Simple interrupted and continuous interlocking suturing techniquescomparision inmaxillofacial trauma–a Randomised Controlled Trial.

Introduction

Suturing is a fine skill in the field of surgery to keep the dermal/mucosal edges to come into contact and heal together to attain a scar less or relatively fine line scar.¹ Suturing in oral cavity is seen to be technically challenging due to its anatomical nature of confined space and obstacles such as teeth, tongue, buccal musculature, saliva, etc. and maintaining of the suture postoperatively plays a major role.² There are various suturing techniques (simple interrupted, continuous, mattress, subcutaneous, buried, etc) and suturing materials (absorbable and non- absorbable) preferred based on its location, ease of suturing, properties of suture material, andpatientcomfort.¹ Colonization of pathogens are more in multifilament/ braided suture.³ Simple interrupted and continuous interlocking are commonly used and simple method of suturing and Vicryl (Polyglactin) is preferred absorbable intraoral suture material.⁴ This study compares intraoral simple interrupted and continuous interlocking suturing techniques using vicryl sutures both intra-operatively and postoperatively in maxillofacial trauma patients.

Materials and Methods

The study sample includes 20 patients (16 males and 4 females) reporting to the Department of Oral and Maxillofacial Surgery, K.V.G. Dental College and Hospital, Sullia, with maxillofacial trauma requiring ORIF (Open Reduction and Internal Fixation) of maxilla or mandible fractures between December 2016 to May 2017 were included in the study.

They were randomly divided into two groups (Group A and Group B). Inclusion criteria for the study were patients with age groups between 20-50 years requiring ORIF under local anesthesia or general anesthesia through an intraoral approach and incision measuring 5cm. Patients requiring extra-oral incisions, comminuted fractures with acute illness, infection, pregnancy, immune compromised conditions and not willing to participate in the study were excluded from the study.

Patients underwent pre-operative radiographic and hematological investigations prior to surgical intervention under local or general anesthesia. Patients planned under general anesthesia were operated after attaining satisfactory fitness department of general medicine and anesthesiology. Patients were surgically treated with ORIF through intraoral approach with standardized aseptic precautions. Surgical site was closed in single layer using 3-0 Vicryl sutures (Figure 1) with surgeonsknots (4 throws). Intraoperatively time taken for suturing noted.Wound dehiscenceand wound healing were monitored on post-operative day 3, 7 and 30 and results were compared using ANOVA test. Group A: Closure with simple interrupted suturing(Figure 2). Group B: Closure with continuous interlocking suturing (Figure 3).

Results

A total of 20 patients (16 males and 4 females) reported to the Department of Oral and Maxillofacial Surgery, K.V.G. Dental College and Hospital, Sullia, with maxillofacial trauma requiring ORIF (Open Reduction and Internal Fixation) of maxilla or mandible fractures were included in the study.

They were randomly divided into two groups (Group A and Group B) and they were compared for time taken for suturing (Intraoperatively), wound dehiscence and wound healing (Post operatively) using ANOVA test. The results of mean time taken (in minutes) for intraoperative suturing was 22.2± 4.13 and 17.1± 6.02 from the beginning of the first bite of tissue till the end of the suturing for group A and group B respectively with p value of 0.04 [Table 1].

Group B (Continuous Interlocking) showed less time than that of Group A (Simple Interrupted). Wound dehiscence [Table 2] that present in 9/10, 3/10 and 2/10 patients on 3rd, 7th and 30thpost-operative day respectively in group A patients.In group B, debris present only on 3rd post-operative day and absent in subsequent follow ups. It reveals gradual reduction of dehiscence when day passes in both the groups.

Wound healing were assessed and compared [Table 3]. On 3rd post-operative day, healing index 2(1 patient), 3(7 patients) and 4(2 patients) in group A and healing index 3(9 patients) and 4(1 patient) in group B was seen with p value of 0.453. On 7th post-operative day, healing index 3(7 patients) and 4(3 patients) in group A and healing index 3(3 patients) and 4(7 patient) in group B was seen with p value of 0.18. On 30th post-operative day, healing index 3(1 patient) and 4(9 patients) in group A and healing index 4(9 patients) and 5(1 patient) in group B was seen with p value of 0.368.

Overall comparison of two groups, continuous interlocking sutures shows superior results than that of simple interrupted sutures in all aspects such as time taken for suturing, wound dehiscence and wound healing.

Discussion

The maxillofacial region is most prone to trauma owing to its prominent position. The spectrum of etiologies of maxillofacial trauma are diverse. Factors such as geography, seasons, means of livelihood, psychological make-up and living standards of individuals influence its pattern and incidence. Facial fractures can have long term residual effects on the hard and soft tissues both functionally and esthetically, regardless of nature and accuracy of treatment.⁵

Maxillofacial fractures often require ORIF via intraoral approach. The optimum closure of these soft tissue wounds can pose a challenge to the most skilled surgeons. Most surgical interventions require primary wound closure. Soft tissue healing depends on good surgical technique and soft tissue management. Gentle flap manipulation, ideal incision placement and appropriate suture techniques are required for optimal healing. Proper technique and material for suturing will promote wound healing through close approximation of the flap edges, minimized dead space, reduced postoperative bleeding, reduce tension on the flap margins and prevention of infection.

There are various methods to close the wound which includes sutures, staples, adhesive tapes and fibrin glue. For this purpose, a variety of suture materials are available based on the surgeon’s requirements and various other characteristics.

Various suturing techniques such as simple interrupted, continuous (simple and interlocking), mattress, subcutaneous, barbed sutures6 , knotless sutures⁷ and many are available. In these techniques, simple interrupted and continuous interlocking are commonly used techniques.⁸

Simple interrupted suturing may have poor knot security due to multiple number of sutures which may causeloosening of sutures, food debris accumulation, wound exposure, and infections. Irregular tightening of suture may lead to irregular fibrosis. It has many advantages like simple technique, easy replacement of wrong sutures and removal of intermittent sutures for drainage of exudates. Continuous interlocking sutures may take less time for suturing, good approximation of incision edges, less food debris accumulation and easy removal of sutures. Less number of knots employed in this technique which enables operator to avoid tying knots in difficult area of access and also reduces operating time.⁸ It has disadvantages like loosening of the sutures, need of assistance for the beginners and difficulty in revision which require replacement of whole sutures.

Suture materials used for suturing should not impede healing or elicit an inflammatory response or toxic effect. Polyglactin 910 was labeled as “desirable suture materials” in the field of oral and maxillofacial region.⁹

On the other hand, studies have reported that non- absorbable silk sutures are more susceptible to bacterial invasion and severe tissue inflammatory reactions compared to other suturing products. Use of absorbable suture material Vicryl (Polyglactin) reduces patient discomfort and prevents unnecessary suture removal.It also has good knot security than silk where the knot security depends on suture material, tying technique and number of throws.¹⁰

Conclusion

Suturing is a skill which needs expertise in oral cavity which is seen to be technically challenging due to its anatomically confined space and obstacles such as teeth, tongue, buccal musculature, saliva, etc. and maintaining of the suture post-operatively. Commonly used simple interrupted and continuous interlocking sutures using Vicryl (Polyglactin) 3-0 sutures were compared in this study. Both the techniques have its own advantages and disadvantages. Even though simple interrupted is easy technique, continuous interrupted suturing technique showed superior results. Surgeons who operated have their own point of view and technique selection depends on their individual preferences.