The presentation deals with the various suturing materials available and the different kinds of techniques used. Attempts have been made to simplify the text and support with suitable illustrations. Hope you like it! Suggestions and feedback will be highly appreciated! :)

1. SUTURING MATERIALS
AND TECHNIQUES
MADE BY:
Akshat Sachdeva
BDS Final Year
Manav Rachna Dental College

2. INTRODUCTION
The purpose of a suture is to hold tissues in apposition until
the wound has healed sufficiently to be self – supportive.
Sutures function primarily to maintain wound closure and to
promote wound healing during the time when the wound is
most vulnerable.
Wound healing process can be affected by the amount of
suture material used, suture type, suturing technique and the
amount of tension in the suture.

3. SUTURE MATERIAL
Features of an ideal suture material include:
• Should have high tensile strength to hold the wound margins
appropriately till healing is complete.
• Should not be allergic or cause any tissue inflammation.
• Should have least capillarity so that the material does not soak up
much of the inflamed tissue fluid surrounding the wound and further
exaggerate infection.
• Should have good knotting properties.
• Should be easily sterilized.
• Should be visible in the surgical field.
• Should be inexpensive.

4. CLASSIFICATION
Sutures are classified into two groups:
1. Absorbable: These materials lose their tensile strength within 60 days.
They are digested by the enzymes inside the body.
• Natural.
• Synthetic.
2. Non – Absorbable: Cannot be digested by the body and should be
removed by the surgeon at the end of healing.
• Natural.
• Synthetic.
• Metallic.
Sutures can also be classified into monofilament and multifilament.
I. Monofilament: Consists of single strand of suture material.
II. Multifilament: Consists of several filaments twisted or braided
together.

5. Suture material Absorbable Non – Absorbable
Monofilament Surgical gut plain chromic Polyamide
Collagen plain chromic Polypropylene
Monocryl Stainless steel
PDS II Polyester
Polyglactin 910
Multifilament Polyglycolic Acid Surgical silk
Polyglactin 910 Surgical lenin
Polyglactin 910 – rapid Cotton
Polyamide braided
Polyester braided
Polyester braided coated
Stainless steel

6. ABSORBABLE SUTURE MATERIALS
Natural Absorbable Materials:
1. Catgut:
• Also called surgical gut, derived from cattle intima.
• Poor tensile strength and high tissue reactivity.
• Gut soaked in chromic acid salts will have reduction in tissue
reactivity as compared to untreated catgut.

7. 2. Collagen:
• Made by extruding homogenized tendon Achillies of beef cattle and
are almost 100% pure collagen.
• Made in plain and chromic form.
• Stiffer than surgical gut.
• Not in common use.
3. Cartilage Membrane:
• Thin sheet of tissue obtained from submucous layer of caecum of ox.
• Used to prevent adhesions in abdominal surgery, for isolating ligations
and for covering for packing material in submucous resections.
• Permits easy withdrawal of packing after the danger of hemorrhage is
passed.

8. Synthetic Absorbable Materials:
1. Polyglycolic Acid (Dexon):
• First synthetic absorbable suture to become available.
• Renowned for its superb tensile and knot strengths in addition to having delayed
absorption and diminished tissue reactivity.
• Less of inflammatory response due to absorption of polyglycolic acid by hydrolysis.
2. Polyglactic Acid (Vicryl):
• Copolymer of lactide and glycolide, manufactured with a coating of polyglactin 370
and calcium stearate.
• Lubricant coating provides Vicryl with its superb handling and smooth tie down
properties.
• Degraded by hydrolysis like all synthetic polyesters and thus causes minimal tissue
reaction.

9. 3. Polydioxanone (PDS):
• Polymer made from paradioxanone, has prolonged tensile strength.
• Hydrolyzed more slowly than other synthetic absorbables; complete
absorption occurs abou 180 days after implantation.
• Foreign body reactions found to be minimal.
4. Polytrimethylene Carbonate (Maxon):
• Newest absorbable material.
• Developed to combine excellent tensile strength retention qualities of
PDS with improved handling properties.
• Provides wound support over extended period of time.

10. Natural Non – Absorbable Suture Materials:
1. Silk:
• Created from natural protein filaments spun by the silkworm larva.
• Silk is braided, soft and easiest suture material to handle and tie.
• Lowest tensile strength.
• Elicits more inflammatory reaction, should be avoided in areas prone
to infection.
• In cutaneous surgery can be used around eyelids and lips where it lies
flat, causes minimal irritation and has low potential for infection.

11. 2. Linen:
• Made from flax and is cellulous material.
• Twisted to form a fiber to make a suture.
• Material handles the knot well.
• Extensively used for tying pedicles and as ligatures.
3. Cotton:
• Derived from hairs of seed of cotton plants.
• Twisted to form a suture.
• Tissue reaction similar to silk and tends to be a polymorphonuclear
cellular type.
• Handling good but not so good as silk.
• Weaker as compared to linen.

12. Synthetic Non – Absorbable Suture Material:
1. Nylon:
• Most widely used non – absorbable suture in cutaneous surgery as
monofilament.
• High tensile strength, excellent elastic properties, minimal tissue
reactivity and low cost.
• Main disadvantage is its prominent memory which leads to an
increased number of know throws to hold a given stitch in place.
• Multifilamentous braided nylon suture are seldom used because of
higher infection rate and increased cost.
• Encounters partial degradation through hydrolysis at very slow rate.

13. 2. Polypropylene (Prolene, Surgilene):
• It is a plastic suture formed from the polymerization of propylene by
means of a catalyst.
• Prolene is an extremely inert suture because its tissue reactivity and
tensile strength.
• It has a very slippery surface with low adherence to tissue.
• Can extend upto 30% before breaking and hence is useful in situations,
when swelling occurs, this suture stretches to compensate for the
wound and thus results in less trauma to the sutured tissue.
• When wound swelling recedes, the suture remains loose.

14. 3. Braided Polyesters (Ethibond, Dacron, Ethiflex):
• These are polymers formed by condensation polymerization.
• Manufactured to provide as high tensile strength and low tissue
reactivity as the monofilaments along with improved handling and
knot security.
• Polyester sutures are either coated or uncoated.
• They are not commonly used owing to relatively higher cost.
• Ethibond is an excellent skin suture because of its high knot security in
mobile facial areas,

15. 4. Polybutester (Novafil):
• This is the newest of the non absorbable sutures and is a thermoplastic
copolymer.
• Monofilamentous suture designed to be stronger and less stiff.
• Its unique feature is its elasticity, as this suture has the capacity to
stretch 50% of its length at loads of only 25% of its knot-breaking
level.
• This elasticity at low loads has the clinical advantages of elongation of
suture when wound edema occurs and maintenance of tension when
the edema recedes. This characteristic reduces the incidence of suture
marks and suture cut-throughs.

16. SUTURING NEEDLES
Needles are made of either stainless steel or carbon steel. Two shapes of
needles available:
i. Straight.
ii. Curved.

17. Straight Needle:
Types:
• Round bodied: circular or oblong in cross – section and gradually
tapers to a point.
• Cutting: triangular in cross – section and are sharp enough to finely
pass through keratinized mucosa.
Uses:
• For closure of thoracic, iliac or abdominal region.
• In maxillofacial surgery, needle is used for the passage of
circummandibular or circumzygomatic wires.

18. Curved Needles:
Usually used for skin and mucous membrane surgery. Curvatures come
in various type such as ¼, 3/8, ½ and 5/8.
Types:
1. Round bodied.
2. Cutting.

19. PRINCIPLES OF SUTURING
 Needle should be grasped with help of needle holders at approximately 3/4th of its
distance from the tip of the needle.
 Needle should never be held at the suture end as it’s the weakest point of the needle
and grasping at this point results in either bending or breakage of the needle.
 Needle should pierce the tissue perpendicular to its surface.
 Curved needles should be passed through the tissues following the curvature of the
needle to prevent tearing of tissues.
 Suture should be placed equidistant (2 – 3 mm) from incision line.
 When one side of incision line is fixed and other end free, needle should be passed
from free to fixed end.
 When one side of tissue is thinner than other side, needle should be passed through
thinner to thicker side.

20.  When one side is deeper and other side superficial, needle should pass
through deeper to superficial side.
 Distance from the incision point to the needle penetration should be
less than the depth to which the needle penetrates into the tissues.
 Suture should not be tied so tightly that it results in blanching of
tissues.
 Each suture should be placed 3 – 4 mm apart.
 The knot should not be placed over the wound margins.

21. SUTURING METHODS
1. Simple Interrupted Suture:
• Most commonly used.
• Sutures are placed independently.
• Provides great strength.
Advantages:
• Selective adjustments of wound edges can be made.
• Failure of one stitch does nor prejudice the others.
Disadvantages:
• Can lead to suture marks after postoperative edema has occurred.
• Strength of thread reduced by upto 50% due to increased no. of knots.

22. 2. Simple Continuous Suture:
• Provides rapid secure closure with even distribution of tension along length of
wound preventing excess tightness.
• Provides more water tight closure as required by intraoral bone grafting.
• Should not be used in areas of already existing tension.
Indications:
• Well approximated wounds with minimal tension that have been initially created by
well placed buried sutures.
Advantages:
• Quick and has fewer knots.
Disadvantages:
• Not possible to free a few sutures at a time. Even when one breaks, entire closure is
affected.

23. 3. Locking Continuous:
• A degree of locking is provided by withdrawing the sutures through its
own loop.
• Tissues align themselves perpendicular to the incision.
• Prevents continuous tightening of suture as the wound closure
progresses.

24. 4. Mattress Suture:
• Commonly used in region of abdomen or hip.
• Useful in closing the wound of iliac and rib bone graft.
• Provides more tissue eversion.
• Two types: horizontal and vertical mattress.
i. Vertical Mattress Suture:
• Placed by first taking a large bite of the tissue from the wound edge and crossing
through the tissue to an equal distance on opposite side of the wound.
• Needle is then reversed and returned with a very small bite at the epidermal/dermal
edge in order to closely approximate wound edge.
Advantages:
• Decreases dead space and providing increased strength.
• Does not interfere with healing as suture runs parallel to blood supply.
Disadvantages:
• Fine wound edge approximation is difficult.

25. ii. Horizontal Mattress Suture:
• Used for intraoral bone grafting.
• Needle is passed from one edge of incision to other and again from
latter to the first edge.
• Procedure is continued till entire length of incision and a knot is then
tied.
Disadvantages:
• Blood supply to the flap edge maybe diminished and can cause
necrosis if not used properly.
Horizontal Mattress:

26. 5. Figure of Eight Suture:
• Used for closure of extraction sites.
• Provides good adaptation of the gingival papilla along the adjacent
teeth.

27. SUTURE REMOVAL
• Suture is grasped with an instrument and lifted above the epithelial
surface.
• Scissors are then passed through one loop and transected close to the
surface.
• Suture is then pulled out.
• Skin sutures are usually removed after a period of 7 – 10 days.
• Mucosal sutures are removed between 5 and 7 days.

28. REFERENCES
1. Textbook of Oral and Maxillofacial Surgery by Dr. Neelima Anil
Malik (3rd edition).
2. Textbook of Oral and Maxillofacial Surgery by Dr. S.M. Balaji
(2nd edition).
3. Textbook of Surgery for Dental Students by Dr. Sanjay Marwah
(1st edition).

29. THANK YOU!