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SUTURINGSHILPA SHIVANANDII MDS

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IntroductionDefinitionGoals of suturingSuture materials - Requisites of ideal suture - Classification - Selection of suture material - Absorption of suture material - Biological response of body to suture.Suture armamentarium- needles, needle holder, scissorPrinciples of suturingSuturing TechniquesKnotsSuture Removal and complicationsCONTENTS

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Suture means to sew or seam.

In surgery suture is the act of sewing or bringing tissue together and holding them in apposition until healing has taken place.

A suture is a strand of material used to ligate blood vessels and to approximate tissues together.INTRODUCTION4

Suture material is an artificial fiber used to keep wound together until they hold sufficiently well by themselves by natural fiber (collagen) which is synthesized and woven into a stronger scarSuture is a stitch/series of stiches made to secure apposition of the edges of a surgical/traumatic wound WilkinsAny strand of material utilized to ligate blood vessels or approximate tissues Silverstein L.H 1999

DEFINITIONS5

Suturing is performed to Provide adequate tensionMaintain hemostasisPermit primary intention healingProvide support for tissue marginsReduce post-operative painPrevent bone exposurePermit proper flap position

GOALS OF SUTURING(Ethicon)6

It is to hold severed tissues in close approximation until the healing process provides the wound with sufficient strength to withstand stress without the need for mechanical support.

Since wounds do not gain strength until 4-6 days after injury, the tissues are approximated till then by sutures.BASIC PURPOSE OF A SUTURE7

Severed- to cut off (a part) from a whole7

Tensile strength: adequate material strength will prevent suture breakdown & use of proper knots for the material used will prevent untying or knot slippage.

Tissue biocompatibility: sutures made from organic material will evoke a higher tissue response than synthetic sutures.

Tissue reaction amount & size of suture material.REQUISITES OF AN IDEAL SUTUREPostlethwait 1971, Varma 1974, Ethicon 19858

Low capillarity: multifilament type soak up tissue fluid by capillary action providing a rich medium for microbes increasing chances of inflammation & infection.Good handling & knotting properties: ease of tying & a thread type that permits minimal knot slippage also influence thread selection.Sterilization without deterioration of properties: most sutures available in packages are sterilized by dry heat & ethylene oxide gas.

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Non allergic, non electrolytic and non carcinognic

Its use should be possible in any surgery.

Low cost

It should not fray, should slide through tissues readily & knot should not slip after tying.

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Fray- become worn at the edge10

It should be readily visualized , should not shrink & should not be extruded from the wound.

On break down ,it should not release toxic agents.

It should disappear without excessive reaction once its task is completed.

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I. According to source 1. Natural 2. Synthetic 3. MetallicII. According to structure 1. Monofilament 2. Multifilament

CLASSIFICATION OF SUTURE MATERIALS(Food and Drug Administration with ref to Safe Medical Device Act)12

III. According to fate:1. Absorbable (undergo degradation and lose T.S. < 60 days)2. Non absorbable (maintain T.S > 60 days)

IV. According to coating: 1. Coated 2. Uncoated

V. Braided and Twisted

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Non absorbable sutures are categorized by the United States Pharmacopeia (USP) as:Class I - Silk or synthetic fibers of monofilamentswith twisted or braided constructionClass II - Cotton or linen fibers, coated natural orsynthetic fibers in which the coating does not contribute to T.SClass III - Metal wire of monofilament or multifilament construction.14

USP'smission is to improve the health of people around the world through public standards and related programs that help ensure the quality and safety14

AbsorbableCatgutChromic catgutCollagenFascia lata kangaroo tendonBeef tendonCargile membrane

NATURAL

Non AbsorbableSilkSilk worm gut LinenCottonRamieHorse hair

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Fascia lata- deep fascia of thighs, cargile membrane- sterile membrane prepared from peritonium of ox, ramie- china grass/bast fibre crops15

SYNTHETIC

AbsorbablePolyglycolic AcidPolyglactic AcidPolyglactin 910(Vicryl)Polydioxanone(PDS)Polyglecaprone 25

Non AbsorbableNylon/ polyamidePolyPropylenePolyestersPolyethelenePolybutester Polyvinylidene fluoride / PVDF Sutures

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Monofilament

Multifilament17

Advantages Smooth surface Less tissue traumaNo bacterial harborsNo capillarity MONOFILAMENT DisadvantagesHandling and knottingStretch Any nick or crimp in the material leads to breakage.18

MONOFILAMENTAbsorbable

Surgical Gut- Plain, ChromicPolydiaxanonePolyglactin 910Non Absorbable

PolypropylenePolyesterNylon/polyamidePolyvinylidene fluoride / PVDF Sutures

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AdvantagesStrength Soft and pliableGood handlingGood knottingMULTI FILAMENT DisadvantagesBacterial harborsCapillary actionTissue trauma20

MULTIFILAMENTAbsorbable

Polyglactin 910Polyglycolic AcidNon Absorbable

SilkCottonLinen

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MONOFILAMENT

Handling difficult

Smooth & strong

No wicking

ThinnerMULTIFILAMENT

Handling easy

Low strength

Wicking is a problem

Thicker

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Wicking- cord/strand of loosely woven,twisted or braided fibres or piece of material that draws up liquid by capillary action.22

SSTantalum Gold SilverAluminiumMETALLIC23

The selection of suture material by a surgeon must be based on a sound knowledge of :Healing characteristics of the tissues which are to be approximatedThe physical and biological properties of the suture materialsThe condition of the wound to be closed andThe probable post-operative course of the patient.PRINCIPLES OF SUTURE SELECTIONBrian CB, Philip KH 199024

25CHOICE OF MATERIAL

Degraded either by enzymatic process as in gut sutures, or by hydrolysis, as in many of the synthetic materials like glycolic acid, ployglactin 910 or polydioxanone.

Non absorbable sutures are walled off or encapsulated.In infected tissues or in a patient who is febrile or protein deficient, suture breakdown may be accelerated.

If the loss of TS outpaces the healing phase, failure of the wound results.ABSORPTION OF SUTURE MATERIALSCorey SM26

Plain categut- proteolytic enzymatic digestion in 90 days, chromic categut- proteolytic enzymatic digestion in 70 days, polyglycolide- hydrolysis in 60-90 days.26

The initial body response to sutures is almost identical in the first 4-7 days, regardless of the suture material.The early response is a generalized acute aseptic inflammation, involving primarily polymorphonuclear leukocytes.After few days mononuclear cells, fibroblasts & histiocytes become evident. Capillary formation occurs at the end of this initial phase.

BIOLOGIC RESPONSE OF BODY TO SUTURE MATERIALSCorey SM27

Natural Absorbable Proteolytic degradation. Intense tissue response

Synthetic Absorbable HydrolysisLess intense

Non Absorbable Encapsulation Acellular response

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Sutures passing through mucous membrane or skin provide a wick or pathway through which bacteria track down, and bacteria gain access to underlying tissues. The longer the suture remains, the deeper the epithelial invasion of the underlying tissue. When suture is removed, epithelial tract remains.These cells may eventually disappear or remain to form keratin and epithelial inclusion cysts. The epithelial pathway result in typical railroad scar formation. RAILROAD SCAR

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Surgical gut / catgut / plain gutOldest known absorbable suture.Galen referred to gut suture as early as 175 A.D.Derived from sheep intestinal sub mucosa or bovine intestinal serosa.Sub mucosa of sheep has a rich elastic tissue content which accounts for high tensile strength of the catgut. It is monofilament and is available in the plain form as well as tanned in chromic acid. The tanning process delays the digestion by white blood cell lysozymes.Absorbable -Natural

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Catgut should not be boiled or autoclaved as heat destroys its tensile strength.Catgut is sterilized during preparation and kept in a preservative solution (isopropyl alcohol) inside spools or foils. Unused and reusable catgut is hygroscopic so, catgut will swell due to water absorption and its tensile strength will be reducedAbsorption : 60-70daysWhen placed intra orally sutures are digested in 3-5days.

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Hygroscopic- ability of material to attract water and retain it 31

Availability: pre-sterilized in aluminium-coated sterile foil overwrap pack with ethicon fluid as a preservativeLooses TS in 7-10 daysColor: Plain catgut is yellow, while chromic catgut is tanAbsorption: Catgut is absorbed by proteolytic digestive enzymes released from inflammatory cells collected around the catgut. So, in the presence of infection catgut is rapidly absorbed.

Catgut32

Heat treated to speed up absorptionLooses TS in less than 7 days and completely absorbs in 21-42 days33FAST ABSORBING SURGICAL GUT

Coated with thin layer of chromium salt solution to minimize tissue reaction, increase TS, slow the absorption rate, better knot security, and ease of handling.TS 10-14 days Absorbed in 90 days Uses: Ophthalmic surgery (6-0) Oral surgery Suture subcutaneous tissues

CHROMIC CATGUT

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As it is an organic material and susceptible to enzymatic degradation, packed in isopropyl alcohol as a preservative.

Suture absorbs alcohol and swells.

It is combustible and is also irritating to tissues.

It is removed by a quick rinse in saline prior to use.

CHROMIC CATGUT..35

Natural, absorbable, monofilamentObtained by homogenous dispersion of pure collagen fibrils from the flexor tendons of cattle.Absorption 56 daysTS < 10% after 10 days.Used in ophthalmic surgeryDisadvantage premature absorption.

COLLAGEN SUTURE36

Coated and uncoatedMonofilament/multifilamentLactide has hydrophobic qualitiesdelaying loss of TSTS 14 21 days.Absorption 56-70 days.

POLYGLACTIN 910 (VICRYL) Polyglactic acid

SYNTHETIC ABSORBABLE37

Minimal tissue reactivity and can be used in infected tissuesAvailable in purple and undyed. Undyed face.Coated with polyglactin 370 and calcium stearate which allows easy passage through tissues as well as easier knot placement.On skin wounds, associated with delayed absorption as well as increased inflammation.

VICRYL38

It is braided synthetic absorbable suture material.Color: White

It has a similar initial high tensile strength as that of normal vicryl suture.

It gives wound support upto 12 days. It shows 50% of the original tensile strength after 5 days and all of its tensile strength is lost after 14 days. VICRYL RAPIDE39

Its absorption is associated with minimal tissue reaction facilitating improved cosmetics and reduction of postoperative pain.

The absorption is essentially complete within 35-42 days.

Uses: Low tensile strength and rapid absorption rate

Ideal for intra-oral use (dental surgeries).

VICRYL RAPIDE.40

Handles and performs same as normal vicryl

In vitro studies shown that triclosan on VICRYL plus creates a zone of inhibition around the suture. Rasic Z, Schwarz D et al 2011VICRYL PLUS antibacterial suture41

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Polymer of glycolic acid with greater knot pull and TS than gut.Synthetic, absorbable, braidedAbsorption- hydrolysis, which results in minimal tissue reactivity.Braided and so catches on itself, and knot tying and passage through tissues difficult.Does not tolerate wound infection and not percutaneous suture.

GLYCOLIC ACID HOMOPOLYMER (DEXON) POLYGLYCOLIC ACID

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Synthetic, absorbable, monofilament. Polyglycolic acid and trimethylene carbonate TS 14-21 days (>Dexon) Absorption Hydrolysis in 180 days Degradation products of polyglycolic acid and nylon sutures glycolic acid, 1,6-hexane diamine and adipic acid are antibacterial agents. Edlich et al 1973

GLYCOLIC ACID (MAXON) POLYGLYCONATE

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Synthetic, absorbable, monofilament.

Polyester derivative polydioxanone.

TS 14-42 days

Absorption Hydrolysis in 6 months

Passes through tissues easily.POLYDIOXANONE (PDS II)

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Ease of knot-tying and knot security.Minimal tissue reactionFor wounds under tension and contaminated wounds.May extrude through the wound over time. So used only in tissues deeper than subcuticular layer. If in face 6-0 used.

POLYDIOXANONE (PDS II).46

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Natural silk, silk worm gut, cotton , ramie, linenSynthetic-polyester, polyamide, poly propylene, polybutester, polyethyleneMetals : SS Tantalum Platinum Silver wires Gold AluminiumNon absorbable sutures48

Braided or twisted Made from the filament spun by silkworm larva to form its cocoon. Processed to remove the natural waxes and gum. After braiding, the strands are dyed, stretched and impregnated with a mixture of waxes and silicone.Dry silk suture is stronger than wet silk suture.

SURGICAL SILK

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Advantage:Ease of handling more for braidedGood knot securityMade non capillary in order to withstand action of body fluids & moisture. (wax or silicon coated)Cost effective

Contraindications:Should not be used in presence of infection

SURGICAL SILK51

Uses:Plastic surgery, ophthalmic and general surgeries, ligating body tissues.

Although characterized as non-absorbable, studies show that it loses most of their TS after 1 yr.

Cannot be detected in tissues after 2 yrs.

SURGICAL SILK52

Natural, multifilament, non absorbableFrom stable Egyptian cotton fibersGood knot securityNot good in presence of contaminated wounds or infectionRarely used nowadaysUses: Most body tissues for ligating and suturing

SURGICAL COTTON

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Natural, multifilament, non absorbable Made from stable flax fibers Poor TS and so not for suturing under tensionUses: Ligation of superficial vessels Mucosal suturing without stress

LINEN54

Polymer of propylene. Inert and TS for 2 yrs Holds knots better than other synthetic sutures.Advantages Minimal suture reaction and so used in infected and contaminated wounds. Do not adhere to tissues and is flexible. So used for pull-out type of sutures.Uses: General, plastic, cardiovascular surgery, skin closure, ophthalmology.

POLYPROPYLENE (PROLENE) SYNTHETIC NON-ABSORBABLE55

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Synthetic, non absorbable Inert polyamide polymer Braided and sealed with silicon coating Looks and feels like silk, but more stronger Multifilament nylon is weaker and less secure when knotted, offering little advantage over monofilament nylon.

NYLON BRAIDED (SURGILON, NURILON)57

Uncoated, but inert and non irritating to the tissues.High TS and low tissue reactivitySome memory and return to original linear shape over time. Because of this more throws (4 throws) indicated.Moistened nylon monofilament are more easily handled and are packaged wet.Uses: Skin closure, retention, plastic, ophthalmic and microsurgery.

NYLON MONOFILAMENT (DERMALON, ETHILON)

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Tycron, Mersilene -Uncoated Dacron, Ethibond - Coated (with polybutilate) Multifilament fibers of polyester Excellent TS which is maintained indefinitely Uncoated is rougher and stiffer than coated form Coated provides -low infection rate - secure knotting - smooth removal - low reactivity - easy passage through tissuesMore expensive In deeper layers, may last indefinitely.

POLYESTER BRAIDED

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Non-absorbable, synthetic, MonofilamentFrom expanded polytetrafluoroethylene (ePTFE)Extremely low tissue reaction, good knot stability, good TS, ease of handling.Uses All type of soft tissue approximation and cardiovascular surgeries.

GORE-TEX60

Absorbable, synthetic, monofilamentPoliglecaprone 25 copolymer of glycolide and caprolactoneHydrolysis 90-120 daysTissue reaction minimalGood knot strengthUsed for soft tissue closureMost pliable material ever made

MONOCRYL61

New, monofilament, nonabsorbable, syntheticMade of polyglycol trephthate and polybutylene terephthalate and is considered as a modified polyester suture.Significant memory compared to polypropylene and nylon. Easier to manipulate and greater knot security.Unique feature is their ability to elongate or stretch with increasing wound edema. When edema subsides, suture resumes original shape; so it is an ideal suture for lacerations secondary to blunt trauma.POLYBUTESTER (NOVOFIL)62

Natural, monofilament/multifilament, non absorbableAlloy of iron, nickel and chromiumGood TS even in infectionDifficult to handle and tendency to cut through tissues.Very hard to tie, and knot ends require special handling.

SURGICAL STEEL

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PackagingMETRIC GUAGE IMPERIAL GUAGE PRODUCT CODENEEDLE SIZE & CURVATURE NEEDLE TYPE NEEDLE TIP NEEDLE PROFILESTERILIZEDETHELENE OXIDE DO NOT REUSESEE INSTRUCTIONS FOR USE EXPIRY DATE BATCH NO64

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Largest size 1-0 to extremely fine 11-0. Increasing number of zeros correlates with decreasing suture diameter and strength.Thicker sutures approximation of deeper layers, wounds in tension prone areas and ligation of blood vessels. Thin sutures closing delicate tissues like conjunctiva and skin incisions of the face. Size is chosen to correlate with the tensile strength of the tissue being sutured.

SUTURE SIZES65

3-0 or 4-0 OMFS, muscle, deep skin5-0 or 6-0 facial skin closure9-0 or 10-0 microsurgery

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Surgical needles are designed to lead suture material through tissue with minimal injury. Needles can be - straight (GIT) or curved - swaged or eyedMade up of either SS or carbon steel.

Needle is selected according to:-type of tissue to be sutured-tissue accessibility-diameter of suture materialSUTURE NEEDLES68

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1.According to eye -eye less needles -needles with eye2.According to shape -straight needles. -curved needles3.According to cutting edge a) round body b) cutting -conventional -reverse cuttingCLASSIFICATION OF SURGICAL NEEDLES69

4.According to its tip -triangular tip -round tip -blunt tip5.Others -spatula needles -micro point needles -cuticular needles -plastic needles

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High quality stainless steelSmallest diameter possibleCapable of implanting sutures with minimal trauma to tissues.Stable in the needle holderShould be sharp.Sterile and corrosion resistant.

IDEAL PROPERTIES OF NEEDLES71

ANATOMY OF A NEEDLE

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Term Definition

Chord

Length of needle

Radius

DiameterThe linear distance between eye and tip.

The distance between eye and tip following the curvature

The distance of the body of the needle from the centre of the circle

Gauge or thickness of the metal wire out of which the needle is made.

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1. The eye2. The body3.The pointThe eye can be - closed - swaged - chanelled/drilledShape of the eye may be - round - oblong - squareOpen French-eye needle is easy to load with varying caliber, but has additional bulk.

COMPONENTS OF SURGICAL NEEDLE

CLOSEDSWAGED

CHANELLED75

1.Deviatingfromasquare,circular,orsphericalformbybeingelongatedinonedirection.2.Havingtheshapeoforresemblingarectangleorellipse.3.BotanyHavinganelongatedformwithapproximatelyparallelsides75

Eyed require threading prior to use, results in pulling a double strand through tissue. Tying the suture to the eye increases bulk of suture material drawn through tissues. So they are also called traumatic needles.Most suture materials and needles are difficult to sterilize. Needles are also difficult to clean after use and become blunt and work hardened so that they snap.

Suture loop inserted through eyeLoop placed over tipLoop drawn backSuture tied on eyed needle76

Swaged needleSwaged needles do not require threading and permit a single strand of suture material to be drawn.Suture attached to needle via a hole drilled through the end of the needle, and the end is swaged during manufacturing. It is atraumatic and act as a single unit Pre-packed and pre-sterilized by gamma radiation.

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Needle attached to sutureFavorable for Intra-oral use but expensiveLess tissue damageNew needle each time

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Body is the widest portion of the needle It is known as grasping area. Most commonly used are 3/8 circle. They can be easily manipulated in large and superficial wounds and require only less wrist movement.1/2 circle used for suturing tissues in small wounds, and body cavities and orifices. Require less space, but more supination and pronation of wrist.5/8 used in oral cavity.THE BODY 80

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RADIUS OF CURVATURE OF THE BODY(NEEDLE)CLINICAL USEStraight Needle

circle

3/8 circle

circle

5/8 circle Needle of choice for the skinLimited use in oral surgeryMay be used in surgery of the nose, pharynx, tendons

Needle of choice for microsurgery associated with very fine sutures; ophthalmology

Oral surgery, flap surgery, wound closure after placement of osseointegrated implants and GTR procedures May be used in all surgical wounds

Needle of choice in oral surgery Wide range of uses in many surgical wounds

Wounds of the urogenital tract

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Point runs from tip to the maximum cross sectional area of the body.Can be-triangular tip/cutting -round tip -blunt tipCutting needles are ideal for suturing keratinized tissues like skin, palatal mucosa, subcuticular layers and for securing drains.Round/tapered needles used for closing mesenchymal layers such as muscle or fascia that are soft and easily penetrableTHE POINT 83

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The conventional cutting point has two opposing cutting edges and third edge on the inside curvature of the needle.The reverse cutting point has two opposing cutting edges and third cutting edge on the outer curvature of the needle.

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The tapered point is used primarily on soft, easily penetrated tissues . It leaves small hole and can be used in vascular surgery as well as facial soft tissue surgery.

The blunt point has a rounded end which does not cut through the tissue .It is used in friable tissue suturing or to the parotid duct or lacrimal canaliculi.

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CUTICULAR NEEDLESSharpened 12 timesDesignated as C or FS (CUTICULAR or FOR SKIN)PLASTIC NEEDLES Sharpened an additional 24 timesDesignated as P or PS or PC (PREMIUM or PLASTIC SURGERY or PRECISION COSMETIC ).Needles in the PC series are made up of stronger SS alloy and have flattened and conventional cutting edge. 87

Curvature of the needle is selected according to the accessibility. The needle must exit in a visible spot so that the surgeon is aware of the position of the point of the needle at all the times.Try to match the needle thickness with suture diameter .

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It is not appropriate to use wide thick needle with small suture material . This will cause laxity of immediate suture line and allows bacterial contamination & in growth of epithelium & in vascular surgery it may allow oozing of blood through suture hole.

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Laxity- looseness89

Force should always be applied in the direction that follows the curvature of the needle.Movable to a non-movable tissue.Only sharp needles with minimal force.Never force the needle through the tissue. Avoid retrieving the needle from the tissue by the tip.PLACEMENT OF A NEEDLE INTO THE TISSUE Ethicon 198590

Grasp the needle in the body 1/4th to half of the length from the swaged area.Do not hold the needle by the swaged area or the eye.Avoid excessive tissue bites with small needles, as it will be difficult to retrieve them

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The needle holder is used to handle the suture needle and thread while suturing the surgical wound.

If used properly it enables the surgeon to perform procedures correctly and with great precision.

NEEDLE HOLDER

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Working tip/ jawsHinge deviceShank/bodyCatch mechanism/ ratchetGrip area

PARTS OF NEEDLE HOLDER

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NEEDLE HOLDER

There are different types of needle holders. The beaks may be short or long, broad or narrow, slotted or flat, concave or convex, smooth or serrated. Commonly used have a locking hand and short beaks and 6 longGilles needle holder (scissors incorporated into blades)Kilner needle holder94

Atraumatic needle holder ensures needle movement and compatibility of clamping movement. It has textured tungsten carbide jaw inserts, and its rounded needle holder jaw edges do not cause structural damage to monofilament suture or needle

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GILLES NEEDLE HOLDER

Scissors are incorporated into the blades96

OLSEN HEGAR NEEDLE HOLDERKILNER NEEDLE HOLDER97

MAYO HAGER NEEDLE

YASARGIL MICRO NEEDLE HOLDER98

THE SCISSOR GRIP Used in the anterior part of the mouth and in areas of easy access The instrument is stabilized with the index finger

GRIPPING NEEDLE HOLDER

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PALM GRIP

Used in the deeper parts of oral cavity

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Use appropriate size for needleGrasped 1/4 to distance from swaged areaTips of the jaws should meetNeedle placed securelyDo not over closeAlways directed by surgeons thumbDo not use digital pressure on tissues

101NEEDLE HOLDER SELECTIONEthicon 1985

PRINCIPLES OF SUTURING

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1.Needle grasped at th to the distance from eye.

2.Needle should enter perpendicular to tissue surface

PRINCIPLES OF SUTURINGEthicon 1985

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3.Needle passed along its curve4.The bite should be equal on both sides of the wound margin and the point of entry of the needle should be closer to the wound edge than its point of exit on the deep surface5.The bite should be about 2-3 mm from the wound margin of the flap because after wound closure the edge of the wound softens due to collagenolysis and the holding power is impaired.

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6. Usually the needle should be passed from mobile side to the fixed side but not always(exception in lingual mucoperiosteal flap) and from thinner to thicker & from deeper to superficial flap.7.The tissues should not be closed under tension , since they will either tear or necrose around the suture

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8.Tie to approximate; not to blanch

9.Knot must not lie on incision line

10.The distance b/w one suture to another should be about 3-4 mm apart to prevent strangulation of the tissue & to allow escape of the serum or inflammatory exudate & to get more strength of the wound.

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11.Sutures placed at a greater depth than distance from the incision evert wound margins.

..Close deep wounds in layers

13.Avoid retrieving needle by tip

14.Adequate tissue bite to prevent tearing

15.Sutures should have correct tension while tying knot for provision of the slight edema post operatively... More tensioned sutures cause ischemia of the edges of the incision causes tearing of the tissues may leave suture mark & edges may get overlapped.107

16.Occasionally extra tissue may be present on one side of incision and cause DOG EAR to be formed in the final phase of wound closure.

17. Simply extending the length of the incision to hide the exists will produce an unsatisfactory result.

18. Thus after undermining excess tissue, incision is made at approx. 300 to parent incision directed towards undermined side. Extra tissue is pulled over incision and appropriate amount is excised. Incision is closed in normal manner. 108

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IMPROPER SUTURING TECHNIQUE110

SUTURING TECHNIQUES

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IndicationsVertical incisionTuberosity and retromolar areasBone regeneration procedures with or without guided tissue regenerationWidman flaps, open flap curettage, unrepositioned flaps, or apically positioned flaps where maximum interproximal coverage is requiredEdentulous areasPartial- or split-thickness flapsOsseointegrated implants112Interrupted Sutures

Types Four most commonly used interrupted sutures:1. Circumferential, direct, or loop2. Figure eight 3. Vertical or horizontal mattress4. Intrapapillary placement113

Suturing is begun on the buccal surface 3 to 4 mm from the tip of the papilla 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 the connective tissue under the surface (circumferential) of the lingual flap.The needle is then returned through the embrasure and tied buccally.114Figure Eight and Circumferential Sutures

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Figure Eight

Circumferential Sutures

116Circumferential suture

117Figure eight

Mattress sutures are used for greater flap security and controlThey permit more precise flap placement, especially when combined with periosteal stabilization. They also allow for good papillary stabilization and placement.118Mattress Sutures

The flap is stabilized and needle is inserted 7 to 10 mm apical to the tip of the papilla. It is passed through the periosteum , emerging again from the epithelialized surface of the flap 2 to 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 buccally119Vertical Mattress

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A needle is inserted 7 to 8 mm apical to and to one side of the midline of the papilla, emerging again 4 to 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. For greater papillary stability and control, the double parallel strands of this suture can be made to cross over the three tops of the papillae. (double crossed-over suture)122Horizontal Mattress

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This technique is recommended for use only with modified Widman flaps and regeneration procedures in which there is adequate thickness of the papillary tissue.A needle is inserted buccally 4 to 5 mm from the tip of the papilla and passed through the tissue, emerging from the very tip of the papilla.This is repeated lingually and tied buccally, thus permitting exact tip-to-tip placement of the flaps124Intrapapillary Placement

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The sling suture is primarily used for a flap that has been raised on only one side of a tooth, involving only one or two adjacent papillae.It is most often used in coronally and laterally positioned flaps. The technique involves use of one of the interrupted sutures, which is either anchored about the adjacent tooth or slung around the tooth to hold both papillae126Sling Suture

127Sling suture about adjacent tooth

128Sling suture about single tooth

Laurell modified mattress suture (1993) for coronal flap positioning and primary flap coverage is a technique which, although capable of being employed for all regenerative techniques, is used predominantly when standard interproximal incisions are used. Start bucally below the papilla (24mm) and insert the needle to and then through the undersurface of the lingual flap.The suture needle is then reinserted lingually 24 mm above the initial suture and continued to and then through the buccal flap The suture is then brought lingually over the coronal aspect of the flap and through the loop.The suture is afterwards returned bucally and sutured129Specialized Interrupted Suturing Techniques for Bone Regeneration and Retromolar and Tuberosity Areas. Laurell Modification.

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This technique (Cortellini et al 1995) was introduced specifically for achieving maximum interproximal coverage and primary closure over intrabony defect is treated by GTR. The modified flap technique requires the initial incision be made at the buccal line angles in the area of the interproximal defect. It is a papillary preservation technique. The suturing permits coronal positioning, flap stabilization, and primary interproximal closure.131Modified Flap Suturing Technique

The first suture is begun buccally 56 mm below the initial incision. The suture is passed through the buccal and palatal flaps. It is then reinserted palatally and allowed to exit the buccal flap 2 mm above the initial placements. This is tied off and should stabilize the body of the flap. The second suture is now begun 34 mm below the initial incision and above the first suture.The suture is passed through the interproximal papilla and returned as a horizontal mattress suture on the buccal surface and tied off.132Technique

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This technique (Hutchenson 2005) is specially designed for gaining intimate tissue-tooth contact where regeneration is being attempted. It is employed when there is an intrabony defect distal to the last tooth on the lower teeth. It not only permits primary flap closure but close approximation of the tissue on the distal aspect of the tooth.134Retromolar Suture Modification for Primary Coverage

Suture is begun on the mesiobuccal of the terminal tooth. The suture is passed through interproximal to the distal and inserted through only the undersurface of the buccal flap. The suture is brought almost 360 around the tooth starting lingually and continuing bucally until again reaching the distal surface.The needle is passed through the undersurface of the lingual flap and tied on the buccal surface135

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When multiple teeth are involved, the continuous suture is preferred.Advantages1. Can include as many teeth as required2. Minimizes the need for multiple knots3. Simplicity4. The teeth are used to anchor the flap5. Permits precise flap placement6. Avoids the need for periosteal sutures7. Allows independent placement and tension of buccal and lingual or palatal flaps. Buccal flaps can be positioned loosely, whereas lingual and palatal flaps are pulled more tightly about the teeth.8. Greater distribution of forces on the flaps137Continuous Sutures Sling

DisadvantagesThe main disadvantage of continuous sutures is that if the suture breaks, the flap may become loose or the suture may come untied from multiple teeth.TypesThe choice of continuous suture depends on the operators preference. These, too, can be periosteal or nonperiosteal:1. Independent sling suture2. Mattress suturesa. Verticalb. Horizontal3. Continuous locking138

The continuous sling suture, although most often begun as a continuation of tuberosity or retromolar suturing, can also be started with a looped suture about the terminal papilla (buccal, lingual, or palatal). It is then continued through the next interproximal embrasure in such a manner that the suture is made to encircle the neck of the tooth.The needle is then passed either over the papilla and through the outer epithelialized surface or underneath and through the connective tissue undersurface of the papilla.139Independent Sling Suture

The needle is passed again through the embrasure and continued anteriorly. This procedure is repeated through each successive embrasure until all papillae have been engaged.Terminal End Loop. On completion of suturing, the suture is tied off against the tooth as opposed to the other flap. This is accomplished by leaving a loose loop of approximately 1 cm length of suture material before the last embrasure. When the last papilla is sutured and the needle is returned through the embrasure, the terminal end loop is used to tie the final knot140

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This technique simultaneously slings together both the buccal and lingual or palatal flaps.INDICATIONS.1. When flap position is not critical2. When buccal periosteal sutures are used for buccal flap position and stabilization3. When maximum closure is desired (unreposition or Widman flaps or bone regeneration)142Alternative Procedure

TechniqueAfter the initial buccal and lingual tie, the suture is passed buccally about the neck of the tooth interdentally and through the lingual flap. It is 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 the buccal surface of the tooth. This alternating buccal- lingual suturing is continued until the suture is tied off with a terminal end loop143

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The continuous locking suture 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 is broken, however, it may completely untie.145Locking

TechniqueThe procedure is simple and repetitive.A single interrupted suture is used to make the initial tie. The needle is next inserted through the outer 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 end146

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KNOT TYING

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Sutured knot has 3 components1.Loop created by knot2.Knot itself which is composed of a number of tight throws3.Ears which are the cut ends of the suture

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Use the simplest knot that will prevent slippage.Tying the knot as small as possible and cutting the ends of the suture as short as reasonable to minimize foreign body reaction.Avoid friction or sawingAvoid damage to suture material Avoid excessive tensionTying sutures too tightly strangulates the tissue

PRINCIPLES OF KNOT TYING151

Maintenance of traction at one end of the suture after the first loop is thrown, to avoid loosening of the knot.

Placing the final throw as horizontally as possible to keep knot flat

Limiting extra throws to the knot, as they do not add strength to a properly tied knot.

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SQUARE KNOTFormed by wrapping the suture around the needle holder once in opposite directions between the ties.Atleast 3 ties are recommended. Best for gut, silk, cotton and SS

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Formed by 2 throws on the first tie and one throw in the opposite direction in the second tie.Recommended for tying polyester suture materials such as Vicryl and MersilineCan be given as 2-1 and 2-2

SURGEONS KNOT154

A tie in one direction followed by a tie in the same direction and a third tie in the opposite direction to square the knot and hold it permanently.

GRANNYS KNOT155

SUTURE REMOVAL156

Skin wounds regain TS slowly. It can be removed in 3-10 days when the wound gained 5%-10% of final TS. Skin sutures on face removed between 3-5 days.Alternate sutures removed on 3rd day and remaining sutures after 2 days.

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Intra oral Mucoperiosteal closure (without tension) 5-7 days Where there is tension on the suture eg : Oro-antral fistula- 7-10 daysContinuous subcuticular can be left for 3-4 weeks without formation of suture tracksA good guide is that as soon as they begin to get loose they should be taken out.

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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. 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.159PRINCIPLES OF SUTURE REMOVALEthicon 1985

3. A cotton pliers is now used to remove the sutures. The location of the knots should be noted so that they can be removed first. This will prevent unnecessary entrapment under the flap.

Sutures should be removed in 7 to 10 days to prevent epithelialization or wicking about the suture.160

Sutural abscess. Suture scarring or stitch mark Implanted dermoid cyst

Possible Complication Of Leaving Suture For Many Days

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Ligating clipsSkin staplesSurgical tapeSurgical adhesivesOther Methods of Wound Closure162

Atlas of Cosmetic and Reconstructive Periodontal Surgery - Edward S. Cohen DMD- 3rd editionIllustrated manual of Oral and Maxillofacial Surgery- Geeti Vajdi MitraSuturing techniques in Oral Surgery Sandro SiervoCarranza's Clinical Periodontology- 10th editionWound management and suturing manual- Corey S MassTextbook of Oral and Maxillofacial Surgery- Neelima Anil Malik- 2nd edition

REFERENCEs

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7. Brian CB, Philip KH. Review: Polymers for absorbable surgical sutures-Part I. J Bioactive Compatible Polymers 1990.8. Ricardo SG et al, Reaction of human gingival tissue to different suture materials used in periodontal surgery. Braz Dent J 1991.9. Chu CC, Mechanical properties of suture materials: an important charecterization. Ann Surg 1981.10. Parirokh M et al, A scanning electron microscope study of plaque accumulation on silk and PVDF suture materials in oral mucosa. International Endodontic J 2004.164

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