A Clinical Study On The Influence Of Suture Materials In Oral Wound Healing

Keywords

Extraction; Oral Surgery; Postoperative Analysis; Sutures; Wound Healing.

Introduction

Suture materials play an very important role in healing wounds, which helps in reconstruction and reassembly of tissue separated by a surgical procedure or trauma [1] and at the same time provides hemostasis and wound healing [4]. This location differs from other body sites due to the presence of saliva, high vascularization, specific microbiota as well as its functions related to speech, mastication and swallowing [38]. Suturing is conventional method for approximating wound margins and also suturing may cause permanent suture scars, wound dehiscence, needle prick injuries, foreign body reactions, granulations, ischemia, tissue tearing and various types of infection [35]. Various alternative materials have been used for wound healing since ancient times, ranging from human hair to silk sutures. Although the modern suture materials and techniques are very advanced, intended wound closure still may not be achieved [14] .Therefore, there is a need for alternative closure options. The suture can also be known as a strand of material utilized to ligate blood vessels and also approximate tissues [13]. A good understanding of the physiologic process of wound healing is needed to select the suture material which consequently decrease further complications [29]. Suturing is time consuming and requires proper adequate skill [9]. Resorbable sutures must be removed as soon as healing is done because they can act as niders with food lodgements and cause infection to the patient [37]. Besides these, suturing also requires an additional visit for suture removal.

First suture materials were used in ancient Egypt, but significant development occurred in the 1960s and 1970s. First suture materials made up of a polyvinyl alcohol [7, 31]. Suture materials are widely used in most of the oral surgeries and are considered to be one of the biocompatible substances commonly implanted in our human body. Suture materials are classified based on origin, structure and biological properties. suture materials can be natural or synthetic, monofilament or multifilament, absorbable or nonabsorbable [28]. The main classification is based on biological properties [33] - Natural Absorbable Suture material are Catgut, Collagen, Kangaroo Tendon, Synthetic Absorbable suture material are Dexon, Polyglycolic Acid, Vicryl, Polyglactin. Natural Nonabsorbable Suture Materials are Silk and Cotton, Synthetic Nonabsorbable Suture Materials are Nylon Polypropylene, Polyesters, Polybutester (Novafil). Four basic features of suture materials are knot safety, tissue reactivity, stretch capacity and wound safety. The knot safety shows the capacity of suture materials to retain strength and firmness [36]. Knot safety is reversely proportional to the suture materials, thickness and directly proportional to its quality and functional output [22]. Stretch capacity of suture material is a stretch power capacity per unit area. The wound safety is directly related to the suture capacity that is required for safe healing of the wound [35]. Suture materials in oral and maxillofacial surgery [6] behave differently from those used for other parts of the body due to difference in tissue qualityc [23, 24], presence of saliva, high level of vascularisation and continuous functions like speech, chewing and swallowing [33]. Oral surgery interventions are finished customarily by a surgical suturing of the wound [32]. The choice of suture materials to be used depends on the site and depth of the tissue to stitch [10]. In this type of intervention includes suturing overlying tissue, non absorbable materials are routinely used, which are removed after 5-7 days post operatively. Ideal suture materials not only depend on the biological compatibility and good clinical behavior it also needs features like resistance to traction, dimensional stability, low memory effect, good knot security and good flexibility [5]. The diversity of suture material [38] used in different surgical branches which led to their proper and rationale classification. The silk suture material showed less incidence of alveolar osteitis [20] than other reported studies and also reduced pain [16, 2], inflammation, infection [15] involved in better wound healing [12] . Paracetamol (500mg) [27] and ketorolac(10mg)(19)are the drugs given after dental extractions to reduce pain and infections [17].

There is a lack of information on behaviour of these materials in the oral cavity [26]. Oral environment is characterised by presence of saliva [8], pH [3], saprophytic bacteria [21]. In spite of modern technologies applied in the production of suturing materials, an ideal suture material is not yet found [18]. Though the lack of an ideal stitch is evident [25], surgical sutures must satisfy some basic criteria for suture material. The aim of the present study is to evaluate the influence of suturing materials in oral wound healing.

Materials and Methods

This Retrospective study was done in Saveetha Dental College and Hospitals, Chennai, India. We reviewed patient records and analysed the data of 86000 patients between June 2019 and March 2020. Records of the total number of patients who underwent extraction followed by a suturing of the wound were collected and studied. There were both male patients as well as female patients. Approval of the ethical committee was done before starting the study. Ethical approval was obtained from the institutional ethical committee (ethical approval number: SDC/SIHEC/2020/DIASDATA/ 0619-0320). A total of 785 case sheets were reviewed. These data were cross verified with photographs. Study sampling bias can be minimised by inclusion of all available data. Both Internal and external validity is available. The parameters like age, gender, types of suture materials were analysed, postoperative analysis and surgical site healing records were collected and tabulated. Data was analysed using SPSS statistical software. Descriptive statistics and bi-variant data using chi-square test is done as appropriate. P value was set as 0.05 as a level of significance.

Results and Discussion

A Total of 785 case sheets of extractions were reviewed. From the statistical analysis suture material used in oral wounding is most common with male 57.5% than females 42.5%. The proportion of male is greater than the female. The most commonly seen age group is between 21-35 years (69%) Silk is the most commonly used suture material for oral wound healing (88.9%)compared to polyglactin (10.2%). Number of silk sutures used is one (69.4%), two (13.9%). Most of the patients were reviewed (57.7%) after suturing is done. Patients were reviewedafter 1-2 weeks. Frequency of surgical site healing is mostly satisfactory (58.5%). Association results values and gender results showed suture materials in oral wound healing have a higher male predilection in its occurrence 57.5% in males and 42.5% in females [Figure 1]. In Frequency distribution of the age group of the patients, the most common age group involved is between 21-35 years(69%) other age groups were 12-20 years (12.4%), 36-45 years(13.3%), 46-55 years (3.3%), 55-75 years(1.78%)[Figure 2]. In frequency distribution in type of suture material used for closure of oral wound healing, results obtained are silk-(88.9%), polyglactin-(10.2%)and others-(0.8%) [Figure 3]. In frequency distribution of patient reviewed or not reviewed, results obtained are patient not reviewed-(42.2%) and patient reviewed-(57.7%)[Figure 4]. In frequency distribution of surgical site healing, results obtained are satisfactory healing-( 58.5%) and not satisfactory healing-(41.3%)[Figure 5]. The choice of the type and size of suture materials depends upon the site and condition of tissue to be sutured. Suture material is a foreign substance implanted into a tissue provoking tissue reaction. In this present study suture material in oral wound healing has a higher male predilection in its occurrence 57.5% in males and 42.5% in females. The findings coincide with a study provided by Dejanpelemis et al in 2015 [7], he stated that among 96 cases 56.2% in male and 43.75% in females. Prevalence of age group, most common is above 30 years(86.2%). Sorting F et al in 2008 [31] stated-majority of the age group seen with an oral wound healing and suture is 9% to 75%. The possible explanation of this study is the effect of increasing age, loss of alveolar bone, loss of attachment and malnutrition. From the analysis of suture material, silk(84.2%) is most commonly used, this contradicts the finding of storch M and scalzo in 2002, [34], they stated vicryl and polyglactin are most commonly used. The possible explanationour study results differ with other articles quoted because of different patient ethnicity and study setting, whereas our study is an institutional study where treatments are done for lower socioeconomic populations.

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The results of the study shows most of the patients were reviewed with satisfactory wound healing. This result coincided with the study stated by a Monsour AL et al in 2012 [11], he stated patients have a satisfactory healing with a mild inflammatory reaction and for inflammatory reaction proper medications are given [30]. Reason for limitation of the study is due to the small sample size and area of the study. Future scope of this study is suture material in oral wound healing helps in finding the age, sex, type of suture material used, number of suture materials, post operative analysis and to identify the healing. By knowing all these parameters we can reduce the risk complications and delayed wound healing.

Conclusion

The results of our study showed that silk is a most common suture material used in study. Silk rapide contributes more than polyglactin to faster healing of oral wounds with fewer inflammatory reactions. Silk is most commonly used because of people's ethnicity and study setting, and moreover economical whereas our study is an institutional study where treatments are done for a lower socioeconomic population that is too free of cost. So from our study we can conclude that silk suture can be safely used in most oral surgical procedures particularly in lower socioeconomic populations because it has better tissue compatibility and is cost effective.