sutures

1. SUTURES AND SUTURING TECHNIQUES
DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF REQUIREMENTS FOR
THE DEGREE OF BACHELOR OF DENTAL SURGERY IN ORAL AND
MAXILLOFACIAL SURGERY
VESTA ENID LYDIA.R,
FINAL YEAR, B.D.S
2011
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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 “SUTURES
AND SUTURING TECHNIQUES” was conducted by the UnderGraduate
student, VESTA ENID LYDIA.R, under my guidance and supervision in
partial 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 Surgery
Date:
Madurai.
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3. ACKNOWLEDGEMENT
First of all, I would like to thank the almighty , for giving
me the strength and health to do this library dissertation
work until it be done Not forgotten to my family for
providing everything, such as money, to buy anything that
are related to this project work and their advice, which is
the most needed for this project. Internet, books, computers
and all that as my source to complete this project. They also
supported me and encouraged me to complete this task so
that I will not procrastinate in doing it.
It is with deep satisfaction and gratitude that I
acknowledgenmy guide,DR.JAYAPRAKASH ,MDS, HOD of
oral surgery CSICDSR for scholoraly guidance,help and
confidence ,encouragement which enabled me to complete
this study.
I whole heartedly thank DR.RATHNAKUMAR our
principal for providing the necessary infrastructure and
environment that is conductive for research activities,in
college.
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4. And Im greatfull to DR.THANVIR MOHAMMED NIAZI,
MDS,
DR.ULAGANATHAN,MDS,DR.YOGANATHA,MDS, for
their mentoring heartfull discusions,continious guidance and
advices.
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5. S.NO TABLE OF CONTENTS PAGE.NO
1. INTRODUCTION 1
2. REVIEW OF LITERATURE 3
3. ARMAMENTARIUM 11
4. SUTURING MATERIALS 16
5. ESSENTIAL SUTURE CHARACTERISTICS 30
6. SUTURE SIZES 35
-7. SUTURE NEEDLES 37
8. PRINCIPLES OF SUTURING 47
9. SUTURING TECHNIQUES 49
10. SURGICAL KNOTS 52
11. KNOT TYING 61
12. SUTURE REMOVAL 66
13. CONCLUSION 67
14. REFERENCE 68
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6. 6

7. INTRODUCTION
Wound repair is a well orchestrated and highly coordinated process that includes
a series of overlapping phases: inflammation, cell proliferation, matrix deposition,
and tissue remodeling.Sutures play an important role in wound healing after
surgical interventions and thus the selection of suture material, especially in oral
procedures, must be made carefully. This location differs from other body sites
due 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 ultimately
leads to severely disturbed wound healing conditions.Systemic diseases which
delay wound healing is another significant point that ef- fects the choice of suture
material and represent major clinical importanc.Diabetic wound healing
impairment is one of the most well-known chronic wound situations.The factors
ensuring appropriate intercellular communication during wound repair are not
completely understood.
The primary objective of dental suturing is to position and secure surgical flaps to
promote optimal healing. When used properly, surgical sutures should hold flap
edges in apposition until the wound has healed enough to withstand normal
func- tional stresses. When the proper suture technique is used with the
appropriate thread type and diameter, tension is placed on the wound margins
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8. so primary intention healing occurs.1 Accurate apposition of surgical flaps is
significant to patient comfort, hemostasis, reduction of the wound size to be
repaired, and prevention of unnecessary bone destruction. If surgical wound
edges 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 thorough
understanding of the theory of wound care and the basic principles of suturing.we
belive that this work on sutures and suturing techniques will enlighten your
knowledge on patient care with the available source.
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9. REVIEW OF LITERATURE
Sometime between 50,000 and 30,000 B.C. eyed needles were invented, and by
20,000 B.C., bone needles became the standard that was not improved upon until
the Renaissance. It is reasonable to assume that these needles were used to sew
wounds together, because Neolithic (“of the ‘New’ Stone Age”) skulls have been
found, showing that trepanning (a form of surgery where a hole is drilled or
scraped into the skull) was used successfully. Evidence shows that the wounds
must have been closed up after the procedure because there is bone growth
inward from the edges of the hole;
this means that the patient was not only alive at the time of the operation, but lived
for a considerable period of time afterward.
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10. The primitive men in the beginning of more modern times give examples of how
early surgery was performed. Native Americans used cautery (the burning of the
body 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 through
the wound with strips of leaves wound around the two protruding ends in a figure
eight.
A South African method of wound closure uses large black ants to bite the wound
edges together, with their powerful jaws acting as Michel clips. The bodies would
then be twisted off, leaving the head in the place to keep the wound closed. In
more ancient times (1,900 B.C.), the king of Babylon, Hammurabi, engraved his
country’s laws on a pillar. Some of these law related to surgical practice; one
stated that “If a physician should make a severe wound with an operating knife
and 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
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11. declined so far that people with illness and disease were carried into the market
square so that they could get recommendations and advice from people who had
already experienced the illness.
The Mesopotamian civilizations are known to have been in regular contact with
the India and one Indian man wrote a surgical text which was a great reservoir of
information. 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 was
having the offender’s nose cut off. There were many different, yet successful,
surgical procedures performed, such as the opening of the intestines and removal
of any blockage, rinsed with milk, then lubricated with butter and then finally
closed by the ant head method described before. Instruments were described in
detail in this surgical text, including triangular,round-bodied, curved, or straight
needles; sutures were made from hemp, hair, flax, and bark fiber. Training for
incisions was very important and they used melons, gourds, and animal bladders
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12. to practice suturing and lotus stems for ligating. It is obvious from this and other
texts that Indian surgery was considerably ahead of any other early civilization
and it can be assumed that much of Arabic, Babylonian, Egyptian, and Greek
surgery techniques originated in India.
In the seventh century B.C., the Greeks began to found medical schools because
of the great demand for surgical and medical attention; it was also at this
particular time that medicine was finally recognized as a science. A Greek
physician by the name of Hippocrates is considered to be one of the most
outstanding figures in the history of medicine.
His main contributions to surgery were his detailed clinical descriptions and the
discarding of treatments founded on tradition or wishful thinking rather than on
rationality
Sometime around 30 A.D., a medical encyclopedia was written by a Roman
named Aurelius Cornelius Celsus. His work, De Re Medicina, tells the reader that
sutures should be “soft, and not over twisted, so that they may be more easy on
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13. the part.” He is also credited with first substantiated mention of ligating by
recommending it as a secondary means of stopping haemmorhage
Galen, an ancient Greek physician from A.D. 150, gained a sterling reputation
from treating and suturing the severed tendons of gladiators, giving them a
chance at recovery ratherthan the sure fate of paralysis.
He was an authority on suture thread materials and has many recommendations
on which material would be best for each sort of wound closure in his book Del
Methodo Medendi. Also, Galen, along with Hippocrates, recognized two kinds of
wounds: a clean wound and a dirty wound (which required drainage before
healing could occur).
A Muslim scholar named Avicenna became known as the Prince of Physicians
because at twenty years old, he had already written extensively on philosophy,
natural history, mathematics, law, and medicine (of which he was already an
authority).
13

14. Another development in suturing was Avicenna’s realization that some traditional
materials had a tendency to break down rapidly; because of this, he invented the
first monofilament suture by using pig’s bristles.Avicenna may have been the
Prince of Physicians, but the Prince of Surgeons was undoubtedly Albucasis. In
his first book, he recommended the indiscriminate use of cautery, but in his
second book, the use of cutting instruments and sutures were implemented
instead. In this book he described a technique called a “double suture” which is
still used today.
The technique of closing wounds by means of needle and thread is several
thousand years old. The history of surgical sutures can be traced back to ancient
Egypt, and the literature of the classical period contains a number of descriptions
of surgical techniques involving sutures.
Before catgut became the standard surgical suture material towards the end of the
19th century, many different paths had been followed to find a suitable material for
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15. sutures and ligatures. Materials that had been tried included gold, silver and steel
wire, silk, linen, hemp, flax, tree bark, animal and human hair, bowstrings, and gut
strings 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 an
advantage. Nevertheless, metal threads had major disadvantages: their stiffness
rendered knotting more difficult and could easily result in knot breakage; in
addition, suppuration of the wound edges occurred frequently.
These negative experiences with metal contributed to the establishment of silk as
the number one suture material. Wounds sewn with silk cicatrised within a few
days, and the small knot caused no problems. For these reasons most surgeons
at that time chose silk for sutures and vessel ligatures. A fundamental change in
the assessment of suture materials followed the publication in 1867 of Lister’’s
research on the prevention of wound suppuration. On the basis of work by Koch
and Pasteur, Lister concluded that wound suppuration could be prevented by
disinfecting sutures, dressings, and instruments with carbolic acid. Initially Lister
used silk as a suture material, on the assumption that it was absorbable and
therefore could also be used for ligatures. Later he searched for a more rapidly
absorbable material and consequently began to use catgut.
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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 America
were most suitable because they had the lowest fat content thanks to their natural
husbandry conditions.
The use of catgut was never called into question until the appearance of BSE at
the beginning of the 21st century. Alternative products had already been
developed by this time. These are the synthetically manufactured absorbable
suture 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.In
response to the requirements of modern surgery and thanks to the efforts of users
and manufacturers over the last few decades, a wide variety of sutures have now
been developed have made these sutures available to all Surgeons
ARMAMENTARIUM
TOOLS FOR SUTURING
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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 SCISSORS
Surgical scissors are classified according to the 2 blade tips - thus:
• Sharp–sharp
• Sharp–blunt
• Blunt–blunt
Sometimes 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
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18. Use your medium Sharp–blunt scissors for general cutting purposes and to cut
off 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
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19. A dentist uses a sharp curved probe to examine teeth
and detect cavities.Anesthetists and radiologists
use flexible blunt probes to maneuver their way into
specific veins or arteries in the body (for diagnostic or therapeutic purposes)
SKIN HOOK
A skin hook is used to lift a section of skin, to facilitate the placement of sutures
while minimizing the amount of injury to the tissues.By placing two skin hooks into
the tissue at the corners on the 2 sides of a laceration, and gently lifting both skin
hooks, one can facilitate eversion (having a slightly raised sutured laceration
compared to the adjacent tissue).
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20. SCALPEL
A scalpel is a surgical knife with a fixed or removable blade (cutting area).
Removable blades are produced in a variety of patterns and sizes.
FORCEPS
A 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 handling
and gripping of tissue or objects.
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21. The other forceps is called a tissue forceps. The tip of this forceps shows a
sharpish tip (jaws) on the one leg and a v-shaped groove on the other side. It is
commonly referred to as a rat-tooth forceps. Use this forceps to handle tissue
when placing sutures.
NEEDLE HOLDER
A Needle Holder is a special type of forceps, designed to securely hold
the surgical suture needle when placing sutures. Artery forceps are somewhat
similar in appearance, but have longer jaws – some with straight and some with
curved jaws.
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22. SUTURE MATERIALS
In 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 flaps
contributes to patient comfort, hemostasis, reduction of wound size, and
prevention of unnecessary bone resorption. If surgical wound edges are not
properly approximated, hemostasis can be compromised and blood/serum may
accumulate under the flap. This could result in a space between the underlying
soft tissue and bone, thus delaying the healing process. In addition, when this
occurs, 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 as
required by the surgical procedure being performed. Certain periodontal surgical
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23. procedures (eg, excisional new attachment procedure [ENAP] and modified
Widman flap procedure) require the surgical flap margins to be positioned in their
original location, whereas other periodontal procedures may require that the
surgical flaps be placed apically, coronally, or laterally to their original position in
order to achieve the surgical objectives.
Suturing technique, the type and diameter of suture material (thread), the type of
surgical needle, and the design of the surgical knot are essential factors in
achieving optimal wound healing. Wound closure variables are different when
suturing over hard versus soft tissue, or suturing over various types of materials
placed into the surgical site to promote periodontal regeneration (eg, bone graft
material or a membrane). The suture material and needle design will change
accordingly.
Tensile strength is an important quality when determining which suture material is
appropriate for specific situations. Tissue biocompatibility and ease of handling,
with a focus on minimal knot slippage, also influence which thread should be
selected. The clinician should select the suture material and diameter based on
the thickness of the tissue to be sutured and whether there is a need for flap
tension.
Therefore, selection of the suturing technique and material should be based on
the goals of the surgical procedure and the physical/biologic characteristics of the
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24. suture material in relationship to the healing process. Adequate strength of the
suture material will prevent breakage during suturing, and proper tying of the knot
in consideration of the material being used will prevent untying or knot slippage.
The clinician must also understand the nature of the suture material, the wound
healing process, the biologic forces exerted on the healing wound (eg, muscle
pulls and swelling), and the interaction of the suture and tissue. The suture must
retain its strength until the tissues of the flaps regain sufficient strength to keep the
wound edges together. In clinical situations where the tissues will not regain their
preoperative strength, or tension is exerted on the surgical flaps, consideration
should be given to using a suture material that retains long-term strength (up to 14
days) 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 has
muscle attachments close to the crestal ridge; when the flap margins are
reapproximated there will be tension on the margins. Should a resorbable suture
material be used that loses its tensile strength after a few days, the re-adhesion of
the periosteum to the underlying bone will not have gained enough strength to
overcome the muscle pull. Therefore, a longer-lasting suture material should be
utilized until the flap has achieved sufficient reattachment to the bone.
Resorbable sutures lose tensile strength over a period of time from several days
to several weeks, and the breakdown of the resorbable material should equal the
healing rate of the tissue being coapted by the material. If a suture is to be placed
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25. in tissue that heals rapidly, a resorbable suture should be used that will lose its
tensile strength at approximately the same rate as the tissue gains strength. The
suture will be absorbed by the tissue, leaving no foreign material in the wound
after 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 the
tissue, whereas resorbable sutures fabricated from synthetic materials such as
polygycolic acid are hydrolyzed via the Kreb's cycle.2 Surgical gut suture material
is made from animal protein (ie, gut), thus it can potentially induce an antigenic
reaction.6 When used intraorally, this material loses most of its tensile strength in
24 to 48 hours; coating the material with a chromic compound extends resorption
to 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 the
material during the resorption process may occur too rapidly to maintain flap
apposition, particularly if used in patients with a very low intraoral pH.4 Many
physiological events can cause a decrease in intraoral pH, including disorders
such as epigastric reflux, hiatal hernia, and bulimia. Sjogren's syndrome,
chemotherapy, radiation therapy, and certain medications (eg, angiotensin-
converting inhibitors, anti-psychotics, diuretics, antihypertensive agents,
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26. antipsoriasis medications, and steroid inhalers) can cause xerostomia and a low
intraoral 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 low
intraoral pH (and surgical gut sutures are contraindicated). PGA-FA suture
material is not affected by low intraoral pH; it is manufactured from synthetic
polymers and is mainly degraded by hydrolysis in tissue fluids (via enzymes
involved in the Kreb's cycle). This requires 7 to 10 days. This material has a
higher tensile strength than surgical gut suture material, but its resorption rate is
comparable to that of surgical gut sutures under normal intraoral physiologic
conditions.
Nonresorbable sutures are fabricated either from natural or synthetic materials.
Silk has been the most widely used material for dental and many other types of
surgery. Silk is easy to handle, is tied with a slipknot, and costs less than many
other nonresorbable suture materials. However, silk sutures have certain
disadvantages. Being nonresor-bable, silk sutures must be removed by the
clinician, usually 1 week following surgery. The patient generally is not
anesthetized for this suture removal. Further, being a multifilament thread, silk
demonstrates a "wick effect," which pulls bacteria and fluids into the wound
site.9Therefore, silk is not the suture material of choice when foreign materials
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27. such as dental implants, bone grafts, or regenerative barriers are placed under a
mucoperiosteal flap, or when infection of the surgical site is present at the time of
surgery (ie, removal of a septic tooth).
Nonresorbable sutures that can be used in situations where silk is contraindicated
include nylon, polyester, polyethylene, polypropylene, or expanded
polytetrafluoroethylene (e-PTFE). Polyester sutures comprise multiple filaments of
polyester polymer, which are braided into a single strand that possesses high
tensile strength and does not weaken when moistened. A biologically inert,
nonresorbable compound of proprietary composition4 is often used to coat these
sutures to aid the suture in passing more easily through tissues. However, this
coating allows the material to untie easily unless the suture is secured with a
surgeon's knot. Nonresorbable e-PTFE suture material is a monofilament with
high tensile strength, good handling properties, and good knot security. It is,
however, expensive compared with other nonresorbable suture materials.In
addition to material composition, surgical threads are also classified by numbering
from 1 to 10; higher numbers indicate thinner, more delicate thread. 10 For
example, in implant dentistry a 3-0 thread diameter is generally used to secure
flaps when a mattress suturing technique is used, and a 4-0 thread is used closer
to the flap edges to coapt tension-free flap edges. A 4-0 thread also is used to
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28. secure implant surgical flaps when interrupted sutures, horizontal or vertical
mattress sutures (depending on where the tissue is positioned), and most
continuous suture techniques are utilized. In periodontal plastic surgery
procedures a 5-0 thread diameter is most often used to secure soft-tissue grafts
and transpositional/sliding pedicle flaps. When securing most other periodontal
mucoperiosteal flaps, 4-0 thread is used
ABSORBABLE MATERIALS
Catgut plain – used to suture mucous membrane of lips, tongues superficial
laceration of the genital area. They are easily absorbed within one week.
Catgut chromic – used to suture fascia, muscles, or ligature of blood
vessels.It is usually absorbed within 30 – 45 days.
vicryl – same as above. Takes at least 70 days for absorption. Rapid vicryl is
easily absorbed.
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29. PDS – expensive, takes at least 5 – 6 months to be absorbed.
However, vicryl is the most commonly used suture materials during surgery
while 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. (poliglecaprone Monofilament Undyed Copolymer of Approximately Complete
25) 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 weeks.day.
Approximately Essentially
Clear 50% remains atcomplete
four weeks.within six
Approximately months.
25% remains Absorbed
at six weeks. by slow
Braided Braided hydrolysis.
Copolymer of lactide Approximately Essentially
Undyed
Synthetic (White) and glycolide coated80% remains atcomplete
Absorbable with caprolactone/3 months.between 18
Suture glycolide. Approximately and
60% remains at30 months.
6 months.Absorbed
Approximately by slow
20% remains hydrolysis.
at 12 months.
NON-ABSORBABLE MATERIALS
Ethilon – most commonly used to close and suture skin after surgery or
trauma to the skin. Cutting needles are usually used.
30

31. Prolene – used to suture nerve, tendon or blood vessels. Preferable round
body needles are used.
Silk and Linen – have similar properties. They are very strong, but they are
adherent to the tissues and can caused reaction or infection.
TENSILE
COLOR OF STRENGTH ABSORPTIO
SUTURE TYPES RAW MATERIAL
MATERIAL RETENTION N RATE
in vivo
Silk Braided Violet Organic Progressive Gradual
Suture 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. Nonabsorbabl
Steel Suture metallic e.
Multifilament
Nylon Monofilament Violet Long-chain Progressive Gradual
Suture 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 Gradual
Suture 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.
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32. Polyester Fiber Braided Green Poly No Gradual
Suture (ethylene significant encapsulatio
Monofilament Undyed terephthalate) change n by fibrous
(White) . known to connective
occur in vivo. tissue.
Braided Green Poly (ethylene No Gradual
Polyester Fiber terephthalate) significant encapsulatio
Suture Undyed coated with change n by fibrous
(White) polybutilate. knownto connective
occur in vivo. tissue.
Polypropylene Monofilament Clear Isotactic Not subject toNonabsorbabl
Suture crystalline degradation e.
Blue stereoisomer of or weakening
polypropylene. by action of
tissue
enzymes.
PolyMonofilament Blue Polymer blend ofNot subject toNonabsorbabl
(hexafluoropropyle poly (vinylidenedegradation e.
ne- 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 the
edges have to be removed.
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33. TYPES OF SUTURE MATERIALS
33

34. IDEAL SUTURE CHARACTERISTICS
34

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 infection
Unfortunately, at the present time, no single material can provide all of these
characteristics. In different situations and with differences in tissue composition
throughout the body, the requirements for adequate wound closure require
different suture characteristics.
ESSENTIAL SUTURE CHARACTERISTICS
All sutures should be manufactured to assure several fundamental characteristics,
as follows:
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36. • Sterility
• Uniform diameter and size
• Pliability for ease of handling and knot security
• Uniform tensile strength by suture type and size
Freedom from irritants or impurities that would elicit tissue reaction
OTHER SUTURE CHARACTERISTICS
The 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)
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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 tissue's ability to resist deformation
and breakage
Wound breaking strength - Limit of tensile strength of a healing wound at which
separation of the wound edges occurs
37

38. 38

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. SUTURE SIZES
Modern suture diameters range from thick to thin and are represented by the
series 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 and
11-0 sutures are micro-fine monofilament sutures used by ophthalmic surgeons
operating with the aid of a surgical microscope. Number 5-0 or 6-0 sutures are
used to stitch up lacerations in cosmetically sensitive areas like face
40

41. SUTURE NEEDLE
The 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 most
commonly used.
When using the three-eighths needle to close tissue in the oral cavity, the clinician
rotates the needle on a central axis to pass it from the buccal surface to the
lingual surface in one motion, whereas the one-half circle needle is traditionally
used in more restricted areas (eg, buccal surface of maxillary molars and facial
surface of maxillary and mandibular incisors). The one-half circle needle is
routinely used for periosteal and mucogingival surgery.
Suture needles may also be classified as either conventional cutting or reverse
cutting. In the oral cavity, reverse-cutting sutures should be used to prevent the
41

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 associated
with cut out because the inside concave (inner) curvature is sharpened; as the
needle is pulled through the tissue, it cuts the tissue. This is detrimental in dental
surgery because the tears that are created will complicate healing. In contrast, the
inner curvature of a reverse-cutting needle is smooth, with a third cutting edge
located on the convex (outer) edge.
Figure illustrates the inner curvature of a reverse-cutting needle compared to a
conventional needle. For suturing of mucoperiosteal flaps in the oral cavity, the
three-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 commonly
used combinations.
42

43. Modern needles are pre-assembled with a suitable suture material attached to the
blunt end. These needles are referred to as “atraumatic” meaning they do not
have an eye that may injure the tissue as it traverses the tissues. The needles in
your Kit have a small eye on the side opposite to the tipfor you to attach the suture
to. Atraumatic needles are manufactured in all shapes for most sizes of sutures.
ATTACHMENT OF SUTURE MATERIAL TO A NEEDLE
43

44. In past generations, a medical professional would routinely use a needle with an
eye (an “eye” is a small hole on the blunt side of a needle where the thread is
held) for suturing purposes. The eye part of such a needle may cause minimal
damage as it traverses the tissue.
Modern suturing materials have pre-attached thread. Pre-attached sutures allow
for 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 to
the tissue).
The needle-suture attachment is an occasional weak link, and on rare occasions
may become undone. This attachment occupies about ⅛ inch (3 mm) on the
suture end of the needle (the swage). One should avoid clamping the Needle
Holder to the swage of the needle as one may interfere with the secure
attachment 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 the
needle roughly in the middle of the needle’s body. Secure the Needle Holder by
clamping it to the first ratchet. (Be careful when working with sharp objects).
44

45. STEPS I N ATTACHMENT OF
SUTURE MATERIAL TO A NEEDLE
:
45

46. STEP 3
Fold the last 1½-inch (4 cm) of suture double and pass the double thread through
the eye of the suture needle.
STEP 4
open up the double thread slightly to form a loop, and pass the needle through the
loop firmly pull the long and short loose ends of the double hread away from the
needle - thus tightening the simple loop knot to attach the thread to the needle.
STEP 5
Firmly pull the long and short loose ends of the double hread away from the
needle - thus tightening the SImple loop knot to attach the thread to the needle.
4
46

47. SUTURING TECHNIQUE GRIP
The 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 handle
loops. The needle should be grasped between 1/3 to 1/2 of the distance between
the suture attachment and the needle tip
THE BASIC PRINCIPLES OF WOUND CARE
KNOW YOUR PATIENT
If 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 local
anesthetics, antibiotics and pain medication, antiseptic solutions or
plasters/strapping? Does he/she suffer from chronic diseases like Diabetes or
bleeding disorders? Are they using any chronic medications? Etc
47

48. .
GOOD VISION (GOOD LIGHTING)
Fact is that medical schools have trained a number of blind physicians over the
years – but no blind surgeon yet. Scrub sisters have a saying that the good
surgeons are those who always complain about the light – might be true, because
the whole success of the surgical procedure depends on good, proper lighting of
the operative field offering the surgeon with optimal visual sensory input!
ANESTHESIA
The surgeon will make decisions regarding local anesthesia / general anesthesia
and/or sedation. You cannot do your best for a patient who is jumping, jerking
screaming or crying all the time.
48

49. ASEPTIC TECHNIQUE
Complete sterility of the operative field is not attainable. Sterile instruments and
suture material must be used. Excess suture material must be discarded in a
container purposed for biological waste. The needle must be discarded in a
suitable biological sharps waste container). Avoid using strong antiseptic
preparations for cleaning the wound. Most antiseptic solutions will cause damage
to the friable exposed tissue cells. In most cases a normal saline solution will be
sufficient to clean an uninfected wound!
REMOVE ALL FOREIGN MATERIAL
The 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 traumatic
tattooing (very difficult if not impossible to remove at a later stage!) If necessary
brush 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. the limits of getting a secure closure. Remember that suturing materials although
necessary are considered by the tissue as foreign material.
LEAVE MINIMAL DEAD SPACE
While suturing, the operator will try to suture living tissue to living tissue. Do not
leave empty spaces filled with air, blood or tissue fluid. Dead spaces produce
wonderful opportunities for bacteria to proliferate and to cause infection. Dead
space may fill up with blood clot and will contribute to the formation of excessive
scarring.
HANDLE TISSUE GENTLY
Always perform surgery - showing respect for living tissue. Careless suturing may
cause more unsightly damage compared to the original wound! Use a toothed
forceps to handle the skin (gently touch though). A flat forceps slipping all the time
will cause more damage compared to a toothed forceps handled gently.
CONTROL BLEEDING
Bleeding can be reduced with suctioning and gentle sponging, and controlled by
Electro-cautery (electrical burning) and suturing – ligate (tie-off) larger veins and
arteries and use tight suturing over bleeding areas (within reasonable limits of
course). Excessive bleeding will decrease your ability to see what you are doing
and good vision is the first principle of surgery!
50

51. General bleeding and an inability of blood to clot may be due to a number of
medications e.g. aspirin (pain-killer), Hemophilia (a hereditary absence of clotting
factors in the blood), Liver disease, a number of blood diseases, anti-cancer
medication (chemotherapy may reduce the blood platelets which are essential for
normal blood clotting to occur) and alcohol consumption (not an infrequent finding
with patients reporting to a hospital’s emergency section). Do take a thorough
patient history before you start treating the injury!
THE REPAIR OF WOUNDS
Goals For Suturing Wounds
Optimal wound care aims at maximizing functional restoration as well as
optimizing the esthetic result. These goals must occur within the limits of
maximum patient safety and patient comfort (a calm patient experiencing
the 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 a
substitute for normal bleeding control measures e.g. ligating arterial bleeds in the
depth of the wound etc.
• It reduces the chances of wound infection. A closed wound is much less prone to
51

52. wound sepsis than an open wound. Further contamination from the outside
environment 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 retaining
its blood supply, and at the same time minimizing the formation of unsightly
scar 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 the
medical professional anticipates debridement of the wound (cleaning
and 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 and
try to close the wound under tension – it will break down!
• Sepsis. Common reasons for sutured wounds to open up again are wound
contamination 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. 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. • 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 remains
controversial. Perhaps the biggest advantage of continuous suture patterns is
54

55. their speed, allowing faster wound closure, thereby saving anaesthetic and
surgical time in critically ill patients. However, interrupted patterns allow the
tension along the wound line to be more precisely controlled, adjusting tension
according to the variable spreading forces along the margin.These types of forces
are usually more of a problem with irregular wound edges. How these wound
edges look once they are apposed and the suture pattern is applied can be
descr ibed as either inverting, appositional, or everting. For most tissue
closure, appositional suture patterns are preferable, as they allow the best
anatomical approximation of the disrupted tissue planes. Inverting suture
patterns have been traditionally described for the closure of hollow viscera.
However, studies have shown no added benefit of using inverting suture
patterns on routine closure of hollow viscera, and have even documented a
delay in healing when compared to appositional suture patterns (Radasch
1990). An inverting pattern can sometimes be quite useful, for example to
invaginate a section of stomach wall when managing a patient with gastric
dilatation and volvulus whose gastr ic mucosal viability is questionable.
Otherwise, due to concerns regarding possible stricture formation and delayed
healing, inverting patterns for gastrointestinal surgery have largely fallen into
disfavour. Everting suture patterns are used primarily in areas that require
dispersal of tension forces along the wound closure line. Many of the tension
relieving suture patterns commonly in use will produce slight eversion. The
benefit of having slight eversion on skin closure becomes evident after
55

56. removal of sutures (or staples), as the scar has a tendency to flatten rather than
widen. More commonly, most skin closures are accomplished using a more
traditional interrupted or continuous appositional type pattern.
ADVANTAGES AND DISADVANTAGES OF INTERRUPTED VERSUS CONTINUOUS
SUTURE 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. SURGICAL KNOTS
All suture patterns start with one basic component - the square knot. Also known
as 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’, and
by reversing directions after each throw and applying even pressure as the knot
is tightened, the resulting knot leaves the ‘tags’ of the knot coming out on the
same side of the loops. Extra throws are placed over the square knot to produce
the 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 will
result in unnecessary extra bulk.
Failing to reverse directions while tying the knot produces a ‘granny’ knot , thus
producing ‘tags’ that exit on opposing sides of the suture loops. This knot is
inferior 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 the
first throw of a square knot, is occasionally used for closure of tissues where
57
5

58. tension on the tissues makes it difficult to apply a regular square knot.The
increase in frictional forces obtained from passing the strand through the
Surgeon’sHalf-hitch loop twice will allow a second throw to be placed without loss
of significant tightening. However, this does produce an asymmetrical knot, and
subsequent regular square knot throws must be utilised to prevent the knot from
slipping or coming undone. The increased bulk and asymmetry of the knot
makes it less suitable for general ligation than the square knot. There should
never be a need to routinely use a surgeon’s knot other than in areas where
the tension is too great to facilitate tying a square knot.
In addition, surgeon’s knots should not be utilised with catgut as the increased
friction has a tendency to make the material fray.An alternative to the surgeon’s
knot for utilisation in areas of wound tension is to tie a ‘half-hitch’ knot, slide it
down 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’.This
technique requires some patience and practice, but can be a very useful
addition to the surgeon’s ar mamentar ium, particularly when ligating
structures within deep cavities. It leaves a square knot rather than the more bulky
58
5

59. and asymmetrical surgeon’s knot. However, it must be tightened correctly in order
to avoid the suture material slipping off the pedicle.
Surgeons will often utilise a ‘buried’ knot for subcuticular or intradermal
patterns.This knot is tied using the same knotting technique as a square knot, but
the suture is passed on the near side from deep to superficial and then across to
the 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 layers
of the tissues.
GENERAL PRINCIPLES OF TYING KNOTS
There are three basic methods for tying knots:
1. instrument
2. one-handed
3. two-handed tying techniques
Numerous methods have been described for each technique, and detailed
descriptions can be found in the recommended reading list at the end of this
article. Instrument tying is the most widely used tying technique, and has the
advantage of producing consistent and reliable square knots. This technique can
be difficult to apply in deep cavities, where the one-handed tie may be more
useful.The two-handed tie produces reliably more consistent square knots than
the one-handed method, but can be slower and unwieldy in small areas. All three
techniques have their distinct advantages and disadvantages, and mastery of
59

60. these three methods allows the surgeon to secure ligatures in a wide variety of
situations.
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 suture
material. As a general rule, use sutures no larger than 3-0 (2M) on individual
vessels and 0 (3.5M) on tissue pedicles)
● Ensure that adequate and equal tension is applied to each strand during
knot 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, and
only use instrumentson the end of the suture material. This tag end will be
removed at the completion of the knot anyway.
● Extra knots produce more bulk and potentially more tissue reaction. Only
use the recommended number of throws for your particular suture material.
EXAMPLES OF USEFUL SUTURING TECHNIQUES IN ORAL SURGERY
60

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 loop
and the criss-cross (which is a modification of the horizontal mattress suture
technique). In dental surgery, the simple loop is used most commonly to coapt
tension-free, mobile surgical flaps.4 Procedures where the simple loop is useful
include surgery of edentulous ridge areas, to coapt vertical releasing incisions, for
periosteal suturing, and to coapt flaps as part of certain periodontal surgical
procedures (ie, modified Wid-man flap, some periodontal regeneration surgery,
and some exploratory flap procedures). A simple loop is created by entering the
buccal flap from the epithelial surface (position 1) and crossing under the
periosteum to exit the epithelial surface of the lingual flap (position 2); a knot is
tied toward the buccal (Note: This example assumes a simple flap where all the
soft tissue has been elevated off the bone, including the periosteum.)
. A criss-cross suture placed at
an extraction site to close the
margins and aid in retention of
graft material placed in th
61

62. socket.
The criss-cross is similar to the simple loop on the buccal aspect; however, on the
lingual aspect, the needle penetrates first through the epithelial surface of the
lingual flap, thus interposing additional suture thread between the surgical flaps.
The criss-cross technique is useful when suturing on the lingual aspect of the
man-dibular molars, especially in a patient with an active gag reflex or a large
tongue.4 A criss-cross suture is tied by entering the mesial buccal aspect (position
1) and exiting the distal buccal aspect (position 2); the suture is then crossed over
the socket, enters the mesial lingual aspect (position 3), and exits the distal lingual
aspect (position 4). The suture at the distal lingual (position 4) is tied to the free
end at the mesial buccal (position 1), and the knot is positioned toward the buccal
Interrupted sutures should be used only with tension-free mobile flaps and should
have needle penetration ap-proximately 3 mm from the wound edges or at the
base of an interdental papilla. For closing wounds with flaps free of tension, these
interrupted suture techniques achieve similar results.
The mattress technique is a variation of the interrupted suture and is usually used
in areas where tension-free flap closure cannot be accomplished.4 Mattress su-
turing techniques generally are used to resist muscle pull, to evert the wound
edges (which keeps epithelium away from underlying structures), and to adapt the
tissue flaps tightly to underlying structures when a bone graft or regenerative
membrane 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. mattress suture technique1 Mattress sutures are usually left in place for 14 to 21
days before dissolution or removal.
There are variations of the mattress suture technique referred to as the horizontal
mattress 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 surgical
flap should be approximately 8 mm away from the flap edge or just above the
muco-gingival junction . A horizontal mattress suture is placed by penetration of
the needle at the mesial buccal (position 1) apical to the mucogingival junction
63

64. and is then crossed under the flap to exit at the mesial lingual (position 2). The
suture then penetrates the tissue at the distal lingual (position 3) and again
crosses under the flap to exit at the distal buccal (position 4) apical to the
mucogingival junction. The suture at the distal buccal (position 4) is tied to the free
end 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 referred
to as the sling suture. This technique is used when only 1 side (or 1 or more
papillae of a flap) is independently repositioned to its original position or coronally
repositioned. The sling suture technique is especially useful when performing
coronally repositioned sliding flaps. When tying a sling suture, the needle enters
64

65. the buccal flap papilla distally (position 1) and is carried lingually around the neck
of the tooth or implant to penetrate the papilla mesially (position 2), exiting
buccally. The suture is then looped back around the same tooth or implant
lingually and is tied with the free end, positioning the knot buccally. With this
technique, each suture includes the papilla on the mesial and distal aspects of
every other tooth, using separate ties.
Another variation of the interrupted suture technique is called a continuous
suture. Continuous sutures can be used to attach 2 surgical flap edges or to
secure multiple interproximal papillae of one flap independently of the other flap.
This technique offers the advantage of fewer individual suture ties; however, there
are significant disadvantages associated with this technique. If one knot or loop
breaks, the integrity of the entire surgical site will be compromised.12 For this
reason, 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 holder
twice before grasping the short end of the suture with the needle holder. The first
double knot is then pulled gently tight. Two (or three) further single throws are
then added in a similar fashion to secure the knot. Each throw is pulled in the
opposite direction across the wound edge.
65

66. SIMPLE INTERRUPTED SUTURE
The wound edge should be gently stabilised with either toothed forceps or a
skin hook. The needle should enter perpendicular to the skin 3-5mm from the
wound edge.Entering perpendicular causes a wider bite of deeper tissue to
be included in the suture than at the surface and consequently causes more
wound edge eversion and ultimately a superior cosmetic result with a thinner
scar. A common mistake is to enter the skin at a flatter angle resulting in
much less wound edge eversion The knot is then tied
.
66

67. CONTINUOUS SUTURE
Using a continuous suture rather than multiple interrupted sutures offers a
significant time saving. However,it is not as strong as interrupted sutures,
and can strangulate the blood supply in wounds under more than minimal
tension. An interrupted suture is performed, but only the free suture end is
cut before the needle is reintroduced and directed diagonally across the
wound to exit the skin on the other side. The suture is then brought
across perpendicular to the wound edge and reintroduced on the first side
again with each bite. Once the entire wound is closed, a loop is made
with the last pass of suture, and this loop is grasp by the needle holder to
tie the knot.
VERTICAL MATTRESS SUTURE
This suture provides excellent wound support, decreases dead space,
67

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 secured
HORIZONTAL MATTRESS SUTURE
This suture is especially good for distributing wound tension across larger
wounds particularly for the initial sutures. The needle is introduced 5-10mm from
the wound edge and exited on the opposite side of the wound. The needle is
then reintroduced on the second side of the wound but 3-5mm along the wound
edge from the exit point. The suture exits in the same position on the first side of
the wound and the suture is tied. The disadvantage of this suture is the risk of
strangulation of the dermal blood supply and subsequent edge necrosis.
68

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. This suture is extremely important for distributing wound tension to the dermis
rather than the epidermis and also for closing dead space. It provides longer-
term support to the healing wound and improves the cosmetic result. The wound
edge is everted with a skin hook and then an absorbable suture is introduced at
the subcutaneous level and brought back out at dermal level on the same side of
the wound.. The needle then enters the same dermal level on the opposite side
of the wound and exits the in the same subcutaneous level as it was initially
entered into on the first side of the wound. The knot is tied deep at the
subcutaneous level and the free ends cut short
70

71. SUTURE REMOVAL
The time to suture removal depends on the location and the degree of
tension the wound was closed under. This varies between surgeon and
situation, but as a general rule sutures on the head and neck are usually
removed between five and seven days post-operatively, while sutures on
trunk or extremity wounds are typically removed between ten and fourteen
days. To remove sutures, one tail of the suture should be grasp with
forceps and pulled gently towards one side to the wound, elevating the
knot. The opposite side of the suture should then be cut with stitch-cutters
or fine suture scissors immediately under the knot.. The suture can then
be pulled out of the tissue by pulling towards the opposite side of the
wound
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72. CONCLUSION
Suturing in essence is a surgical procedure and is governed by the basic
principles of surgery like aseptic technique etc. At the end of the day we
should be reminded that historically, surgery has been seen as a last
resort. Let us also be reminded of the famous quotation by the famous
surgeon in history, Ambrose Paré (1510–1590), who on occasion
remarked, “I dressed the wound, and God healed it!”
The body has healing mechanisms of its own. Most wounds if left for a
sufficient period of time will close completely/significantly on its own by the
process of wound contraction. Remember – do not suture each and every
single little wound – some minor cuts and bruises in esthetically unimportant
areas will heal perfectly well without suturing. Sometimes cleaning and a
small band-aid strapping is the appropriate way to manage a cut. Some
wounds may even heal better if left undisturbed by invasive measures…
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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
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