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Transcript of Suture material
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Dr V.RAMKUMAR
CONSULTANT DENTAL &FACIOMAXILLARY SURGEON
REG NO:4118 –TAMILNADU -INDIA(ASIA)
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INTRODUCTION
The primary purpose for suturing -to hold tissue
layers and wound edges in close approximation
until the healing process provides the wound with
sufficient strength to withstand stress without the
need for mechanical support.
Sutures may be used to either assist healing by
first intention or to minimize wound
contamination or to control haemorrhage.
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SUTURE MATERIALS
Ideal suture materials have following
properties:
Adequate strength
Good handling and knot tying
characteristics
Sterilizable
Evoke little tissue reaction
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Types of suture materials
Absorbable Plain surgical gut (catgut)Chromic catgut Collagen Polyglycolic acid (Dexon)Polyglactin 910 (Vicryl)
Non-absorbable
Silk
Cotton
Nylon
Dacron (Mersilene)
Polypropylene (Prolene)
Stainless steel
Tantalum
Titanium
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Natural / Biological
Catgut
Collagen
Silk
Cotton
Linen
Synthetic / Artificial
Polyglycolic acid (Dexon)
Polyglactin 910 (Vicryl)
Nylon
Dacron (Mersilene)
Polypropylene (Prolene)
Stainless steel
Tantalum
Titanium
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Monofilament
Catgut
Polypropylene (Prolene)
Polyethylene
Multifilament
Silk
Cotton
Linen
Polyglycolide
Polyester
Polylactide
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Braided
Silk
Polyglycolide
Polylactide
Polyester
Polyamide
Twisted
Cotton
Linen
Coated
Polyester
Polyglycolide
Polylactide
Cotton
Linen
Uncoated
Polyamide
Polypropylene
Polyethylene
Catgut
Collagen
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ABSORBABLE SUTURE MATERIALS
degraded in vivo by enzymatic and phagocytic mechanisms and / or hydrolysis and thus over time diminish in strength and disappear from the tissue.
The speed of absorption of a suture is roughly proportional to the vascularity of the surrounding tissues.
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In general, absorbable sutures are made to be buried in deep subsurface layers of tissues where they will be slowly absorbed over several days while holding the sutured tissues together.
Examples: • Plain surgical gut (catgut)
Biologically derived
Chromic catgut (tanned gut)
Polyglycolic acid (Dexon)
Synthetic
Polyglactin 910 (Vicryl)
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• Gut
– Derived from sheep intestinal submucosa or bovine
intestinal serosa
– Smallest tensile strength
– Packaged in isopropyl alcohol as a preservative
(since highly susceptible to enzymatic degradation).
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– Absorbed by proteolytic degradation and
phagocytosis. This is accompanied by
considerable inflammation and tissue reaction.
– Plain gut – more difficult to use than other suture
materials as it is stiff and has insecure knot
holding characteristics when wet.
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• Chromic gut – is plain gut that has been tanned with a solution of
chromium salts prior to being spun, ground and polished.
Chromium salts act as a cross-linking agent and increase the tensile
strength of the material and its resistance to absorption by the body.
• Advantages of chromic gut over plain gut:
• Slightly increased strength
• Prolonged rate of absorption
• Lesser stimulation of tissue reaction
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• Polyglycolic acid and polyglactin 910
– Resorbed by hydrolysis
– Since they are synthetic polymer, they
produce very little tissue reactions.
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NON-ABSORBABLE SUTURE MATERIAL
• Primarily used on surface layers .
• Require surgical removal after fulfilling their mission.
• Can be natural or synthetic
• Example – Natural – silk, cotton, linen
Synthetic – Dacron, nylon, polyester
polypropylene
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• Silk
Most popular suture material for intraoral use
braided which gives it excellent handling
characteristics
produces a moderate tissue response
does not irritate adjacent mucous membrane
Inexpensive
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• Nylon
Braided or monofilament forms
Because of its stiffness, the large knot required
and a tendency to tear through non-keratinized
tissue, nylon is not frequently used intraorally.
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NATURAL / SYNTHETIC SUTURE MATERIALS
Natural
• Biologically derived
• Example:
Catgut (plain gut, chromic gut)
Silk (black braided silk)
Cotton
Nylon
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Synthetic
– superior tensile strength
– minimal capillary action within the wound
– induces less inflammatory reaction.
– Example: polyglycolic acid sutures, Dacron, nylon,
polyester, polypropylene.
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MONOFILAMENT / POLYFILAMENT SUTURE
MATERIALS
Monofilament: contains single strand
– Example : Polyamide, polypropylene, catgut.
Polyfilament: made up of multiple fibres – either braided or
twisted
– Example: polyglycolide, silk, cotton, linen, steel.
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• The size of suture material is with reference to its diameter.
• The smallest size that will provide the desired wound tension must be chosen.
• The higher the number, the smaller the suture.
• Sutures are sized such that No3 is the largest and 7-0 is the smallest in general use.
• The more zeroes in the number the smaller the diameter of the strand.
• Sutures of 5-0 or 6-0 are generally used for skin closure in the head and neck, while 3-0 and 4-0 are used intraorally.
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INSTRUMENTATION
• Instruments and materials needed during suturing techniques are
as follows:
– A needle holder
– A pair of tissue forceps
– Suturing needles
– Suture material
– A pair of scissors
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NEEDLE HOLDERS
– Resemble artery forceps, but it is characterized by the presence of short
and stout beaks with serrated surfaces to prevent the needle from
slipping during the usage. However handles are sufficiently long.
– Ideally the needle is held clamped by the beaks of the needle holder of a
position, nearly two-thirds of the distance from the tip of the needle.
• While the needle is passed through the tissues, the flap is gripped with a
pair of tissue forceps, with the free margin of flap held everted.
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SUTURING NEEDLE
• The needle for suturing vary in size, Curvature, profile of
their cutting point.
• Needles are made of either stainless steel or carbon steel.
• Two basic shapes :
Straight
Curved
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• Straight needle
tapered configuration (circular / oblong in cross section)
cutting configuration (triangular in cross section)
• Straight cutting needle
• -used for skin closure in places with adequate access, such as
abdominal, thoracic or iliac regions. -In oral and maxillofacial surgery
-used for the passage of circumzygomatic or circummandibular wires.
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Curved Needles• used for both skin and mucous membrane surgery • Manufactured with varying curvatures such as 1/4 , 3/8, ½, 5/8 circle.Needles: A - ¼ circle, B - 3/8 circle, C – ½ circle D – ¾ circle, E – straight with curved end F – straight
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Needles in cross section
A – Tapered, B – Cutting, C – Reverse cutting
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• Tapered or cutting types:
• Cutting needles are further categorized as :
– Conventional – has one of its three cutting edges along the internal
curvature of the needle.
– Reverse cutting – has a flat internal surface.
• Tapered needle is generally used for closing mesenchymal layer
such as muscle /fascia that are soft & easily penetrable.
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• Cutting needle – is used for keratinized
mucosa, skin or subcuticular layers
where the tissue is difficult to penetrate.
• The cutting edge needle make a lateral
cut as it is perforating. It makes suturing
easier through ligamentous tissue.
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Needles also vary in their attachment for the suture material
In swaged needle the suture material is inserted into the hollow
end during manufacture and metal is compressed around it. The
needle is not reusable. It is atraumatic.
Eyed needle is designed to be reused and suture material is tied to
the needle. These produce slightly larger holes in the tissue.
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PRINCIPLES OF SUTURING TECHNIQUES
• The needle holder should grasp the needle at approximately ¾ of
the distance from the needle tip.
• The needle should enter the tissue perpendicular to the surface.
• The needle should be passed through the tissue following the curve
of the needle.
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• The suture should be placed at an equal distance (2 to 3 mm)
from the incision on both sides and at an equal depth.
• It one tissue side is free (as with a flap) and the other fixed the
needle should be passed from the free to the fixed side.
• If one tissue side is thinner than the other then the needle should
be passed from the thinner to the thicker side.
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• The distance that the needle is passed into the tissue should be
greater than the distance from the tissue edge. This will ensure
a degree of tissue eversion. Some degree of tissue eversion is
desirable in anticipation of scar contracture.
• The tissues should not be closed under tension, since they will
either tear or necrose around the suture. If tension is present
the tissue layer should be undermined to relieve it.
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• The suture should be tied so that tissue is merely approximated not
blanched.
• The knot should not be placed over the incision line.
• Sutures should be placed approximately 3 to 4 mm apart. The
closeness of the sutures depends on the anticipated tension across the
suture line. Closer spaced sutures are indicated in areas of
underlying muscular activity such as the tongue or in other areas of
increased tension.
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SUTURING TECHNIQUES Interrupted sutures
Continuous sutures
Mattress sutures
Horizontal
Vertical
Locking continuous suture
Figure of 8
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Factors that determine the type of suture are:
• type of the tissue
• condition of the wound
• healing process
• anticipated post operative course.
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INTERRUPTED SUTURES
• Most commonly used
• Each suture is independent of the next
offering strength and flexibility in placement.
Simple interrupted suture
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• Advantage:
• It is strong
• Successive sutures can be placed in a manner to fit the
individual requirements of the situation.
• The integrity of the suture remains intact even if one suture
is disturbed or lost.
• Only Disadvantage – is the time required when compared to
other techniques.
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• Needle enters the mucous membrane from the external to the
tissue surface of the mobile flap.
• Then needle passes from the tissue surface through the fixed
flap and comes out on the surface. Hence both the points of
entry and exit are on the outer surface of the flaps respectively.
• Both these points should be equidistant from free margins of
the flaps.
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• Both the ends of the suture materials are tied either by hand or
with instruments.
• At the time of tightening the knot wound margins must be everted.
• Tension must be distributed equally.
• The suture material is adjusted in such as way that the knot lie
over the needle puncture point in any one side of the wound and
not on the suture line.
• The suturing is done at regular intervals.
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CONTINUOUS SUTURE
• Used to suture a wide area
• It should not be used in areas of existing tension
• Advantage:
– Ease and conserving the time of suturing
– Even distribution of tension over the entire suture line
– Provides a water tight closure of the wound.
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Continuous Technique
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• Disadvantage :
– If the wound gives way in any one place it disrupts the
entire wound.
• This is very similar to interrupted sutures. But instead of
tying the knot, the needle is passed again through the
mobile flap and the process continued till the entire wound
is sutured. The knot is placed at the end only.
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LOCKING CONTINUOUS SUTURE
• 2 Advantages over simple continuous technique :
suture will align itself perpendicularly to the incision
locking feature prevents continuous tightening of the
suture as wound closure progresses.
Continuous locking technique
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• Suture is passed perpendicular to incision line and degree of locking
is provided by withdrawing suture through its own loop. This suture
technique is begun and ended identically to continuous technique.
• Care must be exercised not to tighten the individual lock excessively
since this can produce tissue necrosis.
• Locking feature may prevent adjustment of tension over the suture
line as tissue swelling occurs
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MATTRESS SUTURE
• Main purpose of mattress suture is to provide
more tissue eversion than occurs with simple
interrupted suture.
• Mattress suture can be horizontal and vertical
type.
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• Point of entry and exit are located in the same flap.
• Point of entry is similar to the interrupted suture.
• The needle passes through the mobile flap and then
through the fixed flap. Instead of placing a knot the
needle is passed in the reverse direction from the fixed
flap through the mobile flap so that ultimately needle
returns back near the point of first entry.
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• In horizontal mattress type, point of entry
and point of exit are situated equidistant
from the free margins of the mobile flap.
That means wider areas of the flap are
sutured.
Horizontal mattress technique
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• In vertical mattress type, point of entry is situated
away from the wound margin deep into the tissues
while the point of exit is near the wound margin.
Both these points are one above the other.
• Horizontal mattress suture if improperly used
compromise blood supply to the flap edge on both
sides of incision causing necrosis and dehiscence.
Vertical mattress technique
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FIGURE OF 8 SUTURE
• Used over extraction sites where it provides some
protection to the surgical area as well as adaptation
of the gingival papillae around the adjacent teeth.
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TYPES OF KNOTS
SQUARE KNOT
• Formed by wrapping suture around needle holder once in
opposite directions between ties.
• It is prudent to provide at least 3 ties for surface knots.
• Certain types of suture material such as nylon,
polypropylene, polyglycolic acid, and gut may require more
ties
Square Knot
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SURGEON’S KNOT
• Formed by two throws of suture around needle holder on first tie and
then one throw in opposite direction on second tie.
• Because of the double throw, the surgeon’s knot offer the advantage of
reducing slippage of the first tie, while second tie is put in place.
• useful in confined or difficult to reach places where the first tie would
ordinarily be loosened in the process of producing the second tie.
• A third tie squared on the surgeon’s knot is usually made for security.
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Surgeon’s knot
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GRANNY KNOT
• This knot involves a tie in one direction followed by a single tie
in the same direction as the first.
• This will allow the knot to be slipped to place and provide
initial holding similar to the surgeon’s knot.
• Moreover a 3rd tie squared on the second must be made to hold
the knot permanently.
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SUTURE REMOVAL
• Usually the wound margins are cleaned with antiseptics. The
sutures are removed between 5th and 7th post-operative day.
• When sutures are removed, the suture (the knot) should be
grasped with an instrument (forceps) and elevated above the
epithelial surface. A scissors should be used to transect or cut
off one side of the loop as close to the epithelial surface as
possible.
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• The portion of suture which is exposed to the outside
environment becomes laden with debris and bacteria.
• So that the minimal portion of this exposed suture to be
dragged through the tissue the loop is cut as close to the
epithelial surface as possible.
• If the suture is cut midway the contaminated external loop is
pulled through the wound that predisposes to wound infection.
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A. An intra-oral suture is loose and impregnated with food detritus after being in situ for 1 week.
B. If suture is cut just below the knot as in B the wound is contaminated as infected silk is pulled through the tissues.
C. if the suture is cut just as it enters the tissues the above complication is avoided.
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