Article Type: Case Report
Received : 12/10/2018
Accepted : 22/10/2018
*Correspondence to: Dr. Ashank Mishra* MDS, MLD (Vienna), Consultant Periodontist, Minor Oral Surgery Centre, Jwala’s Dental Clinic, Hyderabad,Telangana State, India, Tel: + 91 9866205958, E-mail: firstname.lastname@example.org
Article Type: Case Report
Received : 12/10/2018
Accepted : 22/10/2018
Aim of the study:To evaluate clinically the minor oral surgical site after placement of suture and cyanoacrylate adhesive (N Butyl-2-Cyanoacrylate) and compare their efficacy as wound closure material for intra-oral procedure (alveloplasty) on alveolar mucosa.
Materials and Methods:Twenty complete edentulous patients requiring bilateral alveoloplasty were included for the study. The mucoperiosteal flap was sutured on one side of the quadrant with 3-0 black silk suture and on the other side after flap approximation Iso Amyl 2-Cyanoacrylate was applied at incision line.
Results:All the analysis were done using SPSS version 18. A p-value of
Conclusion:According to present study, suturing being the conventional technique achieved better haemostasis, less wound dehiscence and also less pain inducing when comparted to cyanoacrylate adhesives. Further study with larger sample size, long term follow-up is required to evaluate the tissue adhesives in intra-oral wound closure.
KEY WORDS:Alveoloplasty, cyanoacrylate, silk suture.
Management of wound has been an interesting part of oral surgery. The oldest suture dates back to 1100 BC in ancient Egyptian dynasty and is also popular in various civilizations like Greek and Indian. Healing by primary intention requires proper approximation of wound edges and this is conventionally done using appropriate suture techniques and suture materials. Nevertheless, suturing is time consuming, requires anesthesia and the use of needles can pose a threat for needle stick injuries. Non resorbable sutures requires removal on the 7th postoperative day and resorbable suture increases tissue reaction and early/delayed resorption of suture material paves way for wound dehiscence or wound infection respectively. Alternate to sutures include staples, surgical tapes and most recently tissue adhesives. Usages of cyanoacrylate bio-adhesive are fast, painless, aesthetic, reduce surgical time and also maximize patient comfort.
The use of cyanoacrylates in the repair of organs, skin, vessels, nerves, mucosa grafts, closure of laceration wounds and incisions has been done successfully in surgical applications[2, 3, 4]and treatment of extraction sockets, fixation of mandibular fractures, healing of intra oral wounds, fixation of free gingival grafts, healing of periodontal flaps were also found successful with the application of this cyanoacrylate.
The ideal tissue adhesive should demonstrate shelf stability, complete polymerization even in the presence of moisture (blood, saliva or water), it should permit adequate working time, should spread to cover the optimum area, should provide wettability and should not produce excess heat during the process of polymerization and it should provide strong and flexible bond, should be tissue compatible (non-toxic), biodegradable, easily applicable and non-carcinogenic.
The aim of present study is to evaluate clinically the minor oral surgical site after placement of suture and cyanoacrylate adhesive (N Butyl-2-Cyanoacrylate) (Fig 1) and compare their efficacy as wound closure material for intra-oral procedure (alveoloplasty) on alveolar mucosa.
Materials and Methods
The study was conducted in Department of Oral and Maxillofacial surgery, Sri Sai College of Dental Surgery, Vikarabad. Twenty completely edentulous patients requiring bilateral alveoloplasty (fig 2) aged between 45 to 60 years were selected for this clinical study. Patients with ASA 1 and ASA 2 were selected and medically compromised patients with diabetes, acute infection, hypertension were excluded. Ethical committee clearance was duly obtained and informed consent was obtained from all patients.
The procedure was carried under local anesthesia (2% lignocaine with 1:80,000 adrenalin) by elevating a mucoperiosteal flap bilaterally from molar region. Using round bur, the bony irregularities are reduced under copious saline irrigation. The mucoperiosteal flap was positioned in place and sutured on one side of the quadrant with 3-0 black silk suture and on the other side after flap approximation Iso Amyl 2-Cyanoacrylate (AMCRYLATE) was used by just delivering a drop of it in the incision line to seal the incision (fig 3).
Post operatively all the patients were advised to use antibiotic (Tab amoxicillin+clavulanate 625mg BD) and analgesic (aceclofenac paracetamol combination BD) for 5 days. Clinical examinations were made on the 1st, 3rd, 5th, 7th, 10th post-operative day (fig 4,5,6) on each side of the frenum and were evaluated for parameters like pain, bleeding, dehiscence using visual analogue scale (table 1,2,3). On the 7th post-operative day sutures were removed and cyanoacrylate adhesion lost on 10th post-operative day. Visual analogue scale was used to assess the three parameters i.e. pain, bleeding, dehiscence in the following tables.
All the analysis was done using SPSS version 18. A p-value of <0.05 was considered statistically significant. Comparison of mean scores of pain, bleeding and dehiscence were done using Wilcoxon Signed Rank test. Mean values of the VAS score for pain in cyanoacrylate side is comparatively higher than suture side on 1st,3rd,5th,7th,10th postoperative days but statistically significant variation was observed on 5th (p=0.015), 7th (p<0.001), 10th (p=0.001) days indicating higher pain scores on cyanoacrylate side (table 4). Mean values of the VAS score for bleeding in cyanocacrylate side is comparatively higher than suture side on 1st postoperative day (p<0.001) and on 3rd postoperative day (p=0.002) and also statistically significant indicating suturing aided in achieving better haemostasis than cyanoacrylate adhesive. On 5th, 7th, 10th postoperative days, the bleeding scores are insignificant (table 4). Mean values of the VAS score for wound dehiscence in cyanocacrylate side is comparatively higher than suture side on 5th (p=0.021), 7th (p=0.015),10th (p=0.001) postoperative days and also statistically significantvariation indicating higher chances of dehiscence on cyanoacrylate side when compared to sutures side. On 1st, 3rd postoperative days, the wound dehiscence scores are insignificant (table 5).
The healing wound is an overt expression of an intricate and tightly choreographed sequence of cellular and biochemical responses directed toward restoring tissue integrity and functional capacity following injury. Although healing culminates uneventfully, in most instances, a variety of intrinsic and extrinsic factors can impede or facilitate the process.
The primary steps in the management of surgical wounds are haemostasis and tissue approximation. Through ages surgeons have used various materials to close incision like metal clips, adhesive tapes and sutures. Every material has its own advantages and shortcomings. A never ending search for a material to overcome the short comings of the various wound closure techniques led to the discovery of various tissue adhesive.
Braided silk is the most common suture used for closure of oral wounds. Many studies have been done which reports advantages such as careful closure, low dehiscence rate, resilient tensile strength, and optimum handling properties. However various disadvantages like prolonged duration of surgery and anesthesia, maximal tissue reactivity, risk of needle-stick injury, undesirable trauma to intact tissue on either side of the wound, permanent suture tracts, pain and anxiety during removal have been reported.
Cyanoacrylates were first described in 1949 and their first reported use as clinical adhesives was 10 years later by Cover. Members of the cyanoacrylate family include methyl, ethyl, propyl, butyl, hexyl, heptyl and octyl cyanoacrylates.Various groups of cyanoacrylate with longer side chain derivatives were manufactured and the latest adhesives include Isobutyl-2-cyanoacrylate and N-butyl-2-cyanoacrylate. Both are known for reasonable binding strength and lesser degrees of histotoxicity when compared with their shorter-chain predecessors.
According to the present study, VAS scores for pain in the cyanoacrylate adhesive side showed higher values with statistically significant variation observed on 5th, 7th, 10th postoperative days in contrast to the study conducted by Ajit D. Joshi et al12 stated that there was difference in severity of pain in sutured, cyanoacrylate groups after third molar surgery for ﬁrst 3 days, where the severity was found to be maximum on 2nd day in sutured group. On the 4th and 5th day, there was no signiﬁcant difference in both the groups.
Regarding bleeding, the VAS score for bleeding in cyanocacrylate side is comparatively higher and also statistically significant than suture side on 1st postoperative day and on 3rd postoperative day indicating suturing aided in achieving better haemostasis than cyanoacrylate adhesive because of the undermining and flap advancement advocated for suturing in contrast to the study conducted stated that the cyanoacrylate group was found to be superior signiﬁcantly, as no signs of bleeding were seen, but in sutured group at least 5 out of 30 had complained and they reported with blood ooze from sutured wound on 1st postoperative day. No signiﬁcant difference seen in both groups on 2nd and 3rd postoperative day similar to the present study.
In the present study, VAS score for wound dehiscence in cyanocacrylate side is comparatively higher and also statistically significant variation indicating higher chances of dehiscence on cyanoacrylate side when compared to sutures side on 5th, 7th, 10th postoperative days is in agreement with the study conducted by stated that sutures are significantly better than tissue adhesives for minimizing dehiscence. Although surgeons may consider the use of tissue adhesives as an alternative to other methods of surgical site closure in the operating theatre, they need to be aware that sutures minimize dehiscence.
In the process of refining the methods of wound closure, tissue adhesives in maxillofacial region are gaining various levels of importance. According to present study, suturing being the conventional technique achieved better haemostasis, less wound dehiscence and also less pain inducing when comparted to cyanoacrylate adhesives. To conclude, although cyanoacrylate tissue adhesive looks promising, the results indicate that suturing to be better for wound closure in intraoral procedures. Further study with larger sample size, long term follow-up is required to evaluate the tissue adhesives in intra-oral wound closure.
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