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SUTURESSUTURESSUTURESSUTURES

Presented by Dr. Hashmat Gul,

Demonstrator, NUST,

Army Medical College.

Rawalpindi Cantt.

INTRODUCTION

� Successful wound closure is essential in any invasive

surgical procedure

� The most common approach is tissue approximation

with sutures

� Sutures can be defined as filamentous materials used

to approximated wound edges after surgery or trauma

or to hold tissues in place following surgical

transposition of soft tissues

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� In Dentistry Sutures Are Used In� Periodontology� Oral And Maxillofacial Surgery

� The selection criteria for sutures include:

� Required in vivo longevity

� Anatomic location

� Natures & characteristics of the tissue being sutured

CLASSIFICATION OF SUTURES

According to No. of

filaments

Mono-filament Multi-filament

Twisted Braided

According to Source

Natural Synthetic

According to

Nature

AbsorbableNon-

absorbable

See detail on pages 246-48

CLASSIFICATIONCLASSIFICATIONCLASSIFICATIONCLASSIFICATION

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MONOMONOMONOMONO----FILAMENT SUTURESFILAMENT SUTURESFILAMENT SUTURESFILAMENT SUTURES

MULTIMULTIMULTIMULTI----FILAMENT SUTURESFILAMENT SUTURESFILAMENT SUTURESFILAMENT SUTURES

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SUTURE MATERIALSSUTURE MATERIALSSUTURE MATERIALSSUTURE MATERIALS

� BIOLOGICAL MATERIALS

�Silk (Non-absorbable)

�Catgut Suture (Absorbable)

� Plain

� Chromic

� SYNTHETIC MATERIALS

� The Absorbable

� Polyglycolic Acid,

� Polylactic Acid,

� Monocryl

� Polydioxanone

� The Non- absorbable

� Nylon

� Polyester

� PVDF

� Polypropylene

� SS wire

� Sutures differ in

� Diameter� Physical Configuration &� Chemical Composition

� All these factors affect the properties and in vivo

behavior of sutures

� Sutures are coated to improve behavior and

handling properties

PROPERTIESPROPERTIESPROPERTIESPROPERTIES

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CODING SYSTEMS USED FOR SUTURESCODING SYSTEMS USED FOR SUTURESCODING SYSTEMS USED FOR SUTURESCODING SYSTEMS USED FOR SUTURES� Two coding systems used to categorize sutures

according to their diameter

� US Pharmacopeia (USP)

� European Pharmacopeia (EP)

BIOCOMPATIBILITY & BIOCOMPATIBILITY & BIOCOMPATIBILITY & BIOCOMPATIBILITY & BIODEGRADATIONBIODEGRADATIONBIODEGRADATIONBIODEGRADATION

� Micrograph of a H&E stained tissue section

showing a non-absorbable multi-filament

surgical suture with a surrounding foreign-

body giant cell reaction

� Sutures are foreign body so they can affect the

surrounding tissues and the surrounding tissues

affect the properties of sutures

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� The Type And Extent Of Tissue Reactions

to a suture are determined by the

� Chemical Formulations

� The Physical Form Of The Suture,

� The Degradation Products

� Sutures fabricated from natural material

provoke more intense tissue reactions than

synthetic ones because of the availability of

enzymes that can react with them

� Sutures with smaller diameter are preferred,

provided they adequately support the healing

wound and add no risk of cutting through wound

tissue

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�Sutures with poor pliability when knotted

may leave stiff ears projecting from the knot,

which can mechanically irritate the surrounding

tissues

�The problem is less common in braided

multifilament sutures

� The Biocompatibility Of A Suture can be

evaluated by

� Cellular Response,

� Enzyme Histochemistry Or

� Both

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�Cellular Response� Most commonly used

� Provides information about the density and type of

inflammatory cells at the suture site

� Histological evaluation of sectioned tissue is

needed to rate the cellular response, which requires

skilled and experienced evaluator

� Enzyme Histochemistry� Evaluating suture biocompatibility through

enzyme histochemistry is a reproducible,

consistent and quantifiable approach

� It is more time consuming and requires more

sophisticated facilities

� However, it is useful for studying the

biodegradation of absorbable sutures

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� The normal tissue reaction to sutures proceeds

through 3 stages, which are differentiated according

to the appearance & activity of various inflammatory

cellsSTAGE TIME (DAYS) REACTION

Phase 1 0-4 Acute response: infiltration of

polymorphonuclear leukocytes,

lymphocytes and monocytes

Phase 2 4-7 Macrophagic and fibroblastic acivity

Phase 3 7-10 Chronic inflammation and start of

fibrous connective tissue maturation

� Generally, there are virtually no differences in the

tissue and cellular responses to synthetic absorbable

and nonabsorbable sutures over the first 7 days after

implantation

Synthetic Absorbable Sutures Synthetic Non-absorbable

Sutures

�May elicit a slightly greater

inflammatory reaction that

persist until the suture is

completely absorbed and

metabolized

�Elicit minimal chronic

inflammation reactions and by

28 days they are often

surrounded by a thin, fibrous

connective tissue

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ABSORBABLE SUTURES

�Do not elicit long term inflammatory reactions.

�Progressively lose both strength and mass, with the rate of strength

loss always exceeding rate of mass loss.

�Consequently, as the wound healing progress, the suture may no

longer maintain wound closure but a significant amount of material

may remain in the wound area.

�This is more important for treating infected or contaminated

wounds.

�The degradation rate depend on suture type, tissue involved,

temperature, pH, applied stress & microorganisms within the

wound area.

�The accumulation rate and metabolization of the degradation

product in the surrounding tissue is important.

�Degradation products are rapidly metabolized in well vascularized

tissues

Multi-filament Suture Mono-filament Suture

� A consequence of the normal tissue

reaction is the

� Ingrowth of fibrous tissue into

multifilament sutures,

� Ingrowth of epidermis with

sutures that pass through the

cutaneous surface.

� Such tissue ingrowth may hamper

easy removal of sutures from the

healing wound.

� Where multifilament exhibit

capillaries, microorganisms may

migrate throughout the wound area

� Monofilament sutures are preferred

for closing contaminated wounds,

as multifilament sutures elicit more

tissue reaction due to penetration of

inflammatory cells into the

interstitial spaces within the suture,

which can adversely affect the

healing of infected wounds

THANK YOU