SUTURES, SUTURING AND SUTURE REMOVAL

1. 1

2. SHILPA SHIVANAND
II MDS

3. 
• Introduction
• Definition
• Goals of suturing
• Suture materials
- Requisites of ideal suture
- Classification
- Selection of suture material
- Absorption of suture material
- Biological response of body to suture.
• Suture armamentarium- needles, needle holder, scissor
• Principles of suturing
• Suturing Techniques
• Knots
• Suture Removal and complications
CONTENTS
3

4. 
 Suture means to ‘sew’ or ‘seam’.
 In surgery suture is the act of sewing or bringing
tissue together and holding them in apposition
until healing has taken place.
 A suture is a strand of material used to ligate
blood vessels and to approximate tissues together.
INTRODUCTION
4

5. 
 Suture material is an artificial fiber used to keep
wound together until they hold sufficiently well by
themselves by natural fiber (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 utilized to ligate blood
vessels or approximate tissues
Silverstein L.H 1999
DEFINITIONS
5

6. 
Suturing is performed to
 Provide adequate tension
 Maintain hemostasis
 Permit primary intention healing
 Provide support for tissue margins
 Reduce post-operative pain
 Prevent bone exposure
 Permit proper flap position
GOALS OF SUTURING
(Ethicon)
6

7. 
 It is to hold severed tissues in close approximation
until the healing process provides the wound with
sufficient strength to withstand stress without the
need for mechanical support.
 Since wounds do not gain strength until 4-6 days
after injury, the tissues are approximated till then by
sutures.
BASIC PURPOSE OF A SUTURE
7

8. 
 Tensile strength: adequate material strength will
prevent suture breakdown & use of proper knots for
the material used will prevent untying or knot
slippage.
 Tissue biocompatibility: sutures made from organic
material will evoke a higher tissue response than
synthetic sutures.
 Tissue reaction α amount & size of suture material.
REQUISITES OF AN IDEAL SUTURE
Postlethwait 1971, Varma 1974, Ethicon 1985
8

9. 
 Low capillarity: multifilament type soak up tissue
fluid by capillary action providing a rich medium for
microbes increasing chances of inflammation &
infection.
 Good handling & knotting properties: ease of tying
& a thread type that permits minimal knot slippage
also influence thread selection.
 Sterilization without deterioration of properties:
most sutures available in packages are sterilized by
dry heat & ethylene oxide gas.
9

10. 
 Non allergic, non electrolytic and non carcinogènic
 Its use should be possible in any surgery.
 Low cost
 It should not fray, should slide through tissues
readily & knot should not slip after tying.
10

11. 
 It should be readily visualized , should not shrink &
should not be extruded from the wound.
 On break down ,it should not release toxic agents.
 It should disappear without excessive reaction once
its task is completed.
11

12. 
I. According to source
1. Natural
2. Synthetic
3. Metallic
II. According to structure
1. Monofilament
2. Multifilament
CLASSIFICATION OF SUTURE
MATERIALS
(Food and Drug Administration with ref to Safe Medical Device Act)
12

13. 
III. According to fate:
1. Absorbable (undergo degradation and lose
T.S. < 60 days)
2. Non absorbable (maintain T.S > 60 days)
IV. According to coating:
1. Coated
2. Uncoated
V. Braided and Twisted
13

14. 
 Non absorbable sutures are categorized by the United
States Pharmacopeia (USP) as:
Class I - Silk or synthetic fibers of monofilaments
with twisted or braided construction
Class II - Cotton or linen fibers, coated natural or
synthetic fibers in which the coating does not
contribute to T.S
Class III - Metal wire of monofilament or multifilament
construction.
14

15. 
Absorbable
Catgut
Chromic catgut
Collagen
Fascia lata
kangaroo tendon
Beef tendon
Cargile membrane
NATURAL
Non Absorbable
• Silk
• Silk worm gut
• Linen
• Cotton
• Ramie
• Horse hair
15

16. 
SYNTHETIC
Absorbable
Polyglycolic Acid
Polyglactic Acid
Polyglactin 910(Vicryl)
Polydioxanone(PDS)
Polyglecaprone 25
Non Absorbable
Nylon/ polyamide
PolyPropylene
Polyesters
Polyethelene
Polybutester
Polyvinylidene fluoride /
PVDF Sutures
16

17. Monofilament
Multifilament
17

18. 
Advantages
 Smooth surface
 Less tissue trauma
 No bacterial harbors
 No capillarity
MONOFILAMENT
Disadvantages
 Handling and knotting
 Stretch
 Any nick or crimp in the
material leads to
breakage.
18

19. MONOFILAMENT
Absorbable
 Surgical Gut- Plain,
Chromic
 Polydiaxanone
 Polyglactin 910
Non Absorbable
 Polypropylene
 Polyester
 Nylon/polyamide
 Polyvinylidene fluoride
/ PVDF Sutures
19

20. 
Advantages
 Strength
 Soft and pliable
 Good handling
 Good knotting
MULTI FILAMENT
Disadvantages
 Bacterial harbors
 Capillary action
 Tissue trauma
20

21. MULTIFILAMENT
Absorbable
 Polyglactin 910
 Polyglycolic Acid
Non Absorbable
 Silk
 Cotton
 Linen
21

22. MONOFILAMENT
 Handling difficult
 Smooth & strong
 No wicking
 Thinner
MULTIFILAMENT
 Handling easy
 Low strength
 Wicking is a problem
 Thicker
22

23. 
• SS
• Tantalum
• Gold
• Silver
• Aluminium
METALLIC
23

24. 
The selection of suture material by a surgeon must be based
on a sound knowledge of :
 Healing characteristics of the tissues which are to be
approximated
 The physical and biological properties of the suture
materials
 The condition of the wound to be closed and
 The probable post-operative course of the patient.
PRINCIPLES OF SUTURE
SELECTION
Brian CB, Philip KH 1990
24

25. 25
CHOICE OF MATERIAL

26. 
 Degraded either by enzymatic process as in gut sutures, or
by hydrolysis, as in many of the synthetic materials like
glycolic acid, ployglactin 910 or polydioxanone.
 Non absorbable sutures are walled off or encapsulated.
 In infected tissues or in a patient who is febrile or protein
deficient, suture breakdown may be accelerated.
 If the loss of TS outpaces the healing phase, failure of the
wound results.
ABSORPTION OF SUTURE
MATERIALS
Corey SM
26

27. 
 The initial body response to sutures is almost identical in
the first 4-7 days, regardless of the suture material.
 The early response is a generalized acute aseptic
inflammation, involving primarily polymorphonuclear
leukocytes.
 After few days mononuclear cells, fibroblasts & histiocytes
become evident.
 Capillary formation occurs at the end of this initial phase.
BIOLOGIC RESPONSE OF
BODY TO SUTURE MATERIALS
Corey SM
27

28. 
 Natural Absorbable  Proteolytic degradation.
Intense tissue response
 Synthetic Absorbable  Hydrolysis
Less intense
 Non Absorbable  Encapsulation
Acellular response
28

29. 
 Sutures passing through mucous membrane or skin
provide a ‘wick’ or pathway through which bacteria
track down, and bacteria gain access to underlying
tissues.
 The longer the suture remains, the deeper the epithelial
invasion of the underlying tissue. When suture is
removed, epithelial tract remains.
 These cells may eventually disappear or remain to form
keratin and epithelial inclusion cysts. The epithelial
pathway result in typical ‘railroad scar’ formation.
RAILROAD SCAR
29

30. 
Surgical gut / catgut / plain gut
 Oldest known absorbable suture.
 Galen referred to gut suture as early as 175 A.D.
 Derived from sheep intestinal sub mucosa or bovine
intestinal serosa.
 Sub mucosa 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.
ABSORBABLE -NATURAL
30

31. 
 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 : 60-70days
 When placed intra orally sutures are digested in 3-5days.
31

32. 
 Availability: pre-sterilized in aluminium-coated sterile
foil overwrap pack with ethicon fluid as a preservative
 Looses TS in 7-10 days
 Color: Plain catgut is yellow, while chromic catgut is
tan
 Absorption: 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.
Catgut…
32

33. 
 Heat treated to speed up absorption
 Looses TS in less than 7 days and completely absorbs
in 21-42 days
33
FAST ABSORBING SURGICAL
GUT

34. 
 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: Ophthalmic surgery (6-0)
Oral surgery
Suture subcutaneous tissues
CHROMIC CATGUT
34

35. 
 As it is an organic material and susceptible to
enzymatic degradation, packed in isopropyl alcohol as
a preservative.
 Suture absorbs alcohol and swells.
 It is combustible and is also irritating to tissues.
 It is removed by a quick rinse in saline prior to use.
CHROMIC CATGUT..
35

36. 
 Natural, absorbable, monofilament
 Obtained by homogenous dispersion of pure
collagen fibrils from the flexor tendons of cattle.
 Absorption – 56 days
 TS  < 10% after 10 days.
 Used in ophthalmic surgery
 Disadvantage  premature absorption.
COLLAGEN SUTURE
36

37. 
 Coated and uncoated
 Monofilament/multifilament
 Lactide has hydrophobic qualities→delaying loss of TS
 TS  14 – 21 days.
 Absorption  56-70 days.
POLYGLACTIN 910 (VICRYL) Polyglactic acid
SYNTHETIC ABSORBABLE
37

38. 
 Minimal tissue reactivity and can be used in infected
tissues
 Available in purple and undyed. Undyed  face.
 Coated with polyglactin 370 and calcium stearate which
allows easy passage through tissues as well as easier
knot placement.
 On skin wounds, associated with delayed absorption as
well as increased inflammation.
VICRYL…
38

39. 
 It is braided synthetic absorbable suture material.
 Color: White
 It has a similar initial high tensile strength as that of
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.
VICRYL –RAPIDE
39

40. 
 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 –RAPIDE….
40

41. 
 Handles and performs same as normal vicryl
 In vitro studies shown that triclosan on VICRYL
plus creates a zone of inhibition around the suture.
Rasic Z, Schwarz D et al 2011
VICRYL PLUS ANTIBACTERIAL
SUTURE
41

42. 42

43. 
 Polymer of glycolic acid with greater knot pull and
TS than gut.
 Synthetic, absorbable, braided
 Absorption- hydrolysis, which results in minimal
tissue reactivity.
 Braided and so catches on itself, and knot tying
and passage through tissues difficult.
 Does not tolerate wound infection and not
percutaneous suture.
GLYCOLIC ACID HOMOPOLYMER
(DEXON) POLYGLYCOLIC ACID
43

44. 
 Synthetic, absorbable, monofilament.
 Polyglycolic acid and trimethylene carbonate
 TS  14-21 days (>Dexon)
 Absorption  Hydrolysis in 180 days
 Degradation products of polyglycolic acid and nylon
sutures  glycolic acid, 1,6-hexane diamine and adipic
acid are antibacterial agents. Edlich et al 1973
GLYCOLIC ACID (MAXON)
POLYGLYCONATE
44

45. 
 Synthetic, absorbable, monofilament.
 Polyester derivative polydioxanone.
 TS 14-42 days
 Absorption – Hydrolysis in 6 months
 Passes through tissues easily.
POLYDIOXANONE (PDS II)
45

46. 
 Ease of knot-tying and knot security.
 Minimal tissue reaction
 For wounds under tension and contaminated
wounds.
 May extrude through the wound over time.
 So used only in tissues deeper than subcuticular
layer.
 If in face 6-0 used.
POLYDIOXANONE (PDS II)….
46

47. 47

48. 
Natural – silk, silk worm gut, cotton , ramie,
linen
Synthetic-polyester, polyamide, poly propylene,
polybutester, polyethylene
Metals : SS
Tantalum
Platinum
Silver wires
Gold
Aluminium
NON ABSORBABLE SUTURES
48

49. 
 Braided or twisted
 Made from the filament spun by silkworm larva to
form its cocoon.
 Processed to remove the natural waxes and 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.
SURGICAL SILK
49

50. 50

51. 
Advantage:
 Ease of handling – more for braided
 Good knot security
 Made non capillary in order to withstand action of
body fluids & moisture. (wax or silicon coated)
 Cost effective
Contraindications:
 Should not be used in presence of infection
SURGICAL SILK…
51

52. 
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.
 Cannot be detected in tissues after 2 yrs.
SURGICAL SILK…
52

53. 
 Natural, multifilament, non absorbable
 From stable Egyptian cotton fibers
 Good knot security
 Not good in presence of contaminated wounds or
infection
 Rarely used nowadays
Uses:
 Most body tissues for ligating and suturing
SURGICAL COTTON
53

54. 
 Natural, multifilament, non absorbable
 Made from stable flax fibers
 Poor TS and so not for suturing under tension
Uses:
 Ligation of superficial vessels
 Mucosal suturing without stress
LINEN
54

55. 
 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.
POLYPROPYLENE (PROLENE)
SYNTHETIC NON-ABSORBABLE
55

56. 56

57. 
 Synthetic, non absorbable
 Inert polyamide polymer
 Braided and sealed with silicon coating
 Looks and feels like silk, but more stronger
 Multifilament nylon is weaker and less secure when
knotted, offering little advantage over monofilament
nylon.
NYLON – BRAIDED
(SURGILON, NURILON)
57

58. 
 Uncoated, but inert and non irritating to the tissues.
 High TS and low tissue reactivity
 Some memory and return to original linear shape
over time. Because of this more throws (4 throws)
indicated.
 Moistened nylon monofilament are more easily
handled and are packaged wet.
Uses:
 Skin closure, retention, plastic, ophthalmic and
microsurgery.
NYLON MONOFILAMENT
(DERMALON, ETHILON)
58

59. 
 Tycron, Mersilene -Uncoated
 Dacron, Ethibond - Coated (with polybutilate)
 Multifilament fibers of polyester
 Excellent TS which is maintained indefinitely
 Uncoated is rougher and stiffer than coated form
 Coated provides -low infection rate
- secure knotting
- smooth removal
- low reactivity
- easy passage through
tissues
More expensive
In deeper layers, may last indefinitely.
POLYESTER – BRAIDED
59

60. 
 Non-absorbable, synthetic, Monofilament
 From expanded polytetrafluoroethylene (ePTFE)
 Extremely low tissue reaction, good knot stability,
good TS, ease of handling.
Uses
 All type of soft tissue approximation and
cardiovascular surgeries.
GORE-TEX
60

61. 
 Absorbable, synthetic, monofilament
 Poliglecaprone 25 copolymer of glycolide and
caprolactone
 Hydrolysis 90-120 days
 Tissue reaction  minimal
 Good knot strength
 Used for soft tissue closure
 Most pliable material ever made
MONOCRYL
61

62. 
 New, monofilament, nonabsorbable, synthetic
 Made of polyglycol trephthate and polybutylene
terephthalate and is considered as a modified
polyester suture.
 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.
POLYBUTESTER
(NOVOFIL)
62

63. 
 Natural, monofilament/multifilament, non absorbable
 Alloy of iron, nickel and chromium
 Good TS even in infection
 Difficult to handle and tendency to cut through tissues.
 Very hard to tie, and knot ends require special
handling.
SURGICAL STEEL
63

64. 
Packaging………
METRIC GUAGE IMPERIAL GUAGE
PRODUCT CODE
NEEDLE SIZE &
CURVATURE
NEEDLE TYPE
NEEDLE TIP
NEEDLE PROFILE
STERILIZED
ETHELENE OXIDE
DO NOT REUSE
SEE INSTRUCTIONS FOR USE
EXPIRY DATE BATCH NO
64

65. 
Largest size 1-0 to extremely fine 11-0.
Increasing number of zeros correlates with decreasing
suture diameter and strength.
Thicker sutures  approximation of deeper layers,
wounds in tension prone areas and ligation of blood
vessels.
Thin sutures  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.
SUTURE SIZES
65

66. • 3-0 or 4-0 OMFS,
muscle, deep skin
• 5-0 or 6-0  facial
skin closure
• 9-0 or 10-0 
microsurgery
66

67. 67

68. 
 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 accessibility
-diameter of suture material
SUTURE NEEDLES
68

69. 
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
CLASSIFICATION OF SURGICAL
NEEDLES
69

70. 
4.According to its tip -triangular tip
-round tip
-blunt tip
5.Others -spatula needles
-micro point needles
-cuticular needles
-plastic needles
70

71.  High quality stainless steel
 Smallest diameter possible
 Capable of implanting sutures with minimal trauma
to tissues.
 Stable in the needle holder
 Should be sharp.
 Sterile and corrosion resistant.
IDEAL PROPERTIES OF NEEDLES
71

72. 
ANATOMY OF A NEEDLE
72

73. 
Term Definition
Chord
Length of needle
Radius
Diameter
The linear distance between eye and
tip.
The distance between eye and tip
following the curvature
The distance of the body of the needle
from the centre of the circle
Gauge or thickness of the metal wire
out of which the needle is made.
73

74. 
74

75. 
1. The eye
2. The body
3.The point
 The eye can be - closed
- swaged
- chanelled/drilled
 Shape of the eye may be - round
- oblong
- square
 Open French-eye needle is easy to load with varying
caliber, but has additional bulk.
COMPONENTS OF
SURGICAL NEEDLE
CLOSED
SWAGED
CHANELLED
75

76.  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’.
 Most suture materials and
needles are difficult to sterilize.
 Needles are also difficult to clean
after use and become blunt and
work hardened so that they snap.
Suture loop inserted through eye
Loop placed over tip
Loop drawn back
Suture tied on eyed needle
76

77. 
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
 Pre-packed and pre-sterilized
by gamma radiation.
77

78. • Needle attached to suture
• Favorable for Intra-oral use but expensive
• Less tissue damage
• New needle each time
78

79. 
79

80. 
 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.
 5/8 used in oral cavity.
THE BODY
80

81. 81

82. 
RADIUS OF CURVATURE OF THE
BODY(NEEDLE)
CLINICAL USE
Straight Needle
¼ circle
3/8 circle
½ circle
5/8 circle
Needle of choice for the skin
Limited use in oral surgery
May be used in surgery of the nose,
pharynx, tendons
Needle of choice for microsurgery
associated with very fine sutures;
ophthalmology
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
Wide range of uses in many surgical
wounds
Wounds of the urogenital tract
82

83. 
 Point runs from tip to the maximum 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 POINT
83

84. 
84

85.  The conventional cutting
point has two opposing
cutting edges and third
edge on the inside
curvature of the needle.
 The reverse cutting point
has two opposing cutting
edges and third cutting
edge on the outer
curvature of the needle.
85

86.  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 facial soft tissue
surgery.
 The blunt point has a rounded end which does not
cut through the tissue .It is used in friable tissue
suturing or to the parotid duct or lacrimal
canaliculi.
86

87. CUTICULAR NEEDLES
 Sharpened 12 times
 Designated as C or FS
(CUTICULAR or FOR
SKIN)
PLASTIC NEEDLES
 Sharpened an additional 24
times
 Designated as P or PS or 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.
87

88. 
 Curvature of the needle is selected according to the
accessibility.
 The needle must exit in a visible spot so that the
surgeon is aware of the position of the point of the
needle at all the times.
 Try to match the needle thickness with suture
diameter .
88

89. 
 It is not appropriate to use wide thick needle with
small suture material .
 This will cause laxity of immediate suture line and
allows bacterial contamination & in growth of
epithelium & in vascular surgery it may allow
oozing of blood through suture hole.
89

90. 
 Force should always be applied in the direction
that follows the curvature of the needle.
 Movable to a non-movable tissue.
 Only sharp needles with minimal force.
 Never force the needle through the tissue.
 Avoid retrieving the needle from the tissue by
the tip.
PLACEMENT OF A NEEDLE
INTO THE TISSUE
Ethicon 1985
90

91. 
 Grasp the needle in the body 1/4th to half of
the length from the swaged area.
 Do not hold the needle by the swaged area or
the eye.
 Avoid excessive tissue bites with small needles,
as it will be difficult to retrieve them
91

92. 
 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.
NEEDLE HOLDER
92

93. 
 Working tip/ jaws
 Hinge device
 Shank/body
 Catch mechanism/ ratchet
 Grip area
PARTS OF NEEDLE HOLDER
93

94. 
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 94

95. 
 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
95

96. GILLES NEEDLE HOLDER
Scissors are incorporated into the blades
96

97. OLSEN HEGAR NEEDLE HOLDER KILNER NEEDLE HOLDER 97

98. MAYO HAGER NEEDLE YASARGIL MICRO NEEDLE HOLDER
98

99. 
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
GRIPPING NEEDLE HOLDER
99

100. PALM GRIP
 Used in the deeper parts of oral cavity
100

101. 
 Use appropriate size for
needle
 Grasped 1/4 to ½ distance
from swaged area
 Tips of the jaws should meet
 Needle placed securely
 Do not over close
 Always directed by
surgeon’s thumb
 Do not use digital pressure
on tissues 101
NEEDLE HOLDER
SELECTION
Ethicon 1985

102. 
PRINCIPLES
OF
SUTURING
102

103. 
1.Needle grasped at ¼ th to ½ the distance from eye.
2.Needle should enter perpendicular to tissue surface
PRINCIPLES OF SUTURING
Ethicon 1985
103

104. 3.Needle passed along its curve
4.The bite should be equal on both sides of the wound
margin and the point of 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.
104

105. 6. Usually the needle should be passed from mobile
side to the fixed side but not always(exception in
lingual mucoperiosteal 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 suture
105

106. 
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. 106

107. 11.Sutures placed at a greater depth than distance from
the incision  evert wound margins…….
……..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.
107

108. 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.
17. Simply extending the length of the incision to hide
the exists will produce an unsatisfactory result.
18. 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.
108

109. 
109

110. 
IMPROPER SUTURING TECHNIQUE
110

111. SUTURING
TECHNIQUES
111

112. 
Indications
• Vertical incision
• Tuberosity and retromolar areas
• Bone regeneration procedures with or without
guided tissue regeneration
• Widman flaps, open flap curettage, unrepositioned
flaps, or apically positioned flaps where maximum
interproximal coverage is required
• Edentulous areas
• Partial- or split-thickness flaps
• Osseointegrated implants
112
Interrupted Sutures

113. 
Types
• Four most commonly used interrupted sutures:
1. Circumferential, direct, or loop
2. Figure eight
3. Vertical or horizontal mattress
4. Intrapapillary placement
113

114. 
 Suturing is begun on the buccal surface 3 to 4 mm
from the tip of the papilla to prevent tearing of the
thinned papilla.
 The needle is first inserted into the outer surface of
the buccal flap and then either through the outer
epithelialized surface (figure eight) or the connective
tissue under the surface (circumferential) of the
lingual flap.
 The needle is then returned through the embrasure
and tied buccally.
114
Figure Eight and Circumferential
Sutures

115. 
115
 Figure Eight  Circumferential
Sutures

116. 
116
Circumferential suture

117. 
117
Figure eight

118. 
 Mattress sutures are used for greater flap security
and control
 They permit more precise flap placement, especially
when combined with periosteal stabilization.
 They also allow for good papillary stabilization and
placement.
118
Mattress Sutures

119. 
 The flap is stabilized and needle is inserted 7 to 10
mm apical to the tip of the papilla.
 It is passed through the periosteum , emerging again
from the epithelialized surface of the flap 2 to 3 mm
from the tip of the papilla.
 The needle is brought through the embrasure, where
the technique is again repeated lingually or palatally.
 The suture is then tied buccally
119
Vertical Mattress

120. 
120

121. 
121

122.  A needle is inserted 7 to 8 mm apical to and to one
side of the midline of the papilla, emerging again 4 to
5 mm through the epithelialized surface on the
opposing side of the midline.
 The suture may or may not be brought through the
periosteum.
 The needle is then passed through the embrasure, and
the suture, after being repeated lingually or palatally,
is tied buccally.
 For greater papillary stability and control, the double
parallel strands of this suture can be made to cross
over the three tops of the papillae. (double crossed-
122
Horizontal Mattress

123. 
123

124. 
 This technique is recommended for use only with
modified Widman flaps and regeneration procedures
in which there is adequate thickness of the papillary
tissue.
 A needle is inserted buccally 4 to 5 mm from the tip
of the papilla and passed through the tissue,
emerging from the very tip of the papilla.
 This is repeated lingually and tied buccally, thus
permitting exact tip-to-tip placement of the flaps
124
Intrapapillary Placement

125. 
125

126. 
 The sling suture is primarily used for a flap that has
been raised on only one side of a tooth, involving
only one or two adjacent papillae.
 It is most often used in coronally and laterally
positioned flaps.
 The technique involves use of one of the interrupted
sutures, which is either anchored about the adjacent
tooth or slung around the tooth to hold both papillae
126
Sling Suture

127. 
127
Sling suture about adjacent tooth

128. 
128
Sling suture about single tooth

129. 
 Laurell modified mattress suture (1993) for coronal flap
positioning and primary flap coverage is a technique which,
although capable of being employed for all regenerative
techniques, is used predominantly when standard
interproximal incisions are used.
 Start bucally below the papilla (2–4mm) and insert the needle
to and then through the undersurface of the lingual flap.
 The suture needle is then reinserted lingually 2–4 mm above
the initial suture and continued to and then through the
buccal flap
 The suture is then brought lingually over the coronal aspect
of the flap and through the loop.
 The suture is afterwards returned bucally and sutured
129
Specialized Interrupted Suturing Techniques
for Bone Regeneration and Retromolar and
Tuberosity Areas. Laurell Modification.

130. 
130

131. 
 This technique (Cortellini et al 1995) was introduced
specifically for achieving maximum interproximal
coverage and primary closure over intrabony defect
is treated by GTR.
 The modified flap technique requires the initial
incision be made at the buccal line angles in the area
of the interproximal defect.
 It is a papillary preservation technique.
 The suturing permits coronal positioning, flap
stabilization, and primary interproximal closure.
131
Modified Flap Suturing Technique

132. 
 The first suture is begun buccally 5–6 mm below the
initial incision.
 The suture is passed through the buccal and palatal flaps.
 It is then reinserted palatally and allowed to exit the
buccal flap 2 mm above the initial placements.
 This is tied off and should stabilize the body of the flap.
 The second suture is now begun 3–4 mm below the initial
incision and above the first suture.
 The suture is passed through the interproximal papilla
and returned as a horizontal mattress suture on the buccal
surface and tied off.
132
Technique

133. 
133

134. 
 This technique (Hutchenson 2005) is specially
designed for gaining intimate tissue-tooth contact
where regeneration is being attempted.
 It is employed when there is an intrabony defect
distal to the last tooth on the lower teeth.
 It not only permits primary flap closure but close
approximation of the tissue on the distal aspect of
the tooth.
134
Retromolar Suture Modification for
Primary Coverage

135. 
 Suture is begun on the mesiobuccal of the terminal
tooth.
 The suture is passed through interproximal to the
distal and inserted through only the undersurface of
the buccal flap.
 The suture is brought almost 360° around the tooth
starting lingually and continuing bucally until again
reaching the distal surface.
 The needle is passed through the undersurface of the
lingual flap and tied on the buccal surface
135

136. 
136

137. 
 When multiple teeth are involved, the continuous suture is
preferred.
Advantages
1. Can include as many teeth as required
2. Minimizes the need for multiple knots
3. Simplicity
4. The teeth are used to anchor the flap
5. Permits precise flap placement
6. Avoids the need for periosteal sutures
7. Allows independent placement and tension of buccal and
lingual or palatal flaps. Buccal flaps can be positioned loosely,
whereas lingual and palatal flaps are pulled more tightly about
the teeth.
8. Greater distribution of forces on the flaps
137
Continuous Sutures Sling

138. 
Disadvantages
 The main disadvantage of continuous sutures is that if the
suture breaks, the flap may become loose or the suture
may come untied from multiple teeth.
Types
 The choice of continuous suture depends on the
operator’s preference. These, too, can be periosteal or
nonperiosteal:
1. Independent sling suture
2. Mattress sutures
a. Vertical
b. Horizontal
3. Continuous locking
138

139. 
 The continuous sling suture, although most often begun
as a continuation of tuberosity or retromolar suturing, can
also be started with a looped suture about the terminal
papilla (buccal, lingual, or palatal).
 It is then continued through the next interproximal
embrasure in such a manner that the suture is made to
encircle the neck of the tooth.
 The needle is then passed either over the papilla and
through the outer epithelialized surface or underneath
and through the connective tissue undersurface of the
papilla.
139
Independent Sling Suture

140.  The needle is passed again through the embrasure and
continued anteriorly.
 This procedure is repeated through each successive
embrasure until all papillae have been engaged.
Terminal End Loop.
 On completion of suturing, the suture is tied off against
the tooth as opposed to the other flap.
 This is accomplished by leaving a loose loop of
approximately 1 cm length of suture material before the
last embrasure.
 When the last papilla is sutured and the needle is
returned through the embrasure, the terminal end loop is
used to tie the final knot 140

141. 
141

142. 
 This technique simultaneously slings together both
the buccal and lingual or palatal flaps.
INDICATIONS.
1. When flap position is not critical
2. When buccal periosteal sutures are used for buccal
flap position and stabilization
3. When maximum closure is desired (unreposition or
Widman flaps or bone regeneration)
142
Alternative Procedure

143. 
Technique
 After the initial buccal and lingual tie, the suture is passed
buccally about the neck of the tooth interdentally and
through the lingual flap.
 It is then again brought interdentally through the buccal
papilla and back interdentally about the lingual surface of
the tooth to the buccal papilla.
 Then it is brought about the lingual papilla and then the
buccal surface of the tooth.
 This alternating buccal- lingual suturing is continued
until the suture is tied off with a terminal end loop
143

144. 
144

145. 
 The continuous locking suture is indicated primarily
for long edentulous areas, tuberosities, or retromolar
areas.
 It has the advantage of avoiding the multiple knots
of interrupted sutures.
 If the suture is broken, however, it may completely
untie.
145
Locking

146. 
Technique
 The procedure is simple and repetitive.
 A single interrupted suture is used to make the initial tie.
 The needle is next inserted through the outer surface of
the buccal flap and the underlying surface of the lingual
flap.
 The needle is then passed through the remaining loop of
the suture, and the suture is pulled tightly, thus locking it.
 This procedure is continued until the final suture is tied
off at the terminal end
146

147. 
147

148. 148

149. 
KNOT TYING
149

150. 
 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
150

151. 
 Use the simplest knot that will prevent slippage.
 Tying the knot as small as possible and cutting the
ends of the suture as short as reasonable to minimize
foreign body reaction.
 Avoid friction or sawing
 Avoid damage to suture material
 Avoid excessive tension
 Tying sutures too tightly strangulates the tissue
PRINCIPLES OF KNOT TYING
151

152. 
 Maintenance of traction at one end of the suture after
the first loop is thrown, to avoid loosening of the
knot.
 Placing the final throw as horizontally as possible to
keep knot flat
 Limiting extra throws to the knot, as they do not add
strength to a properly tied knot.
152

153. 
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
153

154. 
 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
 Can be given as 2-1 and 2-2
SURGEON’S KNOT
154

155. 
 A tie in one direction followed by a tie in the same
direction and a third tie in the opposite direction to
square the knot and hold it permanently.
GRANNY’S KNOT
155

156. SUTURE
REMOVAL
156

157. 
 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.
157

158. Intra oral
 Mucoperiosteal closure (without tension)
 5-7 days
 Where there is tension on the suture
eg : Oro-antral fistula- 7-10 days
 Continuous subcuticular can be left for 3-4 weeks
without formation of suture tracks
 A good guide is that as soon as they begin to get
loose they should be taken out.
158

159. 
1. The area should be swabbed with hydrogen peroxide
for removal of encrusted necrotic debris, blood, and
serum from about the sutures.
2. A sharp suture scissors should be used to cut the
loops of individual or continuous sutures about the
teeth. It is often helpful to use a no. 23 explorer to help
lift the sutures if they are within the sulcus or in close
opposition to the tissue. This will avoid tissue damage
and unnecessary pain.
159
PRINCIPLES OF SUTURE REMOVAL
Ethicon 1985

160. 
3. A cotton pliers is now used to remove the sutures.
The location of the knots should be noted so that they
can be removed first. This will prevent unnecessary
entrapment under the flap.
 Sutures should be removed in 7 to 10 days to prevent
epithelialization or wicking about the suture.
160

161. 
 Sutural abscess.
 Suture scarring or stitch mark
 Implanted dermoid cyst
Possible Complication Of Leaving
Suture For Many Days
161

162. 
 Ligating clips
 Skin staples
 Surgical tape
 Surgical adhesives
Other Methods of Wound
Closure
162

163. 
1. Atlas of Cosmetic and Reconstructive Periodontal
Surgery - Edward S. Cohen DMD- 3rd edition
2. Illustrated manual of Oral and Maxillofacial Surgery-
Geeti Vajdi Mitra
3. Suturing techniques in Oral Surgery –Sandro Siervo
4. Carranza's Clinical Periodontology- 10th edition
5. Wound management and suturing manual- Corey S
Mass
6. Textbook of Oral and Maxillofacial Surgery- Neelima
Anil Malik- 2nd edition
REFERENCEs
163

164. 
7. Brian CB, Philip KH. Review: Polymers for absorbable
surgical sutures-Part I. J Bioactive Compatible Polymers
1990.
8. Ricardo SG et al, Reaction of human gingival tissue to
different suture materials used in periodontal surgery. Braz
Dent J 1991.
9. Chu CC, Mechanical properties of suture materials: an
important charecterization. Ann Surg 1981.
10. Parirokh M et al, A scanning electron microscope study
of plaque accumulation on silk and PVDF suture materials in
oral mucosa. International Endodontic J 2004.
164

165. 165