Sutures & suture materials

Dr. Shanmuga priya 1 st year pg

Definition
SUTURE:

A strand or thread used to approximate tissues and also to ligate blood vessels.
LIGATURE :

Any thread or strand which obliterates lumen of

ductular structures

History

Arabian, Rhazes kitgut- 900 A.D Word gradually evolved to catgut / surgical gutfrom sheep intestine 1902, Cladius- iodine sterilization of suturing materials 1931-synthetic absorbable sutures Horse hair strands, gold/silver wires, silk, gut, linen, cotton, tendons, human intestines.

Requisites for suture materials

Tensile strength Strong enough to hold tissues during first week. Strength varies with elasticity. Flexible materials greater ability to stretch & bear stress. 2. Chemically inert / biocompatible /low tissue irritation Not hamper healing process organic materials- e.g. Catgut irritants New synthetic material least irritant
1.

3. Low capillarity:
multifilament take tissue fluid by capillary action-medium for microbes-inflammation & infection 4. Good handling & knotting properties 5. Sterilization without deterioration of the properties. Dry heat &

ethylene oxide gas

6. Smoothness

Smooth material Easy passage Least trauma

Eg. Monofilament

Classification
Suture Materials

Absorbable

Non Absorbable

Natural

Synthetic

Natural

Synthetic

Metallic

Monofilament / Multifilament Coated / Non coated Thread diameter 1-0 to 10-0 Higher number of zeros-thinner thread

Monofilament :

Polyfilament :

single filament Eg. Prolene smooth open up

Multiple filaments Eg. Cotton, Silk

rough
knot secure easy to handle promotes bacterial harbour

not easy to handle

impede bacterial harbour no fraying

fraying

Absorbable materials

digested by tissue enzymes

Eg. Catgut plain
chromic catgut Chromate- to increase tensile strength & delay absorption

Hydrolysed by tissue fluids

Eg. Polyglactin (Vicryl)

Natural absorbable:

Catgut / surgical gut

Plain Chromic

Fascialata Kangaroo tendon Cargile membrane

Collagen

Catgut: Natural polymer from aminoacids Monofilament Sheeps intestine / serosa of beef cattle intestine Absorption by proteolytic digestive enzymes Complete absorption-60-120 days Tensile strength- Plain 15 days Chromic 30 days Kept in preservative solution Ethicion fluid Sterilized gamma radiation C/I: prolonged approximation under stress, low pH

Plain Catgut

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

Chromic

Fascialata :

Thigh muscles of beef cattle Was used to repair hernia

Kangaroo tendon :

Tail tendon of small kangaroos High tensile strength

Synthetic absorbable: Non-protein polymer of glycolic acid Absorption hydrolysis (100 days) Sterilized by ethylene oxide White, poly filament, braided
Advantages : Minimum tissue reaction Uniform absorption Used even in presence of infection Knot security better Fraying is less

Synthetic absorbable:

Coated vicryl (Polygalactin 910) Polyglycolic acid (Dexon) Monocryl-polyglecaprone

Polydioxanone

Polyglactin 910 coated vicryl

Co-polymer of 90% Glycolide and 10%Lactide Coated with Calcium stearate & poly galactin Absorption rate-60-90 days Advantages: Unique molecular structure retain strength for long

Minimum tissue reaction Excellent handling characters

Not used under the areas of stress Violet colour

Polyglactin 910 coated- vicryl plus First & only antibacterial suture Contains triclosan
Vicryl Rapide Irradiated polyglactin 910 Rapid absorption 35- 40 days Gamma radiation Tensile strength- upto 12 days intra-oral use / short term wound support

Polyglecaprone 25 Monocryl Co-polymer of Glycolide and Caprolactone Most pliable, flexible monofilament with excellent handling properties Tensile strength double of chromic Polydioxanone Strong but soft & pliable Absorption 180-210 days Support wound beyond 4 week period Recommended in orthopedic surgery

Non-absorbable
Natural : Synthetic : Metals :

Silk
Cotton Linen

Polyamide
Polyester Polypropylene

Stainless steel
Platinum Tantalum

Silver wire
Others :
Tapes Tissue adhesives

Staples

Silk :

Natural from COCOON of silk worm larvae Advantages

natural elasticity high tensile strength ties smoothly & securely-good handling properties
stitch granuloma infection - high tissue reaction - high

Disadvantages

Most universally used material in dentistry

Types

Prema hand surgical silk (7-0 to 1-0) Virgin silk suture ligate blood vessels & pedicles suture nerves, tendons skin & grafts wound over the face

Uses

Non sterile sutures available in 5-0 to 3-0

Cotton

seeds of cotton plant ; poly filament Weaker & handling is not good advantage

economical secure knotting

Linen

obtained from flax (cellulose) ; polyfilament advantage

easily handled tie is secure

uses

tying pedicles ligatures

Polyamide -Nylon
Advantage:

- less irritant
- high tensile strength - economical
-

smooth passage through tissue

Disadvantage:

- HAS MEMORY
- infection

Polyester : Terylene / Dacron

Extremely high tensile strength-C.V.Surgeries
Dis adv:-cuts through tissue Teflon (e-PTFE-expanded polytetra fluroethylene) better handling properties but flakes in tissues, incre suture diameter Ethibond suturesCoated with Polybutylate Does not flake Does not increase suture diameter

Polypropylene : Prolene

Advantage monofilament extremely low tissue reactivity more tensile strength unwetted by blood & tissue enzymes Extend upto 30% - useful in post operative swelling Indications Dental implant surgery & bone graft procedures

Stainless steel wire :

advantage
Strength

& very little tissue reaction

disadvantage

tear of tissue

necrosis if tight
breaking sterile technique-tears gloves

Principles of suture selection

knowledge of the tissues physical and biological properties of suture condition of the wound post-operative course of the patient Suture should lose its tensile strength at the same rate tissues gain strength. skin, fascia & tendon healing slow-non absorbable peritoneum, liver & muscle healing rapid- absorbable multifilament sutures avoided in contaminated wounds intra-oral silk, PGA used but absorbable preferred

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

Comprises of three parts:

1. 2. 3.

Needle eye or swagged end

Needle body
Needle point

Classifications :

Eye

eyeless needles with eye straight curved

Shape

Cutting edge

round body cutting body

triangular round tipped blunt point

Tip

Acc to radius & shape

Straight One-fourth circle Three-eight circle Half circle Five-eight circle

Needles with eye :

Traumatic needlespulling a double thread thr the tissues

can be reused economical

Eyeless / Atraumatic needles :

suture material is attached to the swage of the needle during manufacture advantages

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

Straight
blunt tip for fascia & skin for passage of Circum-zygomatic Circum-mandibular wires

Curved
cutting needle facilitates working in depth more confined operated site greater curvature required

Conventional cutting needle : keratinized mucosa & skin

Round body needles : used for soft & non keratinized tissues

Reverse cutting needle : triangular in crosssection; apex cutting edge on outside of needle curvature

Slim blade needle : plastic and cosmetic surgery

Blunt point suture needle : for friable tissues

Taper cut needle : Cardiovascular surgery

Mayos needle : to penetrate periosteum

Trocar point needle : in dense tissues

Principles of suturing : grasp the needle at approximately 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

knots A knot, is an interwining of threads for purpose of joining them

Knot tying

one hand / two hand instrument tie

Square knot

Formed by wrapping

ties around needle holder once in opposite direction between ties

Surgeons knot

Formed by two throws

of suture around needle on first tie & one throw in opposite direction on second tie

Advantage
reduced slippage of first tie

Granny knot

Involves a tie in one

direction followed by single tie in same direction as first

A third tie in opposite direction is then squared on the second to hold the knot permanently

Suture method
Interrupted

Needle penetration 3mm

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 perpendicular 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

Figure of 8 - in extraction sites

provides protection to
socket as well as adaptation of

gingival papilla around

adjacent tooth

Sub - Cuticular Suture

knot should be inverted Holds the skin edges in close approximation

Cosmetic results Stitches beneath the epithelial layer of skin

Tension suture
to prevent wound dehiscence

non-absorbable nylon

prolene used with plastic

tubing

to reduce tension

Mattress suture

Vertical Horizontal

Tension areas Resist muscle pull Evert wound edges Adapt the flap tightly to the underlying tissues Eg bone grafts dental implant

Vertical Depth of penetration varies- superficial For closing deep wounds Advantage

run parallel to the blood supply of the flap not interfere with healing

Horizontal :

Interrupted produces broad contact of wound margins Extraction wound sockets Continuous intra-oral bone grafting

Distance of needle penetration from incision line & depth of penetration is same. Horizontal distance of the point of penetration differs

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- grasped with an instrument & elevated above epithelial surface

Scissors transected as close to the epithelial surface as possible

Skin suture-5 days Intra oral-7 days Tension areas-10 days

Conclusion Logical decision regarding which suture material / technique to use in a given clinical situation

makes a difference in wound healing