SUTURING MATERIALS hgghjjjgsddfvbbjjjjjjh

Presented By :
Dr. Itisha Chhajed
MDS 2nd Year
Dept. of Prosthodontics, Crown and Bridge & Implantology
Rishiraj college of dental sciences & research centre, Bhopal
SUTURING
MATERIALS & TECHNIQUES

CONTENTS -
 Introduction
 Ideal requirements for suture materials
 Size of the suture materials
 Principles of suture material selection
 Classification of the suture materials
 Armamentarium for suturing
 Principles of Suturing
 Suturing methods and indications
 Knot – parts & types
 Removal of sutures
 Conclusion
 References

SUTURING :
The process of uniting the tissues separated by either a traumatic
or a surgical wound in a specific manner by using an appropriate
material. (GPT 10)

THE PURPOSE OF SUTURING :
- To suture is the act of sewing or bringing tissues or flaps edges
together and holding them in apposition until normal healing takes
place.
- Sutures also help the wound to withstand normal functional stresses
and to resist wound reopening.
- Since the normal healing of the soft tissues takes around 5–7 days
after injury, the tissues are approximated till this period retaining the
sutures.

- Sutures maintain hemostasis and provide adequate tension and
support for the tissue margins.
- Sutures permit proper flap positioning and prevent bone
exposure.
- Suturing the wound protects it and reduces postoperative pain.

IDEAL REQUIREMENTS FOR SUTURE MATERIALS :
• Should have high tensile strength to hold the wound margins
appropriately till the healing is complete.
• Should not be allergic or cause any tissue inflammation.
• Should have least capillarity to avoid retaining the inflammatory
transudate at the wound.
• Should have good knot stability.
• Should be easily sterilized.
• Should be visible in the surgical field.
• Should be affordable

SIZE OF THE SUTURE MATERIALS :
- Available in various sizes depending upon its tensile strength.
- The standard for identifying varying tensile strengths of a
given suture material is determined by the number of zeros.
- The smaller the cross-sectional diameter, the more zeros the
suture has.
- Sizes start with zero and the diameter decreases with
increasing number (1-0, 2-0 ... 10-0). Thus, 4-0 nylon has a
greater diameter than 6-0 nylon and therefore a greater tensile
strength.

PRINCIPLES OF SUTURE MATERIAL SELECTION:
1) Rate of healing of tissues: When a wound has reached
maximal strength, sutures are no longer required. Therefore:
• Various suture materials can be chosen for intraoral and
extraoral use. The surgeon should select a suture that will lose
its tensile strength at about the same rate that the tissues gain
strength. Sutures should be stronger than the approximated
tissues.
• Tissues that ordinarily heal slowly such as skin, fascia and
tendons should usually be closed with nonabsorbable sutures
• Tissues that heal rapidly such as muscles, periosteum may be
closed with absorbable sutures.
Textbook of Oral & Maxillofacial Surgery – Neelima Anil Malik ; 5th
ed.

2) Tissue contamination: Foreign bodies in potentially
contaminated tissues may convert contamination to infection.
Therefore, monofilament absorbable or nonabsorbable sutures are
used in potentially contaminated wounds (Monofilament
polypropylene is good to use).
3) Microsurgical procedures: The tissues most commonly
approximated under microscope are arteries, veins, nerves,
tendons, etc. The most commonly used suture is 100 polyamide
monofilament.

4) Cosmetic results:
Where cosmetic results are important, close and prolonged apposition
of wounds and avoidance of irritants will produce the best results.
Therefore:
• Use the smallest, inert monofilament suture material such as
polyamide or polypropylene.
• Avoid skin sutures and close subcuticularly, wherever possible
with monocryl or vicryl or prolene.
• Under certain circumstances, to secure close apposition of skin
edges, skin closure tape may be used.
• Dermabond liquid stitches provide a quick, effective and sutureless
approximation of skin. It also acts as a barrier to prevent external
microbial infection and gives excellent cosmetic results.

5) Cancer patients:
Hypoproteinemia and chemotherapy can breakdown the wound.
Synthetic nonabsorbable sutures are used. If the patient is to be
irradiated in the postoperative period, monofilament polypropylene
should not be used. Instead, polyester should be used.
6) Nutritional status:
When a patient is undernourished and hypoproteinemic,
nonabsorbable sutures should be used, as tissues need to be kept in
approximation for a longer period. Use of absorbable sutures may
result in wound dehiscence.

7) Wound repair in patients following irradiation:
In these patients, not only the normal healing process is delayed,
but the tolerance to trauma of irradiated tissues is markedly
reduced.
‣ Use extremely careful and gentle surgical technique.
‣ Avoid tension sutures and mattress sutures, as they further
increase the degree of ischemia.
‣ Plan closure in layers.
‣ Avoid continuous and constant pressure in irradiated tissues.
‣ For fascial layer, use nonabsorbable sutures, polypropylene is
ideal.

8) Suture size:
 The size of the suture material should be properly selected,
depending on the tensile strength of the tissues to be approximated
and whether or not there will be flap tension or freely mobile
tissues.
 Sutures are available in largest size no. 1 to extremely thin/fine no.
11-0. Thicker sutures are used for deep layer approximation as well
as in tension prone areas and for ligation of blood vessels. Thin
sutures are used for delicate tissue closure. Size is chosen to match
with the tensile strength of the tissues.
‣ 3-0 or 4-0 : used in oral surgery for muscle, skin suturing.
‣ 5-0 or 6-0 : used for facial skin closure.
‣ 9-0 or 10-0 : is used in microsurgery.

CLASSIFICATION OF THE SUTURE MATERIALS :
• Natural and synthetic
• Absorbable and non-absorbable
• Monofilament and multifilament.

SUTURING MATERIALS hgghjjjgsddfvbbjjjjjjh

ABSORBABLE SUTURE :
These are suture materials that are digested or hydrolysed by the
enzymes present in the body or by other mechanism. Thus they
require no removal from the surgical site. The actual dissolution
time of the suture material depends on: material type, tissue
blood supply, tissue structure and degree of fluid accumulation
on suture material.
- Natural
- Synthetic

NON-ABSORBABLE SUTURE :
These materials cannot be metabolised by the body’s natural
mechanism, therefore they should be removed by the surgeon
at the end of healing or not removed and left in place in repair
of vascular/neural structures.
- Natural
- Metallic
- Synthetic

MONOFILAMENT SUTURE :
This consists of single strand of suture material.
Advantages -
• more smooth and strong.
• They do not allow any bacteria to survive.
Disadvantages -
• Monofilament sutures have to be handled properly and delicately
without any damage to the strand during surgical procedures to
avoid any breakage postoperatively.

MULTIFILAMENT SUTURE :
• This consists of several filaments twisted or braided together,
can be coated to allow smooth movement into tissues.
• Advantage - easier to handle and to tie.
• Disadvantage - they can harbour bacteria and are not suitable
in the presence of contamination and infection.
This transfer of microbes from the oral cavity through the
multiple filaments into deeper tissue is called as
“Wicking effect”.

COATED OR NONCOATED SUTURE :
‾ Some sutures like polyester sutures are usually coated with a
biologically inert non resorbable compound.
‾ This highly effective lubricant provides a thin coating, which
dramatically reduces the surface friction of the braid, which aids
the thread in passing more easily through the tissues.
‾ This coating, however, makes knot security an issue, as the
material will easily untie if not secured with a surgeon’s knot.

Textbook of Oral & Maxillofacial Surgery – Rajiv M Borle

Textbook of Oral & Maxillofacial Surgery – Neelima Anil Malik ; 5th
ed.

The surgical needles are of four types:
1. According to shape: Straight or curved

2. According to the eye:
‣ Closed eyed
‣ Eyeless/swaged
‣ French eye needles
‣ Channeled/drilled

3. According to cutting edge:
‣ Round body
‣ Cutting : Conventional
Reverse cutting.
4. According to it’s tip: Round tip, triangular tip
and blunt tip.

Principles of Suturing –
• The needle holder should grasp the needle
at approximately three fourth of the distance
from the point of the needle.
• The needle should enter the tissue
perpendicular to the surface, if the needle
pierces obliquely, tear may develop.
• The needle should be passed through the
tissue following the curve of needle. The
wrists of the surgeon must move as per the
curvature of the needle to drive the needle in
the tissue smoothly.

• The suture should be placed at equal distance from incision on
both sides and at equal depth.
• The needle should be passed from free to fixed end.
• The needle should be passed from thinner to thicker side.
• The needle should be passed from deeper to superficial tissue.
• The distance the needle is passed into the tissue should be
greater than the distance from the tissue edge to ensure some
degree of eversion in anticipation of some degree of scar
contracture.

• The tissue should not be closed under tension to avoid tear or
necrosis around the suture, undermining of tissue can be done to avoid
it.
• The suture should be tied so that the tissues are merely approximated
and not blanched.
• The knot should not be placed on the suture line as it may interfere
with the healing/epithelialization.
• Consecutive sutures should be placed at least 3 to 4 mm apart for
escape of serum.
• Closer sutures are indicated in areas of underlying muscle activity
like tongue.

• Extra tissue on one side of incision can cause ‘Dog Ear’. It can be
obliterated by undermining of excess tissue. Incision is made approx
30° to parent incision on the side of undermining. Extra tissue is
pulled over incision and the appropriate amount is excised. Incision is
the closed in normal pattern.
• Excessively large sutures, which are tightly closed lead to dead
space below and epithelialization of the suture tract.

 Sutures on the skin are usually removed in 5 days and
intraoral sutures in 7 days.
 If there is tension while suturing, the sutures may be kept for
10 days.
 Cutting sutures : With skin sutures, leave 3–4 mm tail, which
is the amount of suture material left above the knot. Tail helps
to prevent loosening of sutures. Buried sutures are left within
the body, here the suture is cut just above the knot without any
tail.

SUTURING METHODS AND INDICATIONS :
Textbook of Oral & Maxillofacial Surgery –S.M. Balaji.

1) Simple interrupted suture:
Most commonly used suture method. The sutures are placed
independently. The distance between each suture and the incision
line can be varied according to the necessity and convenience. This
suture provides great strength.

Advantages –
• Selective adjustments of wound edges can be made.
• Failure of one suture does not necessarily prejudice the others.
Disadvantages –
• Can lead to suture marks (rail road track scars on the cutaneous
surfaces) after postoperative oedema has occurred.
• Since there are increased numbers of knots they tend to reduce
the strength of the thread by up to 50%

2) Simple continuous suture:
The running continuous suture provides rapid
secure closure with an even distribution of
tension along the length of the wound,
preventing excess tightness in any one area.
This technique also provides additional
wound eversion, accomplished by everting the
wound edges with fingers or an instrument as
the needle enters and exits the skin surface.
It provides more water-tight closure as
required by intraoral bone grafting.
It should not be used in areas where there is
already existing tension.

Indication - Well approximated wounds with
minimal tension that have been initially
created by well placed buried sutures.
Advantages -
• The advantage of this method is that it is quick
and has fewer knots.
• If the tissues swell in one area, the remaining
suture can provide a
degree of slack that will help relieve the
pressure.
Disadvantages -
• It is not possible to free a few sutures at a time
in continuous suture.
• Even when one suture breaks, the whole
closure is affected.

3) Locking continuous suture :
This is similar to the continuous suture, but with an added advantage
that a degree of locking is provided by withdrawing the sutures
through its own loop. Due to the locking mechanism, the tissues align
themselves perpendicular to the incision. Secondly, it prevents the
continuous tightening of the suture as the wound closure progresses

Mattress suture -
Mattress sutures are commonly used in the region of abdomen or
hip and not head and neck. Hence, it is useful in closing the
wound of iliac and rib bone graft. It provides more tissue
eversion than the simple interrupted sutures.
Mattress sutures are of two types:
• Horizontal mattress
• Vertical mattress

4) Vertical mattress suture:
Vertical mattress sutures are similar to simple sutures, but an
additional bite through the wound edge is used to ensure edge
eversion.
This suture is placed by first taking a large bite of the tissue from the
wound edge and crossing through the tissue to an equal distance on
opposite side of the wound.
The needle is then reversed and returned with a very small bite at the
epidermal/dermal edge in order to closely
approximate the wound edge.

Advantages -
•Decreasing the dead space and
providing increased strength across a
wound.
• It does not interfere with healing as
the suture runs parallel to the blood
supply.
Disadvantages -
• The fine wound edge approximation
is difficult.
• Prominent suture marks can form if
the sutures are not taken out earlier
than in other suturing techniques.

5) Horizontal mattress suture:
In this technique, eversion and the
continuity provide a very versatile
closure.
Hence, it is often used for intraoral
bone grafting.
The needle is passed from one edge
of the incision to the other and
again from the latter to the first
edge.
The procedure is continued till the
entire length of the incision and a
knot is then tied.

Disadvantages –
Blood supply to the flap edge may be diminished and can
cause necrosis and dehiscence if not used properly

6) Subcuticular suture:
This procedure was popularised by Halstead in
1893, who explained that the procedure may be
used with no knots by having the ends exit a
short distance from the wound and taping them
to the skin.
In this procedure, the needle penetrates skin
ahead of incision and exits within the wound.
Needle is then inserted on opposite side of the
incision in a continuous fashion. At the end of
incision, the suture is brought out at a distance
from the wound. By pulling both ends of the
suture, incision is closed and the suture ends are
taped to skin.

Advantages –
The subcuticular suture can be left in place more than 1
week in areas of wound tension or underneath a cast with
minimal problems of suture marks and skin irritation.
Disadvantages –
it takes time to perform and does not evert wound edges.
It can still be an ideal suturing technique in certain
locations of the body where minimizing suture marks can
be appreciated.

7) Figure of eight suture:
It is used for the closure of the extraction sites. This suture
provides a good adaptation of the gingival papilla along the
adjacent teeth.

7) Buried Coaptation-Retention
Sutures:
Some surgeons prefer to close
the peritoneum with interrupted
sutures alternately with the
retention sutures that are
placed to penetrate the other
layers from fascia through skin.
The retention sutures are
placed approximately 2
centimeters apart.

KNOT –
 A knot is an intertwining of threads for the purpose of joining
them. Suture security is the ability of the knot and material to
maintain tissue approximation during the healing process.
 Failure is generally the result of untying owing to knot
slippage or breakage. Since the knot strength is always less
than the tensile strength of the material, when force is
applied, the site of disruption is always the knot.
 This is because shear forces produced in the knot lead to
breakage.

Knot slippage is determined by the nature of the material, suture
diameter and type of knot.
• Monofilament and coated sutures (Teflon, silicon) have a low
coefficient of friction and a high degree of slippage.
• whereas Braided sutures such as uncoated Dacron and catgut
have greater knot security because of their coefficient of
friction.

 A Sutured knot has three components :
a. The loop - created by the knot.
b. The knot - which is composed of a number of tight
‘throws’, each throw represents a weave of the two strands.
c. The ears - which are the cut ends of the suture.

 PRINCIPLES OF KNOT TYING :
o The completed knot must be firmly tied so that slippage will
be virtually impossible. The simplest knot is the most
desirable.
o The knot must be small and the as short as possible with a
given material to minimize foreign body tissue reaction.
o A seesaw motion or the sawing of one strand down over
another, while tying the knot, may materially weaken sutures
to the point that they may break when the second throw is
made.

o The two ends of the suture are pulled in opposite directions
with uniform rate and tension, the knot may be tied securely
with less possibility of breakage.
o Clamps and hemostats should never be placed on any portion
of the suture, which will remain in situ. Avoid the crushing or
crimping application of surgical instruments, such as needle
holders and artery forceps, to the strand except when
grasping the free end of the suture during an instrument tie.

o Sutures for approximation rather than hemostatic purposes
should not be tied too tightly as this causes tissue
strangulation. While sitting on the knot to prevent its
loosening hold the knot firmly but without crushing the
thread with plain tissue forceps.
o After the first loop is tied, it is necessary to maintain traction
on one end of the strand for control to avoid loosening.
o Extra throws do not add to the strength of a properly tied
knot, they only contribute to its bulk.

TYPES OF KNOTS :
1. Square knot or half hitch knot or single knot :
The suture is thrown around needle holder once and once in the in
opposite direction between ties. It is always prudent to provide at
least three ties for surface knots. It is indicated in nylon,
polypropylene, polyglycolic acid and catgut may require more ties.

2. Granny knot :
First two ties in the same direction followed by third tie squared on
the first. The knot involves a tie knot in one direction followed by
single tie in the same direction.
It has more holding power than a square knot.

3. Reef knot : (rif = fold, knot used to gather a ship’s sail to reef in a
strong wind)
Loop formed by two throws first clockwise and secondly counter
clockwise or vice-versa.

4. Triple throw knot :
As the name says, 3 throws; first two similar to reef knot as a
clockwise and counter clockwise throw followed by a third throw
similar to the second. This is more reliable and standard method in
surgery.

5. The surgeon’s knot :
• It is a square knot with an extra throw (two clockwise followed by
one anticlockwise).
• Requires two throws of suture around needle holder on first tie
and then one throw in op posite direction on the second tie. It has
advantage of reducing the slip page, while the second tie is put in
the position.
The third tie is usually
for the security of the
previous knot.

REMOVAL OF SUTURES:
Sutures should be removed atraumatically and cleanly as possible.
Principles of suture removal are as follows:
1. The area should be swabbed with hydrogen peroxide for removal of
encrusted necrotic debris, blood and serum from the sutures.
2. A sharp suture cutting scissor should be used to cut the loops of
individual or continuous sutures. 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.

3. During removal, the cut end of the knot is held gently and the
suture is removed towards the incision line. This is to prevent
the tension across the wound
Time of Suture Removal :
• Skin about face and neck—3 to 5 days
• Other skin sutures—5 to 8 days
• Retention suture—10 to 14 days.

Conclusion –
Good, fundamental suture technique is the key to optimal
and predictable healing. Most scenarios can be managed
with a proper, basic technique and a sound understanding
of wound healing. A clinician’s skills and technique are
enhanced with proper selection of materials and size
following the principles as they can minimize the
challenges, leading to surgical success.

REFERENCES:
• S.M. Balaji, Textbook of Oral and Maxillofacial Surgery.
3rd
ed. Elsevier; 2018
• Malik N, Textbook of Oral & Maxillofacial Surgery. 5th
ed. Jaypee Brothers Medical Publishers; 2021
• Borle. R. M, Textbook of Oral & Maxillofacial
Surgery. Jaypee Brothers Medical Publishers; 2014

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