.
q Potential to corrode or break at points
of twisting, bending or knotting.

q Not to be used with a prosthesis of


another alloy.

q Used in abdominal wall and skin closure,


sternal closure, retention, tendon
repair, orthopedic and neurosurgery.

q OMFS- for suspension of splints or


arch bars and not as suture material.
Packaging…
……
METRIC GUAGE IMPERIAL GUAGE
PRODUCT CODE

NEEDLE SIZE &


CURVATURE

NEEDLE TYPE

NEEDLE TIP

NEEDLE PROFILE

STERILIZED
DO NOT REUSE
EXPIRY DATE BATCH NO
ETHELENE OXIDE
SEE INSTRUCTIONS FOR USE
SUTURE SIZES
• Largest size 1 to extremely fine 11-0.
Increasing number of zeroes correlates with
decreasing suture diameter and strength.

• Thicker sutures are used for approximation of


deeper layers, wounds in tension prone areas
and for ligation of blood vessels.

• Thin sutures are used for closing delicate


tissues like conjunctiva and skin incisions of the
face. Size is chosen to correlate with the
tensile strength of the tissue being sutured.
3-0 or 4-0 OMFS, muscle, deep skin
5-0 or 6-0 facial skin closure
9-0 or 10-0 microsurgery
SUTURE NEEDLES
Surgical needles are designed to lead
suture material through tissue with
minimal injury. Needles can be
- straight (GIT) or curved
- swaged or eyed
Made up of either SS or carbon steel.

Needle is selected according to:


-type of tissue to be sutured
-tissue‟s accessibility
-diameter of suture material.
Made up of either SS or carbon steel.

CLASSIFICATION OF SURGICAL NEEDLES


1.According to eye -eye less needles
-needles with eye
2.According to shape -straight needles
. -curved needles
3.According to cutting edge
a) round body
b) cutting -conventional
-reverse cutting
• 4.According to its tip -triangular tip
-round tip
-blunt tip
• 5.Others -spatula needles
-micro point needles
-cuticular needles
-plastic needles
Anatomy of a Needle
Term Definition

Chord The linear distance between eye and


tip.

Length of needle The distance between eye and tip


following the curvature

Radius The distance of the body of the


needle from the centre of the circle

Diameter Gauge or thickness of the metal wire


out of which the needle is made.
COMPONENTS OF SURGICAL
CLOSED
NEEDLE
1. The eye
SWAGED
2. The body; and
3.The point
The eye can be - closed
- swaged
CHANELLED
- chanelled/drilled
Shape of the eye may be - round
- oblong; or
- square
Open French-eye needle is easy to load with
varying caliber, but has additional bulk.
Eyed require threading prior to use, results in pulling a double strand
through tissue. Tying the suture to the eye increases bulk of suture
material drawn through tissues. So they are also called “traumatic
needles‟. Suture loop inserted through
eye
Most suture materials and
needles are difficult to sterilize.
Needles are also difficult to Loop placed over tip
clean after use and become blunt
and workhardened so that
they snap. Loop drawn
back

Suture tied on eyed needle


SWAGED NEEDLE

• Swaged needles do not require threading and


permit a single strand of suture material to be
drawn.
• Suture attached to needle via a hole drilled
through the end of the needle, and the end is
swaged during manufacturing.
• It is atraumatic and
act as a single unit.
• Prepacked and presterilized
by gamma radiation.
Needle attached to suture
Favourable for I/O use but expensive
Less tissue damage
New needle each time
THE BODY
• Body is the widest portion of the needle
• It is known as grasping area.

-Most commonly used are 3/8 circle. They can be


easily manipulated in large and superficial wounds
and require only less wrist movement.

-1/2 circle used for suturing tissues in small wounds,


and body cavities and orifices. Require less space,
but more supination and pronation of wrist
required.
-5/8 used in oral cavity.
Tapered

Cutting

Reverse cutting
RADIUS OF CURVATURE OF THE CLINICAL USE
BODY(NEEDLE)
Straight Needle Needle of choice for the skin
Limited use in oral surgery
May be used in surgery of the
nose, pharynx, tendons

¼ circle Needle of choice for microsurgery


associated with very fine sutures;
ophthalmology

3/8 circle Oral surgery, flap surgery, wound


closure after placement of
osseointegrated implants and GTR
procedures
May be used in all surgical wounds

Needle of choice in oral surgery


½ circle Wide range of uses in many
surgical wounds

5/8 circle Wounds of the urogenital tract


THE POINT
Point runs from tip to the max. cross sectional
area of the body.

• Can be -triangular tip/cutting


-round tip
-blunt tip

• Cutting needles are Ideal for suturing keratinized


tissues like skin, palatal mucosa, subcuticular
layers and for securing drains.

• Round/tapered needles used for closing


mesenchymal layers such as muscle or fascia that
are soft and easily penetrable
• The conventional • The reverse cutting
cutting point has two point has two opposing
opposing cutting edges cutting edges and third
and third edge on the cutting edge on the
inside curvature of the outer curvature of the
needle. needle.
• The tapered point is used primarily on soft,
easily penetrated tissues . it leaves small hole
and can be used in vascular surgery as well as
fascial soft tissue surgery.

• The blunt point has a rounded end which does


nt cut through the tissue .it is used in friable
tissue suturing or to the parotid duct or
lacrimal canaliculi.
Cuticular needles Plastic needles

• Sharpened 12 times • Sharpened an additional


24 times
• Designated as C or FS • Designated as P or PS or
(CUTICULAR or FOR SKIN) PC
(PREMIUM or PLASTIC
SURGERY or PRECISION
COSMETIC ).
• Needles in the PC series
are made up of stronger
SS alloy and have
flattened and
conventional cutting
edge.
NEEDLE HOLDER

• The needle holder is used to handle


the suture needle and thread while
suturing the surgical wound.

• If used properly it enables the


surgeon to perform procedures
correctly and with great precision.
PARTS OF NEEDLE HOLDER

• Working tip/ jaws


• Hinge device
• Shank/body
• Catch mechanism/ ratchet
• Grip area
NEEDLE
HOLDER
There are different types of needle holders.
The beaks may be short or long, broad or
narrow, slotted or flat, concave or convex,
smooth or serrated. Commonly used have a
locking hand and short beaks and 6’ long
Gilles needle holder (scissors incorporated into
blades)
Kilner needle holder
• Atraumatic needle holder ensures
needle movement and compatibility of
clamping movement. It has textured
tungsten carbide jaw inserts, and its
rounded needle holder jaw edges do not
cause structural damage to
monofilament suture or needle
GILLES NEEDLE HOLDER

Scissors are incorporated into the blades


OLSEN HEGAR NEEDLE HOLDER KILNER NEEDLE HOLDER
YASARGIL MICRO NEEDLE HOLDER
MAYO HAGER NEEDLE
Gripping Needle Holder
The scissor grip
Used in the anterior part of the mouth and in
areas of easy access
The instrument is stabilized with the index finger
Palm grip
• Used in the deeper parts of oral
cavity
v Use appropriate size for
needle
v Grasped 1/4 to ½ distance
from swaged area
v Tips of the jaws should
meet before remaining
portion of jaw
v Needle placed securely
v Do not overclose
v Always directed by
surgeon‟s thumb
v Do not use digital pressure
on tissues
PRINCIPLES
OF
SUTURING
PRINCIPLES OF SUTURING
1.Needle grasped at 1/4th to half the
distance from eye.

2.Needle should enter perpendicular to


tissue surface
3.Needle passed along its curve

4. The bite should be equal on both sides of the


wound margin and the point of the entry of the
needle should be closer to the wound edge than
its point of exit on the deep surface
5. The bite should be about 2-3 mm from the wound
margin of the flap because after wound closure
the edge of the wound softens due to
collagenolysis and the holding power is impaired.
6. Usually the needle to be passed from mobile side to the
fixed side but not always(exception in lingual
mucoperiosteum flap) and from thinner to thicker & from
deeper to superficial flap.

7.The tissues should not be closed under tension , since they


will either tear or necrose around the the suture
8.Tie to approximate; not to blanch

9.Knot must not lie on incision line

10.The distance b/w one suture to


another should be about 3-4 mm apart
to prevent strangulation of the tissue &
to allow escape of the serum or
inflammatory exudate & to get more
strength of the wound.
11.Sutures placed at a greater depth than distance
from the incision to evert wound margins

12.Close deep wounds in layers

13.Avoid retrieving needle by tip

14.Adequate tissue bite to prevent tearing

15.sutures should have correct tension while tying


knot for provision of the slight edema post
operatively, more tensioned sutures cause
ischemia of the edges of the incision
causes tearing of the tissues
may leave suture mark
edges may get overlapped
16.Occasionally extra tissue may be present on
one side of incision and cause DOG EAR to be
formed in the final phase of wound closure.

• Simply extending the length of the incision to


hide the exists will produce an unsatisfactory
result.

• Thus after undermining excess tissue incision


is made at approx. 300 to parent incision
directed towards undermined side. Extra
tissue is pulled over incision and appropriate
amount is excised. Incision is closed in normal
manner.
IMPROPER SUTURING TECHNIQUE
SUTURING
TECHNIQUES
1.INTERRUPTED SIMPLE SUTURE

Most commonly used. Inserted singly through side


of the wound and tied with a surgeon’s knot.
Advantages
qStrong and can be used in areas of stress
qPlaced 4-8 mm apart to close large wounds, so that
tension is shared
qEach is independent and loosening one will not
produce loosening of the other
qDegree of eversion produced
qIn infection or hematoma, removal of few sutures
qFree of interferences b/w each stitch and easy to
clean
2. SIMPLE CONTINUOUS / RUNNING
A simple interrupted
suture placed and needle
reinserted in a continuous
fashion such that the
suturepasses perpendicular
to the incision line below
and obliquely above.
Ended by passing a knot
over the untightened end
of the suture.
Advantages
ü Rapid technique and distributes tension
uniformly
ü More water tight closure (Shoen, 1975)
ü Only 2 knots with associated tags

Disadvantages
If cut at one point, suture slackens along
the whole length of the wound which will
then gape open.
3.CONTINUOUS LOCKING/BLANKET
Similar to continuous but locking provided by
withdrawing the suture through its own loop.
Indicated in long edentulous areas, tuberosities
or retromolar area.

Advantages
ü Will avoid multiple knots
ü Distributes tension uniformly
ü Water tight closure
ü Prevents excessive tightening.

Disadvantage :prevents
adjustment of tension over
suture line as tissue swelling
occurs.
4.VERTICAL MATTRESS

q Specially designed for use in


skin. It passes at 2 levels, one
deep to provide support and
adduction of wound surfaces at a
depth and one superficial to
draw the edges together and
evert them.

q Used for closing deep wounds


q This approximates subcutaneous
and skin edges
Needle passed from one edge to the other and
again from latter edge to the fist and knot tied.
When needle is brought back from second flap to
the first, depth of penetration is more
superficial.
Advantages :
• for better adaptation and maximum tissue
approximation

• To get eversion of wound margins slightly

• Where healing is expected to be delayed for any


reason, it is better to give wound added support by
vertical mattress. Used to control soft tissue
hemorrhage.

• Runs parallel to the blood supply of the edge of the


flap and therefore not interfering with healing.

• Uses: abdominal surgeries & closure of skin wounds.


5.HORIZONTAL MATTRESS
q It everts mucosal or skin margins, bringing
greater areas of raw tissue into contact. So used
for closing bony deficiencies such as oro-antral
fistula or cystic cavities.

q Disadvantage: constricts the blood supply to


edges of incision.
Needle passed from one
edge to the other and
again from the latter to
the first and a knot is tied.

Distance of needle
penetration and depth of
penetration is same for
each entry point, but
horizontal distance of the
points of penetration on
the same side of the flap
differs.
Advantages:
Will evert mucosal or skin margins, bringing greater
areas of raw tissue into contact.

-So used for closing bony deficiencies such as oro-


antral fistula or cystic cavities, extraction socket

wounds.

• Prevents the flap from being inverted into the cavity.


• To control post-operative hemorrhage from gingiva
around the tooth socket to tense the mucoperiosteum
over the underlying bone.
• It does not cut through the tissue ,so used
in case of tissue under tension
(inadequate tissue)
Disadvantages:
• More trouble to insert
• Constricts the blood supply to the incision
if improperly used, cause wound necrosis
and dehiscence
6. FIGURE OF 8 SUTURE
Used for extraction socket closure and for
adaption of gingival papilla around the tooth
Suturing begun on buccal surface 3-4mm from
the tip of the papilla so as to prevent tearing of
papilla.

Needle first inserted into the


outer surface of the buccal flap
and then the lingual flap.
Needle again inserted in same
fashion at a horizontal distance
and then both ends tied.
SUBCUTICULAR SUTURE
Used to close deep wounds in layers. Knots
will be inverted or buried, so that the knot
does not lie between the skin margin and
cause inflammation or infection.

To bury the knot, first pass of the needle


should be from within the wound and
through the lower portion of the dermal
layer. Needle then passed through the
dermal layer and emerge through
subcutaneous tissue and knot tied
CONTINUOUS SUBCUTICULAR SUTURE

Continuous short
lateral stitches are
taken beneath the
epithelial layer of the
skin. The ends of the
suture come out at each
end of the incision and
are knotted.
Advantages
q Excellent cosmetic result
q Useful in wounds with strong skin tension,
especially for patients prone to keloid formation.
qAnchor suture in wound and, from apex, take
bites below the dermal-epidermal layer
qStart next stitch directly opposite the one that
precedes it.
9.PURSE STRING SUTURE
A circular pattern that draws together
the tissue in the path of the suture when
the ends are brought together and tied.
KNOT TYING
KNOT TYING

Sutured knot has 3 components


1.Loop created by knot
2.Knot itself which is composed
of a number of tight throws
3.Ears which are the cut ends of
the suture
KNOTS
SQUARE KNOT
Formed by wrapping the
suture around the needle
holder once in opposite
directions between the
ties. Atleast 3 ties are
recommended.
Best for gut, silk, cotton
and SS
SURGEON’S KNOT

Formed by 2 throws on the first tie and one


throw in the opposite direction in the second
tie. Recommended for tying polyester suture
materials such as Vicryl and Mersiline
SUTURE
REMOVAL
SUTURE REMOVAL
Skin wounds regain TS slowly. It can be
removed in 3-10 days when the wound
gained 5%-10% of final TS. Skin sutures on
face removed between 3-5 days. Alternate
sutures removed on 3rd day and remaining
sutures after 2 days.
Ø Intra oral
- Mucoperiosteal closure (without tension)
5-7 days
- Where there is tension on the suture
eg : Oro-antral fistula- 7-10 days
Ø Back and legs where cosmesis is less important –
10-14 days.
Ø Continuous subcuticular can be left for 3-4
weeks without formation of suture tracks

Ø A good guide is that as soon as they begin to get


loose they should be taken out.
• INCORRECT

• CORRECT
• Possible Complication Of
Leaving Suture For Many Days
:
1.Sutural abscess.
2.Suture scarring or stitch mark
3.Implanted dermoid cyst
SCISSORS
Dean’s Scissors
-General purpose scissors
-Used for cutting sutures
-Can also be used to trim mucosal margins.
SUTURE MARKS
Suture marks are caused by 3 factors

1. Skin sutures left in place longer than 7


days, resulting in epithelialisation of
suture track

2. Tissue necrosis from sutures that were


tied too tightly or became tight due to
tissue edema

3. Use of reactive sutures in the skin.


REFERENCE
• Suturing techniques in oral surgery –Sandro
Siervo
• Atlas of Minor Oral Surgery- Harry Dym
• Laskin vol-1
• Oral & Maxillofacial Surgery Vol 1- W. Harry
Archer
• Textbook of oral & maxillofacial surgery-
Neelima Anil Malik
• Minor Oral Surgery- Goeffrey L.Howe
• Text book of surgery: Sabiston
• Periodontology-Caranza.
THANK THANK
YOU YOU