Suturing - Materials and Techniques

What Is a Suture?

Closing the wounds with a needle and thread is age-old. At present we have established several techniques to perform this procedure. A suture is an artificial material or thread used to ligate or approximate the wound tissues until they heal. This provides support for tissue margin and reduces postoperative pain.

Why Do We Need a Suture?

An adequately placed suture is required for the following reasons,

• To approximate the wound edges.

• To provide an adequate tension of wound closure without dead space to enable adequate blood flow to the wound, which promotes healing.

• To ensure hemostasis (blood clot).

• To provide support for the tissues till they heal.

• To reduce postoperative pain.

• To prevent bone exposure.

• To prevent infection of the surgical site.

What Are the Requirements of Suture Material and How Do We Choose Them?

Suture materials are selected based on the physical and biological characteristics of the suture material, the healing properties of the tissue to be approximated, and the nature of the wound.

It should have the following requirements,

1. It should be sterile.

2. It should have enough tensile strength and hold the wound securely throughout the healing period.

3. It should be easy to handle and limit bacterial adhesion.

4. It should have a uniform diameter.

5. It should be biologically inactive.

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What Are the Types of Suture Materials?

Sutures are classified based on the following criteria:

1. According to absorbability- Absorbable or nonabsorbable.

2. According to the source- Natural or synthetic.

3. According to structure- Monofilament or multifilament.

4. According to tissue reaction- Reactive or non-reactive.

5. According to handling- Easy or difficult to handle.

Natural Absorbable Sutures- They are monofilaments of highly purified collagen. They have mild to moderate strength. Also, they have a mild inflammatory reaction and should be avoided in some instances with high acidic environments like Nervosa bulosa, etc.

They are available in two types-

• Plain Gut - They have a resorption rate of 3 days to 5 days.

• The Chromic Gut- It has a longer resorption rate of 7 days to 10 days.

Synthetic Absorbable Sutures- They are braided filaments of polyglycolic acid. They inhibit bacterial growth and resorb within 21 days to 28 days.

They are available in two types-

• Dexon Vicryl

• Vicryl.

Non Absorbable Sutures- They are resistant to resorption and are available as,

• Natural nonabsorbable sutures- for example, cotton and silk. They have poor strength but promote bacterial growth and severe inflammatory reactions.

• Synthetic nonabsorbable suture- for example- Nylon, polyester, etc. They can be braided or unbraided and monofilaments or multifilaments.

What Are the General Principles of Suturing?

• Do not suture very small pieces of tissues as the suture tears through the wound edges. It should be placed at least 2 mm - 3 mm from the wound edge.

• The sutures should always be inserted through the most mobile tissue flap first. If a tissue side is thinner than the other, the needle should pass from the delicate and thin tissue to the thicker one.

• When inserting, the needle should first enter the tissue at right angles.

• It is not advisable to pass through the facial and lingual papillae in one pass.

• Always use sharp needle points to avoid forcing through the tissues.

• Suture needles are grasped in the center and only by a needle holder.

• The needle is inserted and pulled through the tissue in line with the circle. The suture is secured tight enough without restricting the blood supply.

• The knot should not be placed over the incision line.

• Sutures should be placed 3 mm - 4 mm apart.

What Are the Different Techniques in Suturing?

• Simple loop modification of interrupted suture technique.

• Continuous non-interlocking suture technique.

• Continuous locking suture technique.

• Vertical mattress suture technique.

• Horizontal mattress suture technique.

• Continuous horizontal mattress suture technique.

• Modification of interrupted suture technique.

• Cross suture technique.

• Periosteal suturing technique.

• Coronally repositioned mattress suture technique.

• Vertical sling mattress suture technique.

• Single interrupted sling suture technique.

• Continuous independent sling suture technique.

• Independent sling suture technique.

• Sling suture around the single tooth.

Here are some of the most commonly used suturing techniques discussed in detail:

• Interrupted Simple Suture

This is the most commonly used suture inserted through one side of the wound and tied with a surgeon’s knot. These are used in areas of stress and are easy to clean.

• Simple Continuous or Running Suture

It is a simple interrupted suture placed continuously. It distributes the tension uniformly, but the suture, if cut open at one point, slackens along the whole length.

• Continuous Locking or Blanket Suture

It is similar to a continuous suture, but locking is provided by withdrawing the suture through its loop. It is used in long edentulous areas, tuberosity, or retromolar areas.

• Vertical Mattress Sutures

It is a variation of simple interrupted sutures used in wounds under tension. They provide excellent wound support and decrease the dead space.

• Horizontal Mattress Sutures

They are useful in wounds that require distributing the tension across larger wounds, but they strangle the blood supply and cause the death of tissues in the end.

• Periosteal Suturing Technique

This technique involves penetrating the periodontal tissues and periosteum to the bone. The aim is to regenerate the lost alveolar structure for prosthetic purposes.

• Sling Suture About Single Tooth

This procedure is used mainly for root coverage, gingiva esthetics, etc.

• Figure 8 Modification of Interrupted Suture

This technique is used for extraction socket closure and adapting the gingival papilla around the tooth.

Conclusion

Considering the requirements of modern surgery, there are many suturing techniques and methods that have been developed now. Proper knowledge about the suture, needle, instruments, and technique is necessary for a good surgeon. The difference in tissue reaction and bacterial adhesion should always be considered for selecting the suture material. Proper handling of the soft tissues and appropriate suturing techniques can achieve the desired effects of tissue healing.

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