Suturing

1
SUTURE:
sutures are the stitches that doctors
and especially surgeons use to hold
skin, internal organs, blood vessels
and all other tissues of the human
body together, after they have been
severed by injury or surgery.

2
FEATURES OF IDEAL SUTURE

MATERIALS:
1. STRONG (don’t break).
2. NON TOXIC & HYPO-ALLERGIC
(avoid adverse reaction in the body).
3. FLEXIBLE (so they can be tied and
knoted easily).

4. They must be LACK the so called

“wick effect“ which means that
suture
must not allow fluid to penetrate the body
3
 Purpose of suturing
 Closing the wounds by means of suturing promotes healing
and prevents complication, because an open wound is
subjected to entrance of saliva loaded with food debris and
bacteria.

 Suturing also prevents post-operative hemorrhage

 To hold a wound together in good position until natural

healing process is sufficiently well established

4
 Function of suturing
1. Coapt wound margins

2. Aids in hemostasis

3. Help to hold soft tissue flap over bone

4. Helps in maintaining blood clots in the tooth socket

wounds

5
 Advantages of suturing :-

 Promotes healing.

 Prevents complications:

 Infection.

 Hemorrhage.

 Tissue necrosis.

 Preserve the normal contour and shape of tissues.

6
 Suturing armamentarium
1. Needle holder: -There are many different
needle holders the most commonly used needle holder has a rocking handle and short beaks and
are about 6 inches (15cm) long.

2. Suture needles: -The suture needles are

supplied in different patterns and
shapes to maintain accessibility to the sutured area and
avoid complications . -the size or length of
the needle varies according to the field
of application . -nowadays the suture needle
are already threaded with the
suture materials and supplied in sealed and sterile packs this
is for time saving and very practical suture needles

3. Tissue holding forceps

4. Suture cutting scissor

5. Suture material

7
 :Suturing Needles
• They may differ in shape, diameter, cross-sectional
view, and size
• They are usually made of stainless steel, which is a
strong and flexible material.
• The needles are atraumatic disposable needles with pre-
attached sutures on their posterior ends.
• Needles that may be used and sterilized many times are
also available, with an eye or groove in the needle, through
which the suture is passed.

8
 Patterns of suture needles
according to accessibility
1. Straight suture needles : used for skin suturing and require
large space for manipulation and are of little
importance in oral surgery

2. Curved suture needles :

-used for intraoral and deep suturing .
- it’s the most commonly used shape .
- its easier to use in small spaces

9
• there are various curved needles :1/4 circle ,3/8 circle,
½ circle and 5/8 circle

• In the oral cavity the most frequently used needles are 3/8
or ½ circle

10
patterns of suture needles
according to cross section
1. Tapered (round) suture needles :

− The needle is round in cross section through its whole length

− The needle maybe straight , curved of half-circle to be
accessible to the sutured area
− This type is adequate for suturing fragile , delicate or
thinned tissues such as mucous membrane and oral mucosa
− Their advantage is that there’s no cutting , damage and
laceration to the tissue
− Their disadvantage is that great pressure is required when
passing through the tissues, which may make suturing the
wound harder
11
2. Cutting (triangular) suture needles;
- Has triangular cross section.
- Has sharp edges that allow the needle to penetrate tough
tissue like gingiva and skin
- No excessive pressure is needed for the needle to penetrate
the tissue
- Easy and sharp penetration by needle through dense
tissues such as the oral mucoperiosteoum
- If applied to delicate tissue the thin oral epithelium or the
mucosa of the lips, will case excessive cuts and lacerations
of those tissues

12
13
 Eye Needle Sawged Needle
1. Reusable 1. Prepackaged and pre-sterilized
2. May have burs that could weaken 2. Needle attached to suture material
the suture material 3. It’s the most favorable for intraoral
use
4. Its expensive
5. Not reusable
6. Minimum tissue trauma than eye
needles
7. Immediately ready for use
8. Always a new and sharp needle
9. No time for wasting threading

14
15
 :Suture materials
• Are available in different types and gauges (thickness)to be suitable for
different tissues

• The thickness of the suture materials is expressed in the terms of zeros

• The thickness is inversely proportional to the number of zeros i.e. (0) is

the thickest and (00) is thinner etc..

• The less the number of zeros the more is the thickness of the suture
material

• That is to say that 2-0 is thicker that 3-0 is thicker than 4-0 etc..

• The suture material commonly used in the oral cavity is 3-0 or 4-0
thickness
16
suture gauge:
Gauge is the caliber of the suture and is
expressed in no., the gauge used depend on the
strength required and no. of sutures.

• 9-0 or 10-0 is used for micro-surgery

• 5-0 or 6-0 is used for facial skin closure

• 3-0 or 4-0 is used for muscle, deep skin and intra-

oral mucosal closure

17
18
 :Types of suture materials
I. Natural suture materials

1) Absorbable suture materials

 Will break down harmlessly in the body ever time without intervention.
• Catgut : maybe plain or chromic

Plain Cutgut:

Made from submucosal layer of sheep intestine or from serosal layer of beef intestines
Mono-filament,

Supplied in foil packages that prevent desiccation

Digested completely within 5-7 weeks and full tensile
strength remains for at least 7 days

Disadvantage:
- maybe local reaction that may arise form the tissue during digestion and absorption that
may delay healing or even break down of the tissue
- Absolut sterilization of catgut without causing impairing of its tensile strength is not
19
possible
 Plain catgut is used in suturing of deep facia or muscles

 Plain catgut packaged in a solution of 89% isopropanol,

10% water and 1% triethanolmine

 Plain catgut generally causes more severe tissue reaction

than chromic.

20
• Chromic catgut

 Is treated with chromium to decrease tissue reactivity and

to provide greater resistance to absorption.

• Indicated for use in general soft tissue approximation and/or

ligation, including use in ophthalmic procedures, but not for use in
cardiovascular and neurological tissues .

• Chromic gut is processed to provide greater resistance to

absorption

• will provide effective wound support for 10-21 days, but don't
truly dissolve for 90 days .

21
2) Natural Non absorbable suture materials
• Silk :

- it is made from the cocoon of silk worm.

- It is braided, has good handling and knot-tying
- Indicated for use in general soft tissue approximation and/or
ligation, including use in cardiovascular, ophthalmic, and
neurological procedures.

- Its made in black and white silk

- The black silk can easily be differentiated form the oral
tissue
- Well tolerated by the oral tissue

22
- Not expensive
- Can be autoclaved or boiled
- Has great tensile strength so that very fine strands
- Available only in a multi-felamintous form
- The most suitable type used in the oral cavity are gauge
3-0 and 4-0 black silk

23
24
II. Synthetic suture materials
1) Absorbable suture materials:
- Polyglycolic acid (Dexon):
• Absorbtion occurs between 15-30 days
• The physical properties of dexon are superior to those catgut
sutures
• Braided multifilament form
- Polyglactin (Vicryl):
• Digested within 60-90 days
• Less stiff than catgut sutures, so that the sutures knots are more
likely to remain tight
• Maintains its strength for longer than other
absorbable suture,
• More costly that catgut sutures
• Multifilament form 25
Absorbable suture materials cont.
- Polydioxone (PDS)
- Is a sterile synthetic absorbable monofilament suture .
- Made from the polyester (p-dioxanone.).
-  Intended for use in general soft tissue approximation,
including use in paediatric cardiovascular tissue, in
microsurgery and in ophthalmic surgery.
- These sutures are particularly useful where the combination
of an absorbable suture and extended wound support (up to
six weeks) is desirable.
-  These sutures, being absorbable, should not be used where
prolonged (beyond 6 weeks) approximation of tissues under
stress is required or in conjunction with prosthetic devices,
for example, heart valves or synthetic grafts.
26
1) Absorbable suture materials CONT
- Polyglyconate (Maxon)
- Prepared from a copolymer of glycolic acid and
trimethylene carbonate

- Synthetic monofilament absorbable sutures .

- Used in general soft tissue approximation and/or ligation,
including use in pediatric cardiovascular tissue, where
growth is expected to occur, and in peripheral vascular
surgery
- Absorption is minimal until about the 60th day after
implantation and is essentially complete within six months.

27
2) Synthetic Non absorbable suture materials
• The most commonly used nonabsobable suture in oral and
maxillofacial surgery are; Nylon, polyester and polypropylene.

• Nylon:
1. Good for skin closure
2. If used intra-orally it may cause irritation to the oral
tissues due to high hardness
3. available in mono-filamint form

• Polyester
1. Remains in the body
2. Available in multi-filament form
28
• Synthetic Non absorbable suture materials CONT

• Prolene ( polypropylene)
- available in mono-filament form
- Has less tissue reaction than with other suture materials

• Metal sutures
- Rustless steel wire ( stainless steel, nickel,
chromium,aluminium,silver, titanium )
- Smooth, strong, playable
- Non-corrosive
- Non irritant to the tissue
- Occasionally used by surgeons extra-orally

29
 Suture materials according

to filament composition

1. Monofilament
- Made of single strand
- Resists harboring micro-organisms
Examples: plain catgut, chromic catgut, nylon and
prolene
2. Poly Filament or Multi-filamentous
- Consists of several fibers
- Either braded or twisted
- Gives good handling and tighing qualities.
Example :silk, dexon, vicryl, polyester
30
 Characteristics of suture
materials
• The ideal suture materials would be;
1. Sterile
2. High tensile strength, holding the wound securely through
the healing period by rapid absorption
3. Non-allergic and non-cancerogenic
4. Easy to handle, ties down well , provides optimum knot
security
5. Minimally reactive in tissue and not predisposed to
bacterial growth
6. Resistant to shrinking in tissues
7. Absorbed completely with minimal tissue reaction after
serving its purpose
31
The strength of the sutures varies according to their size,
which can be determined by a uniformly applied
number.

Example :-
6-0 suture is more delicate and has less strength
than a 4-0 suture.

32
 Basic requirements for
suturing techniques:
• The needle should be od suitable size and shape and the
material of suitable thickness

• Grasp needle ¾ the distance away form the point

33
• Place needle perpendicular to tissue surface on entry

34
• Suture start first through mobile then non-mobile tissue (from the
loose to the fixed)

• The needle should be passed from the thinner layer

• The insertion of the needle should at an equal distance on both

sides of 2-3mm away form the free edge of the soft tissue, to avoid
laceration

• Suture should not be placed under tension

• Too tight suture cause strangulation of the blood vessels and
delayed healing

35
• The knots should be away from the incision line

• Suture should be removed 5-7days after surgery, otherwise

foreign body reaction may develop

36
• When removing the suture it should be cut as near to the mucosa
as possible, this is to avoid introducing the infection into the tissue
when the suture is withdrawn

37
removal of sutures:
The removal time is balance between strength
of healthy and cosmetic result.
Some areas are better vascularised, under
less tension, and there fore heal quicker than

others .
•The following is arrange of removal of
different areas:
face and neck : 3-4 days.
scalp : 5-7 days.
limbs : 5-7 days.
Hands and feet : 10-14 days.
Abdomen : 8-10 days.

38
39
 Suture techniques
• There are many suture techniques that are used intra orally as
well as extra-orally :
1. Simple Interrupted suture
The most commonly used in oral surgery
Advantage :
- Simplicity of application
- if one knot united other sutures will
maintain the strength of the suture line
Disadvantages :
- Time consuming because of the high number of knots
and consuming of large amount of suture material.

40
2. Continuous sutures

Advantages :
- its simplicity
- can be performed rapidly, and consumption of lesser amount
of suture material.
- Running one continuous length of material
Disadvantages:
when one stitch is untied, the strength of the suture
line can’t be maintained.

41
A. Simple continuous suturing

B. Interlocking continuous suture

42
3. Figure of eight
Used to hold materials (Gel foam or pack in
the socket)

43
• horizontal mattress
- With stents and Without stents
Advantages:
- - It can be used in areas where much tension is
placed on the skin.
- Strength of closure
Disadvantages:
- It interferes with blood supply to the skin and
interferes with healing.

44
• Vertical mattress
Advantages:
• It provides closure for both deep and superficial
layers .
• Allows perfect eversion and vertical opposition of the
superficial skin edges.
Disadvantages:
- It consumes much suture material and more
time.
- A relatively high propensity to dig into skin and cause
prominent stitch mark scars

45
46
• Subcuticular

47
 Principles of suturing

 The curved needle is held approximately two thirds of the

distance between the tip and the base of the needle.

48
 The needle should enter tissue at right angles to the tissue.

 Do not place sutures closer than 2 mm to 3 mm from the flap

edges to prevent tearing through the flap during suturing, or if
postoperative swelling occurs.

49
 The suture needle should be inserted and pulled through the
tissue in line with the curve of the needle.

50
Principles of suturing CONT.
 First insert sutures through the more mobile tissue flap (usually
facial), for better precision, it is best to use two passes in most
situations.

 The needle should pass through the deeper to the superfitial side.

 The needle should pass from the thinner to the thicker side.

 The knot should be positioned to the side of the incision.

 When suturing, flaps should be approximated without blanching

of the tissue.

 Each suture should be placed 3-4 mm apart .

51
 The needle holder is held by using the thumb and the ring finger
in rings and the first and second fingers to control the instrument
.

52
knot-tying procedure

53
54