Suture materials /certified fixed orthodontic courses by Indian dental academy

Principles of Surgery
SUTURES

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


• In surgery, the choice of suture materials has
been largely empirical. One learns the art and
craft of surgery from once chief and the
tendency is to follow the suture materials used
by him or her. Thus the choice of suture
material has not always been scientific.

• History
– Used in closure of wounds – 50,000 B.C
– Large black ants used
– Made from Flax, Bark, Hemp and Fiber
– Metal clips

• SUTURE :

Any thread or strand which
brings into opposition two
surfaces or tissues
• LIGATURE :
Any thread or strand which

obliterates lumen of ductular
structures

Properties :
• Absorbable materials
– digested by tissue enzymes
• Eg. Catgut

– hydrolysis
• Eg. Polyglactin (Vicryl)

• Non-absorbable materials
– Eg. Silk, Nylon etc…


• Tensile strength
– Straight pull – to break the filaments
– Knot pull – to break the knot

• Smoothness
– Smooth material  Easy passage  Least trauma
• Eg. Monofilament


• Monofilament :

• Polyfilament :

– single filament

– Multiple filaments

– Eg. Prolene

– Eg. Cotton, Silk

– smooth

– rough

– open up

– knot secure

– not easy to handle

– easy to handle

– impede bacterial harbour

– promotes bacterial harbour

– no fraying

– fraying

Classification :
SUTURE MATERIALS
Absorbable
Natural

Synthetic

Non-absorbable
Natural Synthetic Metals


Absorbable
• Natural :

• Synthetic :

– Catgut
• Plain

– Polyglactin 910

• Chromic

– Fascia lata
– Kangaroo tendon
– Cargile membrane
– Collagen

– Polyglycolic acid
– Monocryl

– Polydioxanone

Non-absorbable
Natural :

Synthetic :

Metals :

Silk

Polyamide

Stainless steel

Cotton

Polyester

Platinum

Linen

Polypropelene

Tantalum

Polybutester

Silver wire

Others :
Tapes
Tissue adhesives
Staples

Catgut :
•
•
•
•
•
•
•
•
•

Kitgut
Sub-mucosa of sheep’s intestine
Monofilament
Plain – tensile strength 15 days
Chromic  30 days
Kept in preservative solution – Ethicion fluid
Hygroscopic
Absorption by proteolytic digestive enzymes
In infection  rapidly absorbed

• Uses :
• Plain Catgut
–
–
–
–

Subcutaneous suturing
For wounds in lip and oral cavity
Ligation of smoother blood vessels
Not used in tissues deeper to subcutaneous

• Chromic
– 1-0 / 2-0 : ligation of medium sized vessels
– 3-0 / 4-0 : for cleft lip muscle layer closure
– 5-0 / 6-0 : plastic surgery

• Fascia lata :
– Thigh muscles of beef cattle
– Was used to repair hernia

• Kangaroo tendon :
– Tail tendon of small kangaroos

– High tensile strength

Synthetic absorbable sutures :
•
•
•
•

Polyglycolic acid – Dexon
Non-protein polymer of glycolic acid
Absorption – esterase enzyme system (100 days)
Characteristics –
– White, polyfilament, braided

• Advantages –
–
–
–
–
–

Minimum tissue reaction
Uniform absorption
Used even in presence of infection
Knot security better
Fraying is less

• Polyglactin 910 :
–
–
–
–
–

Co-polymer of Glycolin and Lactide
Violet colour
Coated with Calcium stearate
Absorption – hydrolysis
Advantages –
• Unique molecular structure – retain strength
for long
• Minimum tissue reaction
• Excellent handling characters

– Not usedwww.indiandentalacademy.com of stress
under the areas

• Vicryl Rapide – Irradiated polyglactin 910
• Absorption – 35- 40 days  Gamma
radiation
• Supports wound upto 12 days
• Less force is used for tying knots
• Ideal for intra-oral use
•
•
•
•

Polydioxanone
Unique feature of Flexibility
Support wound beyond 4 week period
Recommended in orthopedic surgery

•
•
•
•
•

Polyglecaprone 25 – Monocryl
co-polymer of Glycolide and Caprolactone
tensile strength double of chromic
Absorption – Hydrolysis
Advantages –
–
–
–
–

inert,
used in infection,
memory free,
smooth surface

• Indications –
– subcutaneous


Non-absorbable suture materials :
• Silk :
– Natural – obtained from cocoon
– Advantages –
• natural elasticity
• does not soak up fluids
• ties smoothly & securely

– Disadvantages • stitch granuloma
• infection - high
• tissue reaction - high

• Types
– Prema hand surgical silk
– Virgin silk suture

• Uses
–
–
–
–

ligate blood vessels & pedicles
suture nerves, tendons
skin & grafts
wound over the face

• Cotton
– vegetable origin ; polyfilament
 disadvantage
– advantage
• economical
• secure knotting
• easily handled





absorbs fluid
more tissue reaction
low tensile strength

• Linen
– obtained from flax ; polyfilament
– advantage
• easily handled
• tie is secure

– uses
• tying pedicles
• ligatures


• Polyamide :

•

– Nylon
– thickness – 1-8N
– advantage

• less irritant
• high tensile strength
• economical
• smooth passage through
tissues
– disadvantage

• has memory

Polyester :
– Terylene
– Dacron
– advantage
• high tensile strength
• low tissue reactivity
• retained longer – C.V.S
– disadvantage
• cut through tissue
– Teflon coat – better
handling properties but
diameter of suture increased
– Polybutylate coated

• infection

• Polypropylene :
– Prolene
– advantage
• inert
• monofilament
• smooth
• easily handled
• knot secure
• least thrombogenic
• more tensile strength
• unwetted by blood & tissue enzymes
• elastic
– indications
• vascular surgery
• chest & abdominal www.indiandentalacademy.com
wall defects

• Stainless steel wire :
– advantage
• very little tissue reaction
– disadvantage
• tear of tissue
• necrosis if tight

• cutaneous discomfort
• breaking sterile technique

Principles of suture selection :
• knowldege of the tissues

• physical and biological properties of suture
• condition of the wound
• post-operative course of the patient
• skin, fascia & tendon – healing slow
• peritoneum, liver & muscle – healing rapid
• multifilament sutures avoided in contaminated
wounds

• C.V.S – prolene and polyester are used
• Microvascular surgery – 10-0 polyamide
monofialment used
• Irradiated patients – closure in layers
• Cancer patients – non-absorbable sutures used

• Intra-oral – silk, PGA used but absorbable preferred

Needle holder:


Needles :
• sharp, pointed instruments are used for puncturing
the tissue and guiding the thread to suture or pass a
ligature around vessels
• carbon steel or stainless steel


• Classifications :
– Eye
• eyeless
• needles with eye

– Shape
• straight
• curved

– Cutting edge
• round body
• cutting body

– Tip
• tirangular
• round tipped
• blunt point

• Eyeless needle :
– suture material is attached to the swage of the needle
during manufacture
– advantages
•
•
•
•
•

less trauma
new sterile needle for each patient
faster
time saving
no chance of needle loosing

• Needles with eye :
– can be reused
– economical

• Straight
– Eye
– Eyeless
– round body
– blunt tip
– suturing with hand
– for fascia & skin
– for passage of
• Circum-zygomatic
• Circum-mandibular
wires

• Curved
– Eye
– Eyeless
– round body
– cutting needle
– facilitates working in
depth
– more confined operated
site
– greater curvature
required


• Round body needles : used to separate tissue fibers & for
soft tissues
• Mayo’s needle : to penetrate periosteum
• Blunt point suture needle : for friable tissues

• Conventional cutting needle : keratinized mucosa & skin
• Reverse cutting needle : triangular in cross-section; apex
cutting edge on outside of needle curvature

• Slim blade needle : plastic and cosmetic
surgery
• Trocar point needle : in dense tissues
• Taper cut needle : Cardiovascular surgery

• Micropoint : for Opthalmic

Principles of suturing :
• grasp the needle at apporximately 3/4th the
distance from the point
• enter the tissue perpendicular to the surface
• should follow the curvature of the needle
• from free to the fixed tissue
• thinner to the thicker
• deeper to superficial
• tissues should not close under tension
• knot should not be placed on incision line

• sutures placed 4mm apart
• sutures should be tied so that edges are everted
• dog ear should be eliminated
• suture should be placed at an equal distance from
the incision on both the sides & at an equal depth


Tapes :

• Advantage

– excellent cosmetic
results
– low infection rate
– can be used in
contaminated wounds
– easy & quick
• Disadvantage

& Adhesives :

• Cyanoacrylates
• Advantage
– quick to use
– do not delay wound
healing
• Disadvantage
– perfect hemostasis
required
– expensive
– not used in
contaminated wounds
– blistering of skin

– perfect hemostasis
should be ensured www.indiandentalacademy.com

Staples

& Tissue Glues

• Types –

• Indications –

– Linear

– for hemostasis of liver

– Side by side
– End to end

& spleen

• Advantages

– dural tears

– quick
– accurate closure

– E.N.T surgeries

– easy to remove

– acceptable scars
– access to difficult areas

– to attach skin grafts


Knots :
• A knot, is an interwining of threads for purpose
of joining them
• Knot tying
– one hand / two hand
– instrument tie

• Instrument tie is more convenient in closed
areas

Square knot
• formed by wrapping

ties around needle
holder once in

opposite direction

Surgeon’s knot
• formed by two

throws of suture
around needle on first
tie & one throw in
opposite direction on
second tie
• Advantage
– reduced slippage ofwww.indiandentalacademy.com
first

Granny knot
• involves a tie in one

direction followed by
single tie in same
direction as first
• a third tie is then
squared on the
second to hold the
knot permanently

Suture method
•

Interrupted
– used in areas of
tension
– Advantage

• strong
• independent
• infection –
selected sutures can
be removed


• Continuous –
simple interrupted
suture is placed, a
needle is then reinserted in continuous
fashion
The suture passes
perpendiuclar to
incision line underneath
tissue & diagonally on
surface & ended tying

•

Advantage
– rapid technique
– even distribution of
tension
– water tight closure

• Disadvantage
– infection – whole suture
should be removed
– impedes blood supply to
wound edges


• Locking continuous
suture Degree of locking is
provided by withdrawing
the suture through its own
loop
• Advantage
– suture will align
perpendicular to its
incision
– prevents continuous
tightening of suture as
wound closure
progresses

•

Figure of 8 –
–

used in extraction sites

– provides protection to
socket

– as well as adaptation of
gingival papilla around
adjacent tooth


• Sub-cuticular suture :
– absorbable 4-0 suture

materials used
– knot should be inverted

– a continuous suture can
be used with no knots
by having the ends exit
at a short distance from
wound

• Tension suture

– to prevent wound
dehiscence
– non-absorbable nylon
prolene used with
plastic tubing
– to reduce tension

• Mattress suture
– Vertical
– Horizontal

• Vertical
– needle is passed close to
the incision line on both
sides & then engages
tissue deep to the first
pass when returning to
the original site
– Advantage
• run parallel to the blood
supply of the flap – not
interfere with healing

• Horizontal :
– passes perpendicular to
incision line underneath
tissue & parallel to it on
the surface & then again
perpendicular to incision
line underneath tissue to
be knotted on that side
– Interrupted – produces
broad contact of wound
margins
– Continuous – intra-oral
bone grafting

• Dog ear elimination :
– excess tissue is
undermined & incision is
made at 30 to the
parent incision directed
towards undermined side
– excising the excess
tissue with elliptical
incision followed by
closure


Suture removal :
• Suture should be grasped with an instrument &
elevated above epithelial surface

• Scissors should be used to transect one side of the loop
as close to the epithelial surface as possible


Conclusion :
• Every surgeon should be in a position to make
a logical decision regarding which suture

material / technique to use in a given clinical
situation, because the choice of wound closure
material & technique may make a difference in

Thank you
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Suture materials /certified fixed orthodontic courses by Indian dental academy

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