Rino Burkhardt
Axel Preiss
Andreas Joss
Niklaus P. Lang
Authors’ affiliation:
Rino Burkhardt, Axel Preiss, Andreas Joss, Niklaus
P. Lang, School of Dental Medicine, University of
Bern, Bern, Switzerland
Correspondence to:
Prof. Niklaus P. Lang
Freiburgstrasse 7
Bern
CH-3010
Switzerland
Tel.: þ 41 31 632 2577
Fax: þ 41 31 632 4915
e-mail: nplang@dial.eunet.ch
Influence of suture tension to the
tearing characteristics of the soft tissues:
an in vitro experiment
Key words: flap tension, oral mucosa, periodontal surgery, suture materials, tissue trauma
Abstract
Objectives: To evaluate the influence of flap tension on the tearing characteristics of
mucosal tissue samples in relation to various suture and needle characteristics.
Material and methods: Lining and masticatory mucosal tissue samples obtained from pig
jaws were prepared for in vitro testing. Tension tearing diagrams of 60 experiments were
traced for 3-0, 5-0 and 7-0 sutures with applied forces up to 20 N. In the second part, the
same experiments were repeated with 100 diagrams to test the influence of needle
characteristics with 5-0 and 6-0 sutures using only gingival tissue samples.
Results: 3-0 sutures mainly lead to tissue breakage at an average of 13.4 N. In contrast, 7-0
sutures only resulted in breakage of the thread at a mean applied force of 3.7 N. With 5-0
sutures, both events occurred at random at a mean force of 14.6 N. Irrespective of the
needle characteristics, the mean breaking force for gingival samples with 5-0 and 6-0
sutures was approximately 10 N.
Conclusions: Tissue trauma may be reduced by choosing finer suture diameters, because
thinner (6-0, 7-0) sutures lead to thread breakage rather than tissue breakage.
Date:
Accepted 14 June 2006
To cite this article:
Burkhardt R, Preiss A, Joss A, Lang NP. Influence of
suture tension to the tearing characteristics of the soft
tissues: an in vitro experiment.
Clin. Oral Impl. Res. 19, 2008; 314–319
doi: 10.1111/j.1600-0501.2007.01352.x
314
Wound closure is a key prerequisite for
healing following surgical interventions
and most important to avoid complications. Various techniques are proposed to
achieve optimal wound closure, among
which titanium clamps used in thorax
surgery (Liu et al. 2004; Pearl & Rayburn
2004) and adapted to vascular surgery
needs are the latest development (Demaria
et al. 2003). This technique is not yet well
documented in the oral surgical or periodontal field. The proposed advantages
include a reduction in closing time.
Biocompatibility and stability of the clamp
material are essential. However, various
aspects have precluded the routine use of
these devices so far: (1) the small diameter
of the clamps appears to prevent a closure
of flaps thicker than 1 mm. (2) Closing
forces of clamps are not controllable. (3) A
very high price of the devices will also
render titanium clamps unsuitable for mucosal wound closure in the oral cavity.
Another technique for closure is the application of adhesives (cyanoacrylates), introduced into oral surgery in the 1970s
(Forrest 1974; Miller et al. 1974) . Despite
good acceptance by the patients, an improved control of blood coagulation and a
bacteriostatic effect (Singer et al. 1998),
wound closure by liquid cyanoacrylates is
technically difficult to achieve and hence,
soft tissue healing seems to be delayed
(Greer 1975). In addition, adherence to
the movable wound edges is not guaranteed
for the entire healing period (Bhaskar et al.
1966). Such characteristics render wound
closure by adhesives inappropriate as well.
c 2008 The Authors. Journal compilation c 2008 Blackwell Munksgaard
Burkhardt et al . Suture tearing characteristics
The most popular technique for wound
closure remains the use of sutures that
stabilize the wound margins sufficiently
and ensure a proper closure for a defined
period of time. However, the penetration of
a needle through the soft tissue causes an
additional surgical trauma, and the presence of foreign materials in a wound
may significantly enhance susceptibility
to infection (Blomstedt et al. 1977; Österberg
& Blomstedt 1979). Hence, it is recommended to choose sharp, cutting needles to
penetrate the relatively dense masticatory
mucosa. To reduce trauma (Edlich et al.
1990) and, at the same time, the diameter
of the access hole, less bacteria will invade
the stitch canal. The effects of the initial
surgical trauma caused by the penetration
of needle and thread (Postlethwait et al.
1975) reach a peak on the third postoperative day and may be followed by bacterial
infection (Selvig et al. 1998). These negative effects may be improved by selecting
monofilament threads (Selvig et al. 1998),
with the use of anti-infective agents
(Leknes et al. 2005) during the woundhealing period and the coating of resorbable
suture strands with antibacterial substances (Storch et al. 2004; Ford et al.
2005).
Another shortcoming of wound closure
using sutures is the lack of appropriate
tension control. It is generally recognized
that high tensions exerted by sutures and
applied to the wound edges may lead to
tearing of the soft tissue margins, resulting
in a secondary intention healing. These
soft tissue dehiscences may prolong the
healing time (Selvig et al. 1992), cause
additional bone resorption of the underlying bone (Wilderman et al. 1960; Costich
& Ramfjord 1968) or jeopardize the healing
results (Nowzari & Slots 1994; De Sanctis
et al. 1996). For this reason, ‘passive
wound closure’ is normally recommended
for periodontal and/or oral surgical procedures, especially in combination with
guided tissue regeneration and bone augmentation procedures.
In most surgical specialties, the relationship among wound tension, blood flow and
flap viability is well documented in animal
(Myers et al. 1965; Stell 1980; Larrabee
et al. 1984) and human studies (Cherry
et al. 1983; Marks & Argenta 1988;
Shapiro et al. 1996). As the visco-elastic
properties and the blood supply of the skin
and oral mucosae are not identical (Baker
1991), the results of the skin flap studies
cannot be extrapolated to the mucosal
tissues. Only one clinical study has
focused on wound tension and primary
wound closure after surgical interventions
(Pini Prato et al. 2000). In a split-mouth
designed randomized-controlled clinical
trial, the percentage of root coverage was
investigated in relation to flap tension. On
the test sides, the tension was released by a
periosteal incision before suturing and
amounted to a mean of 0.4 g compared
with the contralateral sides with a mean
of 6.5 g, respectively. Three months after
the surgical interventions, the root surfaces
in the test group were covered to
87 13%. In 45% of the treated recessions, a complete root coverage was
achieved. The corresponding figures for
the control sites were 78 15% for the
mean recession coverage, and 18% of the
treated recessions yielded a complete coverage. A regression analysis showed that a
minimal flap tension did not influence the
results, but with increasing flap tension, a
reduction in recession coverage had to be
expected (Pini Prato et al. 2000).
It is the aim of this study to analyse the
influence of the applied flap tension on the
tearing characteristics of mucosal tissues
for various sutures sizes and needle characteristics in an in vitro experiment.
Material and methods
Harvesting of samples
To calibrate the set-up, a pilot experiment
with eight pig mucosal samples was performed and yielded a tension in the range of
5.1–15.3 N before tearing.
One hundred and sixty samples of pig
jaw mucosa were harvested from the lower
jaws of 40 fresh pig cadavers. The samples
were prepared on the same day of the
experiments. Using a periodontal probe
and a roll technique, the muco-gingival
junction was identified and marked with
a felt pen (Fig. 1). Two gingival and two
lining mucosal samples were harvested
with sharp surgical blades from each jaw.
The rectangular samples were trimmed to a
length of 25 mm and a width of 5 mm. The
desired mucosal thickness of 1 mm was
difficult to achieve due to the softness of
the tissues. To avoid bias, the thicknesses
c 2008 The Authors. Journal compilation c 2008 Blackwell Munksgaard
Fig. 1. Mucogingival junction, marked to define the
area for graft harvesting.
of the tissues were measured at three different locations (bottom, mid and top part)
of the samples using a special caliper designed for soft tissue assessment (Frank
Prüfgeräte GmbH, Birkenau, Germany).
Applying a low constant pressure, the
samples were compressed until no further
thickness changes were seen within 30 s.
The values were then read to the nearest
0.01 mm. To prevent the soft tissues from
drying during the time between harvesting
and the assessment, the samples were kept
hermetically sealed and cooled in a refrigerator at 51C and were only taken out one
hour before starting the experiments to
warm up to room temperature.
Tension experiments of the mucosal
samples
All the measurements were performed in
the technical laboratory of a Swiss textile
company (Swisstulle, St Margrethen, Switzerland). To evaluate the tension-tear behavior of the gingival and mucosal samples
dependent on different suture materials and
sizes, a tear test apparatus (Frank Prüfgeräte
GmbH) from the textile industry was used.
This machine allowed a numerical recording of the tension-tear behavior simultaneous with a graphic documentation.
Before starting the experiment, each
tissue sample was marked with an identification number and three measurement
marks. Two of these were marked simultaneously at the lower and upper sample
margins, 3 mm away from the tissue margins, and one was marked in the centre of
the sample. The tissue sample was attached to the machine by a hydraulic clamp
with its lower end in point C (Fig. 2),
similar to a vice. The upper margin was
penetrated with one of the test sutures in
point A. The suture strand was turned to a
loop, tied together and fixed to the movable
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Clin. Oral Impl. Res. 19, 2008 / 314–319
Burkhardt et al . Suture tearing characteristics
measurement arm of the machine (Fig. 2).
The experiment was started when the
sample was in an upright position with
only minimal tension on the suture. The
measurement arm now moved away with a
constant speed of 10 mm/min, and the
actual tractive force was determined constantly with a precision of 0.001 N.
Data collection and statistical analysis
In the first part of the experiment, the
tensional behaviour of three different su-
Fig. 2. Tissue sample, attached to the test machine
with a 7-0 suture.
Table 1. Events by thicknesses of threads
and tissue composition (mucosal/gingival
tissues)
EventMucosal
samples
3-0
A
B
C
D
9
1
Gingival
samples
5-0
7-0
5
5
10
3-0
5-0
7-0
5
4
1
9
6
1
4
A, breakage of thread; B, breakage of tissue;
C, breakage of tissue at tissue clamp; D, tissue
withstanding.
ture sizes was studied in pig jaw lining
mucosa and gingiva. All the sutures used
in this part of the study were monofilas
ment threads (Ethicon , Norderstedt,
Germany), made of polyamid or polypropylene with suture strengths of 3-0
(metric 0.200–0.249 mm), 5-0 (metric
0.100–0.149 mm) and 7-0 (metric 0.050–
0.069 mm) according to the United States
Pharmacopoe. For each suture strength,
10 mucosal and 10 gingival samples were
evaluated, resulting in a total of 60 tensiontearing experiments.
For the evaluation, four different events
were recorded: (A) breakage of sutures
(inside or outside the knot), (B) tissue tearing (beginning at the penetration hole, at
the middle or upper margin of the sample),
(C) tissue tearing at the attachment clamp
of the machine or (D) tissue withstanding
the applied tension forces up to 20 N. The
behavior of the graft samples under increasing tension was recorded numerically and
traced graphically. Furthermore, the maximum force for the mentioned criteria to
occur was determined. Based on pilot
experiments, the maximum force applied
was limited to 20 N. Besides the tensiontearing behaviour of the different suture
diameters, the influence of the sample
thickness and tissue characteristics (gingiva
vs. lining mucosa) was evaluated as well.
A nonparametric one-way test (Kruskall–
Wallis) was used to analyse the influence of
sample thickness and tissue characteristics
on the maximum force applied.
In the second part of the study, the
influence of the needle characteristics on
Fig. 3. Mean maximum forces applied to the mucosal samples dependent on suture diameters and needle
characteristics.
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Clin. Oral Impl. Res. 19, 2008 / 314–319
the tearing properties of the tissue samples
was recorded. Cutting needles, in combination with monofilament polypropylene
threads of 5-0 and 6-0 strengths, were
compared with round-tip needles in the
the same thread combinations. In each
group, 25 gingival samples were evaluated,
amounting to 100 experiments.
Results
Influence of mucosal thickness and graft
composition
During harvesting of the grafts using a
surgical blade, attempts were made to
keep the width of the graft in the same
order of magnitude. However, the assessed
thickness at the border of the graft with the
penetration hole ranged from 0.56 to
2.42 mm, averaging 2.07 mm for gingiva,
and from 0.38 to 1.46 mm, averaging
0.91 mm for alveolar mucosa.
In tearing the samples, either the sutures
or the tissues were torn to breakage. Table 1
indicates the proportions of broken tissue
or suture samples, respectively, for both
mucosal and gingival tissues and suture
strengths of 3-0, 5-0 or 7-0 sutures, respectively. It was evident that for 3-0 sutures,
the breakage occurred in the tissues rather
than in the threads irrespective of the tissue
characteristics. On the other hand, the 7-0
suture threads generally broke before the
tissues did, while for 5-0 sutures both
events occurred at random (Table 1). The
mean maximum forces, which could be
applied to the mucosal tissue samples until
an event occurred in the different test
configurations, are shown in Fig. 3. There
was a statistically significant difference
(Po0.05) between the 3-0 and the 7-0
suture diameters.
Analysing the tearing behavior of the 3-0
sutures within the range of 20 N, the thickness of the sample had no influence on the
breakage of the tissue irrespective of its
characteristics (Fig. 4). In contrast, the
tearing behaviour of the 7-0 sutures yielded
much lower forces causing breakage of the
thread generally not exceeding 5 N (Fig. 5).
Again, 7-0 sutures broke without any influence of either tissue characteristics or
thickness.
Figure 6 depicts the tearing behaviour of
the 5-0 sutures for both mucosal and gingival tissues. Both tissue and thread breakage
events were observed and appeared to occur
c 2008 The Authors. Journal compilation c 2008 Blackwell Munksgaard
Burkhardt et al . Suture tearing characteristics
from analysis due to breakage of the tissue
at the attachment clamp of the machine.
The fourth event defined as tissue withstanding the applied tension forces of up to
20 N occurred in five gingival tissue samples for the 3-0 sutures. In these samples,
tissue breakage occurred at an applied tension force up to 40.5 N.
Influence of needle characteristics and
thread diameter
Fig. 4. Maximal force applied to the tissue samples up to breakage of either the threads or the tissues relating to
the thicknesses of the tissues at the upper margin. Diagram for 3-0 sutures.
Fig. 5. Maximal force applied to the tissue samples up to breakage of either the threads or the tissues relating to
the thicknesses of the tissues at the upper margin. Diagram for 7-0 sutures.
Based on the results of the previous experiments, the 5-0 and 6-0 suture material was
tested regarding the characteristics of the
attached needles (rounded tips vs. triangular
cutting tips). For each tearing experiment,
25 gingival samples were tested, amounting to a total of 100 samples. Tearing to
tissue breakage occurred in a range of forces
of 3.3–15.1 N, while threads broke at a
force varying from 5.7 to 20 N. The needle
characteristics did not influence tissue
breakage (Fig. 8).
Tearing of the gingival samples occurred
between forces of 5.6 and 15.1 N for round
needles and 3.3 and 13.8 N for triangular
cutting needles, averaging 10.1 N for the
former and 9.9 N for the latter. The mean
breakage of the tissues occurred at 13.2 N
for the 5-0 sutures and 6.8 N for the 6-0
sutures, resulting in a statistically significant reduction in tissue breakage force for
the 6-0 suture independent of the needle
characteristics.
Discussion
Fig. 6. Maximal force applied to the tissue samples up to breakage of either the threads or the tissues relating to
the thicknesses of the tissues at the upper margin. Diagram for 5-0 sutures.
at random within a force range of 7–20 N.
Tissue thickness or characteristics, again,
did not influence the forces needed to cause
breakage. The medium forces applied to
cause either tissue or thread breakage
were 13.4, 3.6 and 16.1 N for the 3-0, 7-0
and 5-0 sutures, respectively (Fig. 7). The
breakage force of the 7-0 sutures was statistically significantly lower (Po0.05) than
that of both the 3-0 and the 5-0 sutures.
Out of the 60 tension-tearing diagrams,
only four assessments had to be excluded
c 2008 The Authors. Journal compilation c 2008 Blackwell Munksgaard
The present study has clearly demonstrated that depending on suture strength,
the dynamic tearing to breakage may both
occur at the tissue level or within the
thread. While the 3-0 suture almost exclusively led to tissue breakage, the 7-0 sutures broke before tissues were torn in
every instance. This in turn means that a
clinician will influence the amount of
damage to the tissue by selecting a thicker
or thinner suture material. Considering
this fact, it may be speculated that wound
dehiscence may be prevented by the choice
of thinner sutures. In addition, the choice
of a thin suture material (7-0) may be
suitable to achieve passive wound closure
and hence, a reduction in trauma to the
tissues.
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Burkhardt et al . Suture tearing characteristics
clinician may choose sizes between the
two extreme values tested in the first part
of this study.
When the 5-0 or 6-0 suture material is
selected in periodontal surgery, the results
of the present study indicated only minor
differences in their tearing characteristics
for two needle designs and between the 5-0
and 6-0 sutures. To achieve primary
wound closure in periodontal plastic surgical procedures, very low tension forces
have to be applied to the suture material.
So far, very low tension forces have been
documented in one study reporting on
recession coverage (Pini Prato et al. 2000).
This principle would preclude the application of hitherto used 3-0 suture materials.
It is, therefore, evident that thinner suture
materials will be recommended for more
advanced periodontal surgery. In this
respect, the findings of the present study
have documented that both 5-0 and 6-0
suture material with different needle
designs may be applicable for routine use,
while 7-0 sutures clearly represent a category of sutures that requires visual rather
than tactile control in handling.
It has to be realized that more than one
suture combination should be available for
covering the various needs associated with
the various procedures in periodontal surgery as the choice of an ideal needle-thread
combination may also be influenced by the
tissue biotype and the surgical procedure
itself. While the very thin suture material,
such as the 7-0, is appropriate for fine
closure of releasing incisions predominantly in the alveolar mucosa or in thin
gingival morphotypes, such material is not
suitable for closure of more dense mucosal
tissue, where the needed forces applied
would result in thread breakage. In the
latter cases and more for routine use of
periodontal flap closure, the clinician may
choose the 5-0 or 6-0 sutures.
Depending on the suture material, the
breaking strengths of 5-0 sutures approximately range from 10 to 25 N (Lünstedt
et al. 1986). This will result in a combination of and optimization of the tearing
characteristics of both the thread material
and the gingival tissues. Considering the
level of breaking resistance of a 5-0 suture,
it may rather be a problem of the needle
characteristics when suturing thick tissue
biotypes or palatal masticatory mucosae
than a problem of the suture thread. Therefore, for suturing dense mucosal tissues,
an appropriate 5-0 thread should also be
attached to an ideal needle with improved
bending properties and a tip that retains its
sharpness after several tissue passages.
Blomstedt, B., Österberg, B. & Bergstrand, A. (1977)
Suture material and bacterial transport. An experimental study. Acta Chirurgica Scandinavica 143:
71–73.
Cherry, G.W., Austad, E.D., Pasyk, K.A. & Rohrich, R.J. (1983) Increased survival and vascularity
of random pattern skin flaps elevated in controlled
expanded skin. Plastic and Reconstructive
Surgery 72: 680–687.
Costich, E.R. & Ramfjord, S.F. (1968) Healing after
partial denudation of the alveolar process. Journal
of Periodontology 39: 5–12.
Fig. 7. Dispersion of maximum forces applied, dependent on different suture diameters. Statistically significant difference between 7-0 and 5-0/3-0 sutures (n), no significance between 3-0 and 5-0 sutures (NS).
Fig. 8. Dispersion of maximum forces applied, dependent on different suture diameters and needle characteristics. Statistically significant reduction in tissue breakage force for the 6-0 suture compared with the 5-0
suture material (n). No influence of the needle characteristics.
On the other hand, several factors may
preclude the use of thin suture material in
periodontal surgery: (1) the handling of 7-0
sutures inevitably requires magnification if
its benefits are to be fully appreciated. (2)
The dense masticatory mucosal tissues
may require cutting needles that may not
be affixed to sutures available in such
dimensions. Neither are the appropriate
lengths or stiffnesses of the needles required for proper suturing, e.g. in the interproximal spaces, available with 7-0 or
smaller sutures. As a consequence, the
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