With the advent of technology, the number of suture material options in surgeries has increased rapidly [
The fixing strength of a suture is basically due to its ability to approximate soft tissues, and this depends on the mechanical properties of the technique and the suture material used. The tensile properties, tensile strength, elasticity, and biocompatibility of the suture material are some of the factors that determine the performance of the suture during clinical use [
Suturing is performed for various purposes in the surgical field, such as the primary closure of tissues that were separated during a surgical implant procedure or accidental trauma, and it promotes healing and manages bleeding [
Scientific evidence indicates that the resistance and adhesion of the sutured tissue increases with time, and a significant increase in flap resistance is achieved between 1 week and 2 weeks after surgery. Therefore, a deficiency in the resistance of the suture material can cause premature rupture of the suture, which leads to poor adaptation of the surgical flaps and the induction of tissue healing by second intention [
Thus, this study compared the tensile strength of one absorbable and two nonabsorbable suture materials, namely, PG: polyglactin, BS: black silk, and PTFE: polytetrafluoroethylene (Teflon), according to different immersion times in artificial saliva.
In the present
Three suture materials were used: Teflon monofilament (PTFE) (Omnia®; Fidenza; Parma, Italy) nonabsorbable suture, nonabsorbable multifilament black braided silk sutures (Unilene Peruvian Surgery; Napo 450; Lima, Peru), and polyglactin 910 multifilament absorbable sutures (Vicryl®; Ethicon, Brazil); all specimens were USP 4-0 caliber.
The Salival® product is a colorless, viscous substance composed of Na+, K+, and CL+ at a percentage ratio in relation to the purified aqueous volume. It has a pH and viscosity similar to natural saliva (Table
Sodium chloride | 0.084 g |
Potassium chloride | 0.120 g |
Calcium chloride dehydrate | 0.015 g |
Magnesium chloride hexahydrate | 0.005 g |
Sodium carboxymethylcellulose | 0.375 g |
Propylene glycol | 4.000 g |
Methyl paraben | 0.100 g |
Own paraben | 0.010 g |
Distilled water csp | 100.000 ml |
An
Each sample was prepared with a knot around two metal poles installed in the universal testing machine with a fixed distance of 15.0 mm between the two poles. The tensile strengths of the suture samples were tested at specific times: preimmersion (baseline) and postimmersion at 3, 7, 14, and 21 days. The evaluation of the tensile strength of the suture samples was performed using a Material Testing Machine (BT1-FR0.5TS.D14; Zwick GmbH & Co.KG; August-Nagel-Strabe 1189079; Ulm Germany; manufactured in 2014) at a speed of 25 cm/min. Each sample was stretched until the material failed, and the maximum load was recorded in Newtons (N) (Figure
Material testing machine BT1-FR0.5TS.D14 (Zwick GmbH & Co.KG), with which the tensile measurements of all suture materials evaluated were performed.
The statistical analysis was performed with the Stata 12.0 software. First, the univariate analysis was carried out by measuring the central tendency (arithmetic mean) and the measure of dispersion (standard deviation) of the variable tensile strength of the suture materials (PG, BS, and PTFE). The statistical assumptions of normality and homoscedasticity were then explored using the Shapiro–Wilk test and the Bartlett test. Finally, the bivariate analysis was performed using the two-way analysis of variance (ANOVA) and Kruskal–Wallis tests depending on the values obtained in the previous analysis. Finally, statistical significance was established with
When analyzing the descriptive statistics, it was found that in relation to the polyglactin (PG) group, the average tensile strength was stable for the various immersion times (baseline and days 3, 7, 14, and 21). The highest mean (28.14 ± 0.89 N) was found on the day (day 21). Therefore, when making the inference with the Kruskal–Wallis test, it was concluded that there were no statistically significant differences in tensile strength of the PG suture with respect to the different immersion times (
Tensile strength of various absorbable and nonabsorbable sutures according to immersion time in synthetic saliva.
Suture material | Immersion time | Mean ± SD | Min | Max |
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PG | Baseline | 26.67 ± 3.11 | 20.02 | 30.69 | 0.180 | 0.522 |
Day 3 | 27.55 ± 1.67 | 25.13 | 30.20 | 0.546 | ||
Day 7 | 27.01 ± 1.59 | 22.78 | 29.76 | 0.341 | ||
Day 14 | 27.49 ± 2.02 | 6.77 | 7.92 | 0.271 | ||
Day 21 | 28.14 ± 0.89 | 6.73 | 7.49 | 0.252 | ||
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BS | Baseline | 14.58 ± 1.64 | 10.12 | 15.72 | 0.001 | 0.001 |
Day 3 | 12.81 ± 2.25 | 7.75 | 15.87 | 0.329 | ||
Day 7 | 9.91 ± 9.90 | 8.54 | 11.87 | 0.270 | ||
Day 14 | 12.87 ± 0.78 | 12.28 | 14.91 | 0.001 | ||
Day 21 | 12.54 ± 0.95 | 11.48 | 14.57 | 0.110 | ||
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PTFE | Baseline | 7.52 ± 0.94 | 4.88 | 8.22 | 0.001 | 0.094 |
Day 3 | 7.59 ± 0.27 | 7.23 | 8.10 | 0.582 | ||
Day 7 | 7.84 ± 0.26 | 7.34 | 8.21 | 0.661 | ||
Day 14 | 7.48 ± 0.29 | 6.77 | 7.92 | 0.100 | ||
Day 21 | 7.21 ± 0.23 | 6.75 | 7.49 | 0.433 |
The tensile strength values are means ± standard deviations expressed in Newtons. PG: polyglactin; BS: black silk; PTFE: polytetrafluoroethylene (Teflon).
Tensile strength of various absorbable and nonabsorbable sutures according to immersion time in synthetic saliva. The tensile strength values are means expressed in Newtons. PG: polyglactin, BS: black silk, PTFE: polytetrafluoroethylene (Teflon).
This phenomenon is not reflected in the black silk (BS) group, which showed heterogeneity in tensile strength. For example, the highest resistance was found at baseline 14.58 ± 1.64 N, and this progressively decreased in direct proportion to the time of immersion in artificial saliva. When performing, the inference was found that in this group, there were statistically significant differences between tensile strength and immersion time (
Table
The success of oral rehabilitation with implants depends on the osseointegration of the implant and the maintenance of the integrity of the perimplant soft tissues. When dental implants are placed, the surgical flap may change in position. The flap should be sutured to maintain its position and immobility. Therefore, soft tissue fixation techniques are important variables to consider in procedures [
The pH of the medium is another important factor in the resorption of suture materials. Therefore, average pH was monitored every day and maintained between 7.4 and 8.1. The solution was replenished every 2 days when a variation in pH was observed, as a decrease in pH leads to resorption of the material. The duration of this study and the selection of test points were based on clinical relevance; the study was conducted for 3 weeks because the sutures for most surgical procedures in oral implantology are eliminated by that time.
In the present work, when analyzing the tensile strength of the sutures, polyglactin maintained strength: the lowest value was obtained at baseline, and the highest was obtained on day 21, for the dislocation of the suture. The comparison showed that the necessary force to achieve detachment was not statistically significant (
In an evaluation of the tensile strength of surgical sutures, Kim et al. [
Several studies on polyglactin [
On the other hand, the monofilament and Polyglactin® resisted higher tensile forces compared with BS and PTFE, so it would be indicating that this seems to be more elastic. It should be noted that it is necessary to perform clinical studies to confirm these findings and thus verify that it has the same performance in the oral cavity [
According to our results, PTFE is a good option because it has stability over time, and being a monofilament and smooth, suture could guarantee a lower accumulation of bacterial plaque, thus facilitating a good healing process of soft tissues. However, a combination between the suture material and the technique is not considered to guarantee a better resistance to stress [
Based on the results of the present study, it does not intend to give a ranking on what material is better, but on the contrary provide, it scientific evidence that can help clinicians to make decisions when choosing the ideal material suture depending on the type and goals of oral surgery that is done.
The main limitation of the present investigation was that although the results of this
Another of the limitations of this research was that we only work with multifilament suture materials, such as black silk and polyglactin, because some biomaterials of better clinical performance do not reach Latin American countries and are only marketed in developed countries. This in turn increases costs and availability; therefore, it is necessary to create evidence with conventional suture materials. The main reason why it was decided to compare easily accessible sutures such as black silk and polyglactin versus PTFE suture. Finally, the main limitations of this research was the methodological design that only focused on an in vitro study, so it is suggested to conduct longitudinal and clinical studies with a longer evaluation time to confirm the findings found in this study. Certain variables must also be controlled such as suture technique, type of saliva, diet, hygiene habits, and so on because they could directly affect the performance of the suture material.
This work showed that when comparing the
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that there is no conflict of interest.
The authors thank Dr. Vicente Zamudio, past coordinator of the Specialty in Oral Implantology at the Universidad Peruana Cayetano Heredia, who during his life was a great person, professional, and friend who supported the authors at all times during the execution of this research work.