Simple Interrupted and Continuous Interlocking Suturing Techniques Comparison in Maxillofacial Trauma – A Randomized Controlled Trial

Introduction

Suturing is a fine skill in the specialty of surgery to keep the dermal/mucosal edges in close contact and heal together to attain a scarless or relatively fine scar line.¹ Suturing in oral cavity is technically challenging due to its anatomical nature of confined space and obstacles such as teeth, tongue, buccal musculature, saliva, etc and maintenance of the suture postoperatively plays a major role.² There are various types of suturing techniques (simple interrupted, continuous, mattress, subcutaneous, buried, etc) and the suture materials (absorbable and nonabsorbable) are preferred based on the location, ease of suturing, properties of suture material, and comfort of the patient.¹ Colonization of pathogens is more in multifilament/braided suture.³ Simple interrupted and continuous interlocking techniques are used most commonly which are simple and vicryl (polyglactin) is preferred absorbable intraoral suture material.⁴ This study compared intraoral simple interrupted and continuous interlocking suturing techniques using vicryl sutures, both intra-operatively and post-operatively in maxillofacial trauma patients.

Patient selection and methodology

The study sample included 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. They were allocated randomly to two groups (Group A and Group B). Patients in the age group between 20-50 years, requiring ORIF under local anesthesia or general anesthesia through an intraoral approach and incision measuring 5 cm were included in the study. Patients requiring extra-oral incisions, those with comminuted fractures with acute illness, infection, pregnancy, immune compromised conditions and not willing to participate in the study were excluded. 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 from the 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 surgeon’s knots (four throws). Intraoperatively, time taken for suturing was noted. Wound dehiscence and wound healing were monitored on third, seventh and 30^th day post-operatively and the 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) who 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 in to two groups (Group A and Group B) and were compared for time taken for suturing (intraoperatively), wound dehiscence and wound healing (post operatively) using ANOVA test.

The results showed that the 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) required less time when compared to Group A (Simple Interrupted). Wound dehiscence (Table 2) was observed in 9/10, 3/10 and 2/10 patients on 3rd, 7th and 30th post-operative day respectively in patients of group A. In group B, debris was observed only on 3rd post-operative day and was absent in subsequent followup visits. This indicated gradual reduction of dehiscence with each post-operative day in both the groups. Wound healing was assessed and compared which is depicted in Table 3. On the third 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 the seventh 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 noted with p value of 0.18. On the 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, continuous interlocking sutures showed superior results when compared to simple interrupted sutures in all the aspects, such as time consumption for suturing, wound dehiscence and wound healing.

Discussion

The maxillofacial region is most prone to trauma owing to its prominent position. There are diverse causes of maxillofacial trauma. Factors like geographical location, seasonal variations, 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 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 intervention and soft tissue management. Gentle flap manipulation, ideal incision placement and appropriate suturing 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, reduced tension over the flap margins and prevention of infection.

There are various methods for wound closure which includes sutures, staples, adhesive tapes and fibrin glue. For wound closure, a variety of suture materials are available depending on the surgeon’s requirements and various other characteristics.

Various suturing techniques such as simple interrupted, continuous (simple and interlocking), mattress, subcutaneous, barbed sutures,⁶ knotless sutures⁷ are available. Among these techniques, simple interrupted and continuous interlocking are commonly used.⁸ Simple interrupted suturing may have poor knot security due to multiple number of sutures which may cause loosening of sutures, food debris accumulation, wound exposure, and infections. Irregular tightening of suture can lead to irregular fibrosis. However, it is a simple technique, facilitates easy replacement of wrong sutures and also removal of intermittent sutures for drainage of exudates.

Continuous interlocking sutures may take less time for suturing, results in good approximation of incision edges, less food debris accumulation and facilitates easy removal of sutures. Less number of knots employed in this technique 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 for assistance for the beginners and difficulty in revision which requires 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 prone 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 in the oral cavity is a skill which needs expertise and can be technically challenging due to its anatomically confined space and obstacles such as teeth, tongue, buccal musculature, saliva, etc. and also for proper maintenance of the sutures post-operatively. Commonly used simple interrupted and continuous interlocking sutures, using vicryl (polyglactin) 3-0 sutures were the materials compared in this study. Both the techniques have its own advantages and disadvantages. Even though simple interrupted technique was easy, continuous interrupted suturing technique showed superior results. However, the operating surgeons can have their own point of view and the technique selection depends on their individual preferences.

Conflict of Interest

None.