ISSN: 2637-4595
Gokarnneshan N*, Anandhakrishnan PG, and Ganesh kumar V
Received:January 10, 2022 Published: January 19, 2022
*Corresponding author: Gokarnneshan N, Department of Fashion Design and Arts, Hindustan Institute of Technology and Science, India
DOI: 10.32474/LTTFD.2022.04.000191
A variety of suture materials are available for primary wound closure following oral surgical procedures. The tissue reactions to the various suture materials used in oral surgical interventions have been analyzed. Databases have been searched relating to cotton, nylon, polyglecaprone 25, polytetrafluoroethylene (ePTFE), Polyglactin 910, polyglycolic acid (PGA), polylactic acid, silk, surgery, suture, and tissue reaction. An interesting compilation has been done from various reliable sources. A number of investigations have been included. Few studies reported that polyglecaprone 25 had positive effects on wound-healing as compared to silk. More studies reported that silk elicits more intense tissue inflammatory response and delayed wound healing as compared to other suture materials (including ePTFE, polyglecaprone-25, PGA, and nylon). Polyglactin 910 sutures were associated with the development of stitch abscess in one clinical study. A number of studies reported that tissue reactions are minimal with nylon sutures. Tissue reactions to suture materials used for oral surgical interventions may vary depending on the surface properties and bacterial adherence properties of the material.
Keywords: Dental surgery; Sutures; Textile materials; Properties; Wound healing
Most oral surgical interventions require primary wound
closure using a previously raised flap. For this purpose, a variety of
suture materials are available which may be classified upon their
origin (organic and synthetic) or according to their durability in
host tissues (absorbable and nonabsorbable) [1,2]. The essential
features of suture material include
a) Knot safety,
b) Stretch capacity,
c) Tissue reactivity, and
d) Wound safety.
Besides the adopted surgical and suturing technique, the choice
of suture material may also influence the healing of the incised soft
tissues [1– 3]. In their study, Vastardis and Yukna [4] reported
three case reports of complications after the use of a subepithelial
connective tissue graft where an abscess occurred following the
initial healing phase. This study [4] concluded that a stitch abscess
or reaction to the suture material used for the submerged sutures
could be a possible cause of the abscesses. Thus, the selection of
the suture material should be brought under consideration during
treatment planning for oral surgical interventions. Tissue reaction
is reflected through an inflammatory response, which develops
during the first two to seven days after suturing the tissue [1–3].
Several studies published over the past four decades have reported
that synthetic materials exhibit a superior behavior to oral tissues
in terms of tissue inflammatory reactions compared to nonsynthetic
suture materials [3–19]. Suture materials that have been frequently
investigated in terms of tissue reactions include cotton, braided
silk, polyester, nylon, and cat gut; however, the study outcomes
remain debatable. Polyester sutures have been reported to cause
a mild inflammatory reaction whereas cotton threads have been
associated with an intense tissue inflammatory response [15–17].
Other commercially available suture materials include polyglycolic
acid (PGA) and polyglactin 910 (derived from copolymerization
of glycosides and lactides) and have been labeled as “desirable
suture materials” [1,15,20]; nevertheless, controversy persists
over the efficacy of suture materials. Sortino et al. [8] reported the
bacterial count over the braided silk and PGA sutures to be similar;
conversely, other studies have reported that silk sutures are more
susceptible to bacterial invasion and severe tissue inflammatory reactions compared to other suturing products [14–17]. However,
in terms of cost-effectiveness, silk continues to enjoy its status as an
“inexpensive” suture material as compared to other nonabsorbable
suture materials [2]. Since the choice of the suture material used in
oral surgical interventions may play a role in optimal postsurgical
wound healing, the present study aimed to review the tissue
reactions to the various suture materials used in oral surgical
interventions.
All the 17 studies [3–5,7–19] included in the present literature
review were either carried out at universities or at healthcare
centers. Six studies [4,8–10,12,15] were clinical and 11 studies
[3,5,7,11,13,14,16,19] had an experimental research design.
The experimental studies were performed on male Wistar rats,
Rhesus monkeys and Beagle dogs [3,5,7,11,13,14,16–19]. In all
clinical studies [4,8–10,12,15], the participants were systemically
healthy, whereas in one experimental study [7], efficacies of
various suture materials were investigated in diabetic male
Wistar rats. The investigated suture materials were catgut, cotton,
nylon, perlon, polyester, polyglecaprone 25, PGA, expanded
polytetrafluoroethylene (ePTFE), braided silk, and steel. In
eight studies [4,10,11,13–15,17], involving periodontal surgical
interventions, tissue reactions were compared between braided
silk and other suture materials including cotton, chromic, nylon,
and polyglactin 910. In four studies [3,5,18,19], oral surgical
procedures were performed on the buccal mucosae and tongues
of beagle dogs and the sutures materials under investigation
included silk, cotton, polyester, steel, and chromic. Two studies
[7,9] reported that polyglecaprone 25 had positive effects on
wound healing and exhibited lesser numbers of adherent bacteria
as compared to braided silk. Six studies [9–11,13,15,16] (five
clinical [9,10,13,15,16] and one experimental [11]) reported that
braided silk elicits more intense tissue inflammatory response
and delayed wound healing as compared to other suture materials
(including ePTFE, polyglecaprone 25, PGA, and nylon). In a study by
Vastardis and Yukna [4], three case reports were presented where
the occurrence of stitch abscess was associated with Polyglactin
910 sutures. In their experimental study, Yilmaz et al. [7] reported
that silk and chromic gut are well tolerated in diabetic rats whereas
Selvig et al. [14] reported bacterial invasion to be common in
these materials, particularly in braided silk sutures. Four studies
[3,16,17] associated cotton sutures with intense tissue reactions.
Eight studies [3,5,15–19] reported that nylon sutures provide
the best biological results. These studies [15–17], also reported
the least inflammatory response. Castelli et al. [17] compared the
tissue inflammatory responses induced by silk, cotton and nylon,
and the results showed that nylon sutures did not elicit any form of
inflammatory response in oral tissues compared to silk and cotton.
Several suture materials are available for dental and medical
surgical procedures; however, it is essential for surgeons to be
aware of the nature of the suture material, the biologic processes
of healing, and the interaction of the suture material with the
surrounding tissues. This is a critical issue because the surgeon
must ensure that a suture will retain its strength until the
tissues of the previously raised surgical flaps recover sufficient
strength to keep the wound edges together. To date, research data
regarding the efficacies of various materials remains debatable
and inconsistent. Thus, the present study attempted to review the
tissue reactions to different suture materials used in oral surgical
interventions. Traditionally, silk has been the mostly used suture
material for dental and several other surgical procedures [21].
Even though silk is inexpensive and easy to handle as compared to
other nonabsorbable suture materials [19,22]; the authors believe
that it should not be considered as a “material of choice” for oral
surgical interventions. Studies on oral tissue reactions to sutures
have revealed constant inflammatory reactions, which are most
prominent with silk and cotton and minimal with others including
nylon, polyester, ePTFE, polyglecaprone 25 and PGA [3,5,7–19].
A histological study [15] compared the oral tissue reactions to
various suture materials. The results showed the presence of a
large number of neutrophilic polymorphonuclear leukocytes in
the premises of silk sutures which were less intense in oral tissues
farther from silk sutures [15]. Another finding was that fibroblasts
and new capillaries formed at a slower pace in the oral tissues in
the vicinity of silk sutures compared to tissues farther from the
silk sutures. This may be a justification for the delayed healing and
severe tissue reactions associated with silk sutures.
Another factor that may instigate tissue reactions is the
capability of bacteria to adhere to various suture materials. In
their in vitro study, Katz et al. [23] investigated the capability
of bacteria to adhere to various types of sutures to cause tissue
reactions. The results showed that bacterial adherence to braided
silk sutures was five- to eight folds higher as compared to nylon
to which the least numbers of bacteria adhered [23]. In another
study [9], colonization on various intraoral suture materials from
patients microbial having undergone dentoalveolar surgery was
investigated. The results showed a larger numbers of bacteria on
silk as compared to polyglecaprone 25 [9]. In an experimental
study, Leknes et al. [10] investigated the inflammatory responses in
oral tissues sutured with silk and ePTFE by recording the presence
or absence of bacterial plaque along the suture track. The results
showed that bacterial plaque was present in 10 out of the 11 silk
and four out of the 11 ePTFE suture channels [10]. These studies
may act as possible explanations to the minimum tissue reactions
evoked in nylon and polyglecaprone 25 as compared to braided
silk sutures. Thus, the different rates of bacterial adherence to
various suture materials support the hypothesis that bacterial
adherence to sutures plays a significant role in the induction of
tissue reactions. Since sutures are immediately contaminated
as soon as they contact the oral cavity, it is recommended that
sutures should be opened just before being passed through the
gingival tissues in order to minimize complications such as stitch
abscesses [4]. It is well known that systemic conditions such as
poorly controlled diabetes mellitus and cardiovascular disease
are directly associated with oral inflammatory conditions [24–28]. Therefore, it may be hypothesized that the massive inflammatory
response induced by such confounding factors may “mask” the
tissue reactions provoked by the suture material. Data from the
clinical studies [8–10,12,15], included in the present review,
revealed that all participants were systemically healthy; therefore,
the influence confounding parameters (such as those mentioned
previously) may be overruled. In one experimental study [7], tissue
reactions to silk, catgut, and Poliglecaprone 25 were investigated
in diabetic rats. The results reported similar activities of silk and
catgut in the diabetic and control groups [7]. Could this similarity in
tissue reactions between the two suture materials be attributed to
diabetes control or to the properties of the suture material, remains
unclear. Other confounding parameters that may also contribute
to oral mucosal inflammation include smoking and use of tobacco
products. Nevertheless, due to the lack of data regarding tobacco
habits in these studies, the role of tobacco habits as a confounding
factor in suture-induced tissue reactions may be a topic to explore
for future clinical studies.
It is still evident that various suture materials used in oral surgical interventions present varying degrees of tissue reactions depending on several factors including surface properties and bacterial adherence properties. The present study emphasizes on the need for careful suture selection of suturing materials for oral surgical interventions.
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