Sutures and Suturing

Dr. Sameer A. Mokeem

faculty.ksu.edu.sa/sameer/
411 PDS
 Goals
1- Provide an adequate tension of wound
closure without dead space but loose
enough to obviate tissue ischemia and
necrosis.
2- Maintain hemostasis.
3- Permit primary intention healing
4- Reduce postoperative pain
 Goals
5- Provide support for tissue margins until
they have healed and the support no longer
needed
6- Prevent bone exposure resulting in delayed
healing and unnecessary resorption
7- Permit proper flap position
 Qualities of the Ideal Suture
Material
1- Pliability, for ease of handling
2- Knot security
3- Sterilizable
4- Appropriate elasticity
5- Nonreactivity
6- Adequate tensile strength for wound healing
 Qualities of the Ideal Suture
Material

7- Chemical biodegradability as opposed to

foreign body breakdown
Postlethwait (1971), Varma et al. (1974), and Ethicon (1985)
 Usage
1- Silk and synthetic sutures are employed
most often
2- Gut sutures are used only when retrieval is
difficult, if not impossible.
3- When using gut (plain or chromic) sutures,
it is recommended to soak the package in
warm water. This will remove the kinks and
straighten the suture.
 Sutures and Suturing
Suture materials:
Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing

Plain gut Collagen from Digested + Moderate + + + Plain Rapidly +

healthy by body (Least) ++++ healing
mammals enzymes mucosa
within avoid
70 days suture
removal

Chromic gut Collagen from Digested + Moderate + + + Chromic As above +

healthy by body but less Slower
mammals enzymes than plain absorption
treated with within gut
chromic salts ++++
Suture materials:
Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing

Coated Copolymer of Hydrolysis + + + Mild ++ Braided Subepi- + + + +

Vicryl lactide and 56-70 days ++ coated elial
(Polyglactin glycolide Mucosal
910) coated with surfaces
polyglactin Vessel
370 and ligation
calcium All types
stearate of general
closure

PDS Polyester Slow + + + + Slight ++ Mono- Absorbable + +

(polydi- polymer hydrolysis + filament suture with
oxanone) 180 - 210 extended
days wound support
Suture materials:
Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing

Dexon Homopolymer slow +++ Mild ++ Braided subepith- + + +

(polygly- of glycolic hydrolysis ++ coated elial
colic acid coated after 60 - sutures
acid) with 90 days Mucosal + + + +
polaxamer surfaces
188 Vessel
ligation

Surgical Natural Usually ++ Moderate + Braided Mucosal + + + +

silk protein cannot be + + + + (least) surfaces
fiber of raw found after
silk. Treated 2 years
with silicon
protein or wax
 Suture materials:
Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing

Nylon Polyamide Degrades at + + + Extremely + + Mono- Skin ++

Duralon polymer a rate of 15- low filament closure
Ethilon 20%per year 0-+

Nylon Polyamide Degrades at + + + Extremely + + Braided Skin ++++

Nurolon polymer a rate of 15- low closure
Surgilon 20%per year 0-+ Mucosal
surfaces

Polyester Polyester Nonabsorbable + + + Minimal + + + Braided Cardiova- + + +

Mersilene Polvethylene + scular and
Dacron Terephthalate plastic
Ethibond surgery
General
surgery
 Suture materials:
Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing

Prolene Polymer of Nonabsorbale + + + Minimal+ ++ Mono- General, + +

(polypro- propylene transient filament plastic,
pylene) acute cardiova-
reaction scular, skin
opthalmology

Gor-Tex Expanded Nonabsorbale + + + Extremely ++ Mono- All Types + + + +

polytetrafluoro- low filament of soft-
ethylene 0-+ tissue
approxi-
mation &
cardiova-
scular
surgery
 Suture materials:
Suture Knot
Tensile Tissue Tensile Ease of
Suture Raw Material Absorption Strength Reaction Strength Type Uses Handing

Monocryl Poliglecaprone Hydrolysis + + + + Minimal +++ Mono- Soft- Most

25 Copolymer 90 - 120 + filament tissue pliable
of glycolide & days closure Synthetic
caprolactone absorbale
mono-
filament
ever
 Knots
• A suture knot has three components
1- The loop created by the knot
2- The knot itself, which is composed of a
number of tight “throws”, each throw
represents a weave of the two stands
3- The ears, which are the cut ends of the
suture
 Principles of Suturing
1- The completed knot must be tight, firm,
and tied so that slippage will not occur
2- To ovoid wicking of bacteria, knot should
not be placed in incision lines
3- Knots should be small and the ends cut
short (2-3mm)
4- Avoid excessive tension to finer gauge
materials as breakage may occur
 Principles of Suturing
5- Avoid using a jerking motion, which
may break the suture
6- Avoid crushing or crimping of suture
materials by not using hemostats or
needle holders on them except on the free
end for tying
7- Do not tie suture too tightly as tissue
necrosis may occur. Knot tension should
not produce tissue blanching
 Principles of Suturing

8- Maintain adequate traction on one end

while tying to ovoid loosing the first loop
Principles for Suture Removal
1- The area should be swabbed with
hydrogen peroxide for removal of
encrusted necrotic debris, blood, and
serum from about the sutures
2- A sharp suture scissors should be used to
cut the loops of individual or continuous
sutures about the teeth
 Principles for Suture Removal
3- 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
4- A cotton pliers is used to remove the suture.
The location of the knots should be noted so
that they can be removed first. This will
prevent unnecessary entrapment under the
flap
Suture should be removed in 7 to 10 days
to prevent epithelialization or wicking
about the suture
 Surgical Needles
• Most of surgical needles are fabricated
from heat treated steel
• The surgical needle has a basic design
composed of three parts
1- The eye which is swaged and permits
the suture and needle to act as a single
unit to decrease trauma
 Surgical Needles
2- The body which is the widest point of the needle
and is also referred to as the grasping area. The
body comes in number of shapes (round, oval,
rectangular, trapezoid, or side flattened)
3- The point which runs from the tip to the
maximum cross-sectional area of the body. The
point also comes in a number of different shapes
(conventional cutting, reverse cutting, side
cutting, taper cut,taper, blunt
 Needle Holder Selection
1- Use an approximate size for the given needle.
The smaller the needle, the smaller the needle
holder required
2- Needle should be grasped one-quarter to one
half the distance from the swaged area
3- The tip of the jaws of the needle holder should
meet before remaining portion of the jaws
 Needle Holder Selection
4- The needle should be placed securely in
the tips of the jaws and should not rock,
twist, or turn
5- Do not over close the needle holder. It
should close only to the first or second
ratchet. This will avoid damaging the
needle
6- Pass the needle holder so it is always
directed by the operator thumb
 Placement of Needle in Tissue
1- Force should always be applied in the direction
that follows the curvature of the needle
2- Suturing should always be from movable to a
nonmovable tissue
3- Avoid excessive tissue bites with small needle as it
will be difficult to retrieve them
 Placement of Needle in Tissue
4- Use only sharp needles with minimal force.
Replace dull needles
5- Never force the needle through the tissue
6- Grasp the needle in the body one-quarter to
one-half of the length from the swaged area. Do
not hold the swaged area; this may bend or
break the needle. Do not grasp the point area as
damage or notching may result
 Placement of Needle in Tissue
7- Avoid retrieving the needle from the
tissue by the tip. This will damage or
dull the needle
8- Suture should be placed in keratinized
tissue whenever possible
9- An adequate tissue bite is required to
prevent the flap from tearing
 Suturing Techniques
1- Interrupted
a- Figure eight
b- Circumferential director loop
c- Mattress-vertical or horizontal
d- Intrapapillary
 Suturing Techniques
2- Continuos
a- Papillary sling
b- Vertical mattress
c- Locking
 Suturing Techniques

• The Choice of technique is generally

made on the basis of a combination of the
individual operator’s preference,
educational background, and skill level,
as well as surgical requirement
 Periosteal Suturing
• Generally requires a high degree of
dexterity in both flap management and
suture placement. Small needles (P-3),
fine sutures (4-0 to 6-0) and proper
needle holder are a basic requirement
 Periosteal Suturing
• Technique
1- Penetration: The needle point is
positioned perpendicular (90°) to the
tissue surface and underlying bone. It is
then inserted completely through the
tissue until the bone is engaged.
 Periosteal Suturing
2- Rotation: The body of the needle is
rotated about the needle point in the
direction opposite to that in which the
needle intended to travel. The needle
point is held lightly against the bone so as
not to damage or dull the needle point
 Periosteal Suturing
3- Glide: The needle point is now permitted to
glide against the bone for only a short
distance. Care must be taken not to lift or
damage the periosteum
4- Rotation: As the needle glides against bone;
it is rotated about the body, following its
circumferenced outline. In this way, the
needle will not be pushed through the tissue
resulting in lifting or tearing of the
periosteum
 Periosteal Suturing
5- Exit: The final stage of gliding and
rotation is needle exit. The needle is
made to exit the tissue through the gentle
application of pressure from above, thus
allowing the tip to pierce the tissue
 Interrupted Sutures
• Indications
1- Vertical incision
2- Tuberosity and retromolar areas
3- Bone regeneration procedures with/without GTR
4- Widman flaps, open flap curettage, repositioned
flaps, or apically positioned flaps where maximum
interproximal coverage is required
5- Edentulous areas
6- Partial or spilt-thickness flap
7- Osseointegrated implants
 Interrupted Sutures
• Types
1- Circumferential, direct, or loop
2- Figure eight
3- Vertical or horizontal mattress
4- Interstitial papillary placement
 Interrupted Sutures
• Figure eight and Circumferential:
- Suturing is begun on the buccal surface 3-4 mm from the tip
of the papilla so as to prevent tearing of the thinned papilla
- The needle is first inserted into the outer surface of the
buccal flap and then either through the outer epithelialized
surface (figure eight) or through the CT under the surface
(circumferential)
- The needle is then returned through the embrasure and tied
buccally
 Interrupted Sutures
• Mattress sutures:
- Are used for greater flap security and
control
- They permit more precise flap
placement especially when combined
with periosteal stabilization
- They also allows for good papillary
stabilization and placement
 Interrupted Sutures
• Vertical mattress technique
– Needle is inserted 7-10 mm apical to the tip of
the papilla.
– Passed through the periosteum, emerging again
from the epithelialized surface of the flap 2-3
mm from the tip of the papilla
– The needle is brought through the embrasure,
where the technique is again repeated lingually
or palatally
– The suture is then tied buccally
 Interrupted Sutures
• Horizontal mattress technique
– Needle is inserted 7-8 mm apical and to one side of
the midline of the papilla.
– Emerging again 4-5 mm through the epithelialized
surface on the opposing side of the midline
– The suture may or may not be brought through the
periosteum
– The needle is then passed through the embrasure,
and the suture after being repeated lingually or
palatally is tied buccally
 Interrupted Sutures
• Intrapapillary technique
– Recommended for use only with modified
widman flaps and regeneration procedures
– the needle is inserted buccally 4-5 mm from
the tip of the papilla, passed through the
tissue emerging from the tip of the papilla
– This is repeated lingually and tied buccally
 Interrupted Sutures
• Sling technique
– It is primarily used for a flap that has been
raised on only one side of a tooth involving one
or two adjacent papillae
– Most often used in coronally and laterally
positioned flaps
– The technique involves use of one of the
interrupted sutures, which either anchored
about the adjacent tooth or slung around the
tooth to hold both papilla
 Continuous Sutures
• Advantages
1- Can include as many teeth as required
2- Minimize the need for multiple knots
3- Simplicity
4- Permit precise flap placement
5- The teeth are used to anchor the flap
6- Avoid the need for periosteal sutures
 Continuous Sutures

• Disadvantages
– The main disadvantage of continuous suture
is that if the suture breaks, the flap may
become loose or the suture may come untied
from multiple teeth
 Continuous Sutures
• Types
1- Independent sling sutures
2- Mattress sutures
a- Vertical
b- Horizontal
3- Continuous locking
 Continuous Sutures

• Independent sling suture

– When flap position is not critical
– When buccal periosteal sutures are used for
buccal flap position and stabilization
– When maximum closure is desired
 Continuous Sutures
• Technique
– After the initial buccal and lingual tie, the suture
is passed about the neck of the tooth
interdentally and through the lingual flap
– Then again brought interdentally through the
buccal papilla and back interdentally about the
lingual surface of the tooth to the buccal papilla
– Then it is brought about the lingual papilla and
then about the buccal surface of the tooth
– This alternating buccal-lingual suturing is
continued until the suture is tied off with a
terminal end loop
 Continuous Sutures
• Vertical and horizontal mattress suture
– The technique is similar to that previously
described for the interrupted suture
 Continuous Sutures
• Locking suture
– It is indicated primarily for long edentulous
areas, tuberosities, or retromolar areas.
– It has the advantage of avoiding the multiple
knots of interrupted sutures
– If the suture broken, it may completely untie
 Continuous Sutures
• Technique
– A single interrupted suture is used to make the
initial tie
– The needle is next inserted through the
underlying surface of the buccal flap and the
underlying surface of the lingual flap
– The needle is then passed through the remaining
loop of the suture, and the suture is pulled
tightly, thus locking it
– This procedure is continued until the final
suture is tied off at the terminal end
 Bibliography
• Postlethwait, R.W.: Wound healing and surgery.
Somerville, New Jersey, Ethicon, Inc., 1971
• Varma, S., et al.: Comparison of seven suture
materials in infected wound. An experimental
study. J. Surg. Res., 17:165, 1974
• Chaiken, R.W.: Elements of surgical treatment
in the delivery of periodontal therapy. Chicago,
Quintessence, 1977
• Ethicon, Wound closure manual. Somerville,
New Jersey, Ethicon, Inc, 1985, p. 9