sutures and suture materials in oral surgery€¦ · puncture wound (vulnus punctum) incised wound...
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Sutures and Suture Materials
in Oral Surgery
DR. KINGA BÉRCZY
2016
Semmelweis University
Faculty of Dentistry
Department of Oro-Maxillofacial Surgery and Stomatology
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Wound healing
PRIMARY (PER PRIMAM INTENTIONEM, PER PRIMAM, PP)
Galenus: the main task of the doctor: gapless wound
closeur and linear scar healing
In primary wound healing there is no tissue loss. Incised wound is held together by a blood clot and
possibly by sutures. An inflammatory process begins in adjacent tissue at the moment of injury. After
several days, granulation tissue forms as a result of migration of fibroblasts to the area of injury and
formation of new capillaries. Epithelial cells at wound margin migrate to clot and seal the wound.
Regenerating epithelium covers the wound. Scarring occurs as a granulation tissue matures and
injured tisssue is replaced with connective tissue
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Wound healing
SECONDARY (PER SECUNDAM INTENTIONEM, PER SEC)
Healing by second intention occurs when there is tissue loss, as in extensive burns and deep
ulcers. The healing process is more prolonged than in healing by primary intention because
large amounts of dead tissue must be removed with viable cells. Open area is more extensive,
inflammatory reaction is more widespread and tends to become chronic. Healing may occur
under a scab formed of dried exudate, or dried plasma proteins and dead cells. Fibroblasts
and capillary buds migrate toward center of would to form granulation tissue, which becomes
a translucent red color as capillary network develops. Granulation tissue is fragile and bleeds
easily. As granulation tissue matures, marginal epithelial cell migrate and proliferate over
connective tissue base to form a scar. Contraction of skin around scar is the result of
movement of epithelial cells toward center of wound in an attempt to close the defect.
Surrounding skin moves toward center of wound in an effort to close the defect.
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Wounds of various origins
Puncture wound (vulnus punctum)
Incised wound (vulnus scissum)
Cut wound (vulnus caesum)
Contuse wound (vulnus contusum)
Lacerated wound (vulnus lacerum)
Gunshot wound (vulnus sclopetarium)
Bite wound (vulnus morsum)
Burn wound (chemical, fire)
Radiation wound
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Methods of uniting wound edges
Surface adhesives (eg. Steri Strip)
Tissue adhesives (eg. human fibrin
adhesives)
Clamps
Sutures
The basic condition for wound healing to be accurate and free of tension
suturing, not to create blind spots and ensure optimal blood flow to the
wound.
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Necessary for suturing
Suture material
Needle
Needle holder
(Tweezers)
(Surgical scissors)
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Selection of suture materials
Adequate tensile strenght
Should hold tissue together safety
Should be no stronger than sutured tissue
Secured knots to prevent loosening of suture material which can be affected by:
Type of suture material
Length of the cut end
Should be easy to handle
Minimal tissue reaction
Condition of sutured tissue (dirty, contaminated or infected wound)
The choice of suture materials should be based on the physical and
biological characteristics of the suture material and the healing
properties of the sutured tissue
Factors influencing selection includes:
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Characteristics of the ideal suture material
Optimal characteristics of application (flexibility, slides well in tissues, easy to tie a knot, knot safety)
Minimal tissue trauma
High tear strength, should hold edges together until healing
Minimal tissue reaction
Complete resorption or removable
Other important characteristics: thickness, elasticity, capillarity, structure, sterilization
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Classification of suture materials
Types of suture material according to origin:
natural
synthetic
Types of suture material according to resorption:
non-absorbable suture materials
absorbable suture materials
Types of suture material according to their structure/filament:
monofilament
multifilament
pseudomonofilament
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Structure of suture materials
monofilament: made of a single elementary fiber
multifilament: made of a number of elementary filaments, twisted or braided
pseudomonofilament: multifilament thread coated with some kind of material (eg. serous membrane, silicone, etilene-propilene, etc.)
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Comparison of the monofilament and
multifilament thread
Monofilament thread Multifilament thread
Advantages Smooth surface
Strong
Low friction
Lower resistance
Less tissue trauma
No bacterial culture
No capillarity
No tumor cell transport
Stronger
Softness and flexibility
Ease of use
Knot safty
Disadvantages Not very elastic
Difficult handling and
knotting
Rough surface
Bacterial culture
Capillarity
Tumor cell transport
Elongation
Tissue trauma
Tissue damage (kerf,
sawing)
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Comparison of natural and synthetic
suture material
Natural Synthetic
Advantages Easy to use
Easy to knot
Economic
Similar to the natural materials
Absorption: hydrolisis
Calcuable absorption
Strength
Disadvantages Absorption: enzymatic
Tissue reaction
Unpredictable absorption
The monofilaments difficult to
handle
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Comparison of non-absorbable and
absorbable suture materials
Absorbable Non-absorbable
Advantages It’s degraded in the human
body
Not perceived as foreian
matter
No foreign body reaction
It keeps closure of the
wound for unlimited time
periode
Disadvantages
Closure of the wound is for
a limited time period
Foreign matter
Foreign body reaction
Rejection of the suture
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Natural absorbable suture material
catgut: Animal intestine (cattle, sheep, goat, sometimes horse, donkey, mule, pig, but not cat!) purified, clean collagen fibres.
Used by al-Zahrawi in the 10th century, also for instrument strings, bow strings, suturing.
Resorption: proteolysis in 30-40 days, but reduced tensile strength after 7 days
chromic catgut: Reduced tensile strength only after 18-21 days.
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Synthetic, absorbable materials
Polyglycolic acid (eg. Dexon)
Keeps tensile strength (TS) for 1 week, after 3 weeks only 20%
Polyglactin (eg. Vicryl)
TS: 14 days, 50-70 days degradation
Polydioxane (PDS)
TS: 6 weeks, 90 days to 6 months degradation
Polyglyconate (eg. Maxon)
After 4 weeks 50% TS
Resorption: mainly hydrolysis
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Natural, non-absorbable materials
Silk – naturally strong multifilament or
pseudomonofilament
Steel
Linen
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Synthetic, non-resorbable materials
Polyamide (eg. Supramid) – 6-0, 7-0 monofilament,
thickers are multifilament, pseudomonofilament
Polyester (eg. Dacron) – easy to handle, to make knots,
holds the knot well, inflammatory reactions may occur
Polypropylene (eg. Prolene) – strong, slides well, minimal
tissue reaction, expensive, more difficult to handle,
stubby suture ends
Teflon (Gore-Tex)
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Size of suture materials USP (United
States
Pharmacopeia)
Diameter (mm)
6 0.8
5 0.7
4 0.6
3 0.6
2 0.5
1 0.4
0 0.35
2-0 0.3
3-0 0.2
4-0 0.15
5-0 0.1
6-0 0.07
7-0 0.05
8-0 0.04
9-0 0.03
10-0 0.02
11-0 0.01
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Needles
The ideal needles:
Should be elastic
Should strain resistant
Should not bend easily
Should not break
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Needle shapes
May have various shapes
3/8ths of a circle (B-needle)
1/2 of a circle (G-needle)
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Cross section of the needle
Round
Triangular (cutting needle)
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End of a traditional needle
Atraumatic suture material
Traditional and atraumatic needles
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Suture material / needle
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Needle holder
Hegar-Mayo
Mathieu
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Special needle holders
Palatinal needle holder
Micro needle holder
Needle holders without a lock
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Principles of suturing
Use suture needle of suitable shape and size
Use suture material that is of suitable type and size for the
tissue being sutured
Good bite (2-3 mm from the free edge of the soft tissue)
Sutures should NOT be placed under tension
Knots should be tied 2-3 mm away from the incision line
Suture material is cut 4-5 mm away from the knot
Superficial sutures should be removed 5-7 days after (exception: sinus closure) surgery to prevent infection / foreign body reaction
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Advantages of suturing (closure)
Promotes healing
Prevents complications
INFECTION
HAEMORRHAGE
TISSUE NECROSIS
Preserve the normal contur and shape of tissues
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Grasping the needle
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HOW TO MAKE A KNOT?
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Suture techniques 1.
Single interrupted suture
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Suture techniques 2.
Figure 8 suture (Z-stitch, crossed matrass suture)
1
2 3
4
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Suture techniques 3.
Horizontal matrass suture
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Suture techniques 4.
Vertical matrass stitch (Donáti)
1 2
3 4
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Suture techniques 5.
Continuous sutures
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Suture techniques 5.
Continuous interlocking sutures
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Thank you for attention!