|Year : 2019 | Volume
| Issue : 3 | Page : 148-152
Evaluating tensile strengths of absorbable suture materials in herbal solutions: An In vitro study
Sudhir Rama Varma1, Mohamed Jaber2, Salim Aboufanas1, Sam Thomas2, Roba Ghanem Al Hujailan3, Shaikha Khaled Al Qaoud3
1 Department of Periodontics, Ajman University, Ajman, UAE
2 Department of Oral and Maxillofacial Surgery, Ajman University, Ajman, UAE
3 Department of General Dentistry, Ajman University, Ajman, UAE
|Date of Web Publication||25-Jun-2019|
Dr. Sudhir Rama Varma
Department of Periodontics, PO Box 20381, Ajman University, Ajman
Source of Support: None, Conflict of Interest: None
Aims: Suture materials are used routinely in periodontal and oral surgical procedures. Strength of the sutures depends on many factors such as tensile strength, compressive strength, and knot configuration. The aim of this in vitro study was to compare herbal rinses and chlorhexidine mouthwashes on the tensile strengths of the commonly used absorbable suture materials. Materials and Methods: Three commonly used absorbable suture materials polyglactin 910 (PLG 910), poliglecaprone (PGCL), and catgut were selected. A total of 15 samples for each suture material for a combined total of 45 were used. The sutures were tested for pre- and post-immersion tensile strength after being placed in three different solutions. Tensile strength was determined by a testing machine with a load set at 50 N. Results: Wilcoxon sign-rank test was used for quantitative data evaluation and Kruskal–Wallis test for intragroup comparison. From the experiment, it is evident that PLG 910 is superior in comparison to other suture materials, with a mean of 600.8 N/mm2 compared to PGCL (422.6 N/mm2) and chromic catgut (229.2 N/mm2). Among the herbal rinses, frankincense showed a statistical significant value in terms of stabilizing tensile strengths of the suture materials. Conclusions: Although PLG 910 was better against the three suture materials, more studies need to be done using varied variables and other media to see the effect in tensile strengths.
Keywords: Absorbable sutures, Catgut, Frankincense, Myrrh, Polyglactin 910, Tensile strength
|How to cite this article:|
Varma SR, Jaber M, Aboufanas S, Thomas S, Al Hujailan RG, Al Qaoud SK. Evaluating tensile strengths of absorbable suture materials in herbal solutions: An In vitro study. J Int Oral Health 2019;11:148-52
|How to cite this URL:|
Varma SR, Jaber M, Aboufanas S, Thomas S, Al Hujailan RG, Al Qaoud SK. Evaluating tensile strengths of absorbable suture materials in herbal solutions: An In vitro study. J Int Oral Health [serial online] 2019 [cited 2021 Dec 3];11:148-52. Available from: https://www.jioh.org/text.asp?2019/11/3/148/261268
| Introduction|| |
Wound repair is a process that involves careful and methodical activation of basic biologic processes, key to an uneventful healing of tissues, i.e., inflammation, multiplication, and proliferation of cellular structures; deposition of extracellular matrix; and remodeling of tissue both biologically and functionally. Correct approximation and handling of tissues during the early stage of wound healing is detrimental for proper healing. Suturing of tissues is vital to healing, and it plays a major role in the overall success of the surgical procedure. The quality of tissues and the oral environment it is placed in also make a difference. In the oral cavity, different suture materials exhibit different degrees of perseverance with relation to tissues. Factors such as salivary enzyme, pH and dietary intake play an important role in tissue inflammation, not just the extent of wound present. Characteristics such as predictability, adaptability, and low inflammatory response determine the selection of an ideal suture material.
One of the characteristic properties which determine the longevity of the suture material in the oral environment is its property of tensile strength. The term tensile strength is the capacity of a material or structure to withstand loads tending to elongate. This property in suture material is a key feature which will be detrimental for the overall healing of tissues; as the faster the suture material loses this property in the oral environment, the quicker the tissues will lose adaptability, which will result in tissue opening more rapidly, resulting in secondary infection and complications. The property of tensile strength has been evaluated in in vitro studies and animal models. Kim et al. reported that sutures may lose its tensile strength over a curve of time as most sutures loose about 60% of its baseline strength, which results in breakage.
Polyglactin 910 (PLG 910) is a synthetic absorbable suture material composed of a copolymer of 90% glycolide and 10% L-lactide. It is coated with a uniform layer of calcium stearate and a copolymer of lactic acid and glycolic acid. The use of copolymers enhances its durability and extends its time frame in the oral cavity. PLG sutures are indicated for soft tissue grafts in the periodontal treatment and in the oral surgical procedures for ligation. It loses its tensile strength, about 70% in 2 weeks after implantation. The knotting capability of PLG is superior compared to other absorbable suture material.
Poliglecaprone (PGCL) 25 monofilament is a synthetic absorbable suture material which gets hydrolyzed in a period of 80–120 days; it contains a copolymer of glycolide and e-caprolactone and is characterized by its memory, strength, and malleability. This suture material can be used for soft tissue grafting in the periodontal surgical procedures and subcuticular dermis closures of the face in the oral and general surgical procedures. It is absorbed by simple hydrolysis.
Catgut is an absorbable suture material manufactured from the intestines of sheep or goat. After the membrane is procured, it is chemically treated and strands are woven and formed to a suture. The suture strands are polished to get a material of uniform diameter, smoothness, and strength. It is available as plain and chromic. The chromic catgut suture is treated with chromic salts and the suture is dark brown. Catgut sutures tend to absorb faster in infected tissues. The suture retains almost 50% of its tensile strength after 14–30 days of implantation, and it is absorbed within 90 days.
Recently, the use of herbal mouth rinses has been on the rise and numerous studies estimate that about 70% of the world population uses adjunct herbal agents. Frankincense is a resin-like extract from the Boswellia species of the Burseraceae family; it contains boswellic acid which has been used for centuries in South Asian countries. It has been used in the management of various inflammatory conditions. The absence of risk in using this extract makes it a promising product as it offers no risk and less cost, compared to commercial rinses.
Myrrh is an exudate, which is obtained from the Commiphora species of the Burseraceae family. A small quantity of myrrh is used as a mouthwash for the treatment of mouth ulcers. It is also used to treat respiratory catarrh and furunculosis, and the oil of myrrh is used to alleviate pain of arthritis. Studies have shown reduction of gingivitis and gingival bleeding on using myrrh. It has also been reported that the minimal inhibitory concentration of myrrh has shown to reduce the growth of varied microorganisms, such as Pseudomonas aeruginosa, Candida, and Staphylococcus aureus. Studies have also explored the possibility of anticancer potential of myrrh.,,
The routine use of frankincense and myrrh mouth rinses postsurgically, after periodontal and oral surgical procedures, and its comparative effect in in vitro settings on commonly used resorbable suture materials have not been investigated.
The objective of this in vitro study is to do a comparative assessment among these commonly used herbal rinses and its effect on the tensile strength on three commonly used suture materials in the periodontal and oral surgical procedures.
| Materials And Methods|| |
This in vitro study was designed in September 2018 at College of Dentistry, Ajman University of Science and Technology. The study was conducted during November 2018 to January 2019. The design and methodology of this study were evaluated and certified by the Research Ethical Committee, Ajman University, on December 19, 2018, Ref No. UGD-L-18-12-19-35.
Three suture materials PLG 910, catgut, and PGCL 25 were exposed to different media (1 control and 2 tests) in in vitro settings to simulate intraoral exposure at controlled time frame. The suture materials were tested for tensile strength preimmersion and after 24 h postimmersion in different media.
Tested suture materials were obtained from sterile, unexpired, and commercially available packets: 3-0 PLG 910 (Vicryl™, Ethicon Inc., Somerville, NJ, USA), catgut (Ethicon Inc., Somerville, NJ, USA), and 3-0 PGCL 25 (Monocryl™ Plus, Ethicon Inc., Somerville, NJ, USA).
Three experimental media which were controlled with temperature gradient were used in this study: (1) Control group – Curasept ADS® Mouthwash (Curaden AG, Kriens, Switzerland); (2) Test group-1 – Commiphora myrrh powder obtained commercially; and (3) Test group-2 – Frankincense powder obtained commercially.
Fifteen samples were obtained for each of the selected suture materials, resulting in a total of 45 samples. The suture materials were measured to a length of 30 cm to accommodate the material in the testing machine. The first suture material (n = 5) was tested for tensile strength preimmersion in a selected medium and was calculated. The sutures were then placed in the same medium for a period of 24 h and the tensile strength was calculated in N/mm2. This was repeated again for the second and third media, respectively.
A Tinius Olsen Universal Testing Machine, Model No 50 ST (Tinius Olsen Ltd, Surrey, UK) was used to record the tensile strength of the samples. The testing was done with an initial load cell capacity set at 50 N for preimmersion. The testing speed to standardize the tensile strength determination for each sample was placed at 2 mm/min to avoid any damage to the suture material. The length of the specimen was kept at 30 cm. Tensile strength was determined preimmersion with a single pull till failure sets in. For postimmersion, load cell was raised correspondingly to 100 N and was recorded at this level as this value was the maximum that failure was seen.
The variables were assessed for normality using the Kolmogorov–Smirnov test. The Wilcoxon sign-rank test was used for quantitative data evaluation within two groups and Kruskal–Wallis test for quantitative data evaluation within three groups with post hoc Bonferroni test (for intragroup comparisons) was used for quantitative data comparison of all indicators. Analysis was done using SPSS version 20.0 (IBM SPSS Statistics Inc., Chicago, Illinois, USA) Windows program. Level of significance was set at P ≤ 0.05.
| Results|| |
[Table 1], [Table 2], [Table 3] comprise the tensile strengths of different suture materials preimmersion. It is evident that PLG 910 with a mean of 600.8 N/mm2 compared to PGCL (422.6 N/mm2) and chromic catgut (229.2 N/mm2) showed superior tensile strength compared to the other two suture materials. Intergroup comparison showed statistically significant results (P < 0.001).
|Table 2: Ethicon coated vicryl-PLG 910 before and after immersion in media**|
Click here to view
|Table 3: Ethicon monocryl™ plus poliglecaprone before and after immersion in media**|
Click here to view
At postimmersion, with frankincense, after 24 h, PLG showed a mean of 1230 N/mm2 and had better tensile strength than PGCL – 425.6 N/mm2 and chromic catgut – 252.4 N/mm2. Intergroup comparison showed significant results [P < 0.001, [Table 2]. Likewise, after insertion in myrrh, after 24 h, PLG again displayed better tensile strength 637.2 N/mm2, compared to PGCL – 414.4 N/mm2 and chromic catgut – 224 N/mm2. On intergroup comparison, the values were statistically significant [P < 0.001, [Table 2]. Using Curasept, after 24 h, PLG showed superior tensile strength of 480 N/mm2, compared with PGCL – 361.8 N/mm2 and chromic catgut – 165 N/mm2 [Table 2], [Table 3], [Table 4].
While evaluating quantitative data within two groups using Wilcoxon sign-rank test [Table 1], the effect of the three media with relation to chromic catgut is seen; from the results, it is clear that frankincense and Curasept showed statistically significant result, P < 0.003 and P < 0.005, respectively, compared to myrrh (P = 0.71). This indicates that the tensile strength of catgut had increased after a period of 24 h when frankincense was used as the media but further brings to light that Curasept has brought about considerable reduction in tensile strength, when compared to the other two herbal mouth rinses. In [Table 2], PLG 910 values have shown a vary significant effect with relation to frankincense after post immersion with a tensile strength of 1230 N/mm2 (P <0.001). Curasept with relation to PLG 910 also showed a significant value (P <0.001) with the Tensile strength decreasing from 600.8 N/mm2 to 480 N/mm2. Again, although the effect of myrrh shows a minor climb from 600.8 N/mm2 to 637.2 N/mm2, the value is not significant (P = 0.11). In [Table 3], PGCL and frankincense showed a minor effect with a three-point climb, though not statistically significant, compared to myrrh and Curasept which showed a decrease in tensile strength for PGCL after 24 h immersion period. The result further strengthens the finding that Curasept had the biggest effect on PGCL in terms of tensile strength loss compared to the two herbal mouth rinses. The result from the study further confirms that among the suture materials, PLG showed superior retention of tensile strength compared to the other two suture materials and Curasept showed a downward curve in terms of tensile strength stability for the three suture materials postimmersion [Table 5].
| Discussion|| |
The present in vitro study aimed to evaluate three different mouth rinses, one commercially available and the other two herbal rinses on three commonly used absorbable suture materials, namely PLG 910, PGCL, and chromic catgut. The results from the study showed that PLG stood more durable with relation to tensile strength before and after immersion post-24 h which is similar to a study by Alshehri et al. Biodegradable linear aliphatic polyesters make up most absorbable suture materials.
In the present study, PLG and other degradable polymers were investigated. Enzymatic hydrolysis after implantation varies from sutures. Comparing between the mouth rinses, myrrh had no effect on the three suture materials; this is not with agreement to a previous study [Table 1], [Table 2], [Table 3] where myrrh had shown significant property differences for the sutures used in that study. This is probably due to the use of nonabsorbable suture materials which were used for this study. Frankincense rinse has never been evaluated to determine tensile strength; the rationale behind selecting this mouth rinse is because of its routine use as mouth rinse in the Middle East for the treatment of common oral conditions. The use of frankincense and myrrh mouth rinse as a test medium was to ascertain the role of both these herbal rinses as an anti-inflammatory agent as both these agents are used in the Middle East as a home-based remedy for ailments.
The role of Curasept was detrimental in relation to the overall study, in contrary to an earlier study by McCaul et al. which reported no significant effect on PLG 910. In the present study, chlorhexidine brought down the tensile strength of PLG 910 [Table 2], chromic catgut, and PGCL [Table 1] and [Table 3]. One of the reasons which could be attributed to this variation in our finding is possibly due to the slow degradation in the initial few days; a similar observation was also reported by Ferguson et al. PGCL has the ability to retard the growth of microorganisms “the wicking effect” owing to its monofilament structure. It was reported that PGCL showed a decrease in tensile strength as reported by Khiste et al. However, in the present study, slight decrease in tensile strength was seen only with relation to Curasept and not with frankincense and myrrh. The tensile strength of PGCL had gradually increased with the effect of frankincense after postimmersion. This could be attributed to the fact that hydrolysis of the suture material did not initiate, possibly due to smaller time frame.
Apart from the reason that absorbable sutures were used in the present study, polyglycolic acid suture is another suture, where studies have already been done in comparison to PLG, and has found to be superior in relation to tensile strength retention. The present study was designed to compare the catgut, PLG, and PGCL as these suture materials were not compared and evaluated before, with the effect of herbal mouth rinses on them. However, myrrh was earlier tested on nonabsorbable suture materials, where the rate of degradation is different.
The results from the current study ascertains the fact that among the three suture materials evaluated in the study, PLG was more predictable and sustainable as tensile strength was maintained, and with relation to frankincense, postimmersion, it showed a significant increase (P < 0.001). Catgut chromic had the least mean compared with the other two suture materials. With relation to frankincense, it showed a significant increase in tensile strength (P < 0.003); however, with Curasept, it showed a statistically significant decrease (P < 0.005) which is in agreement with a study by Mario et al.
The limitations in this study is the small sample size (n = 45) used and also the short time frame (24 h) kept to evaluate. Therefore, a longer time frame is warranted using the same type rinses to evaluate the structural property of the suture materials.
| Conclusions|| |
The tensile strength of PLG significantly increased postimmersion; this increased value needs to be evaluated in a sample with longer time frame. Frankincense had made significant increases in tensile strengths in two suture materials. Myrrh did not produce any changes in tensile strength. Further clinical studies needs to be formulated to confirm the results of this in vitro study.
We would like to express their appreciation to staff of Al Futtaim Exova for providing their equipment and expertise.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abiri A, Paydar O, Tao A, LaRocca M, Liu K, Genovese B, et al.
Tensile strength and failure load of sutures for robotic surgery. Surg Endosc 2017;31:3258-70.
González-Barnadas A, Camps-Font O, Espanya-Grifoll D, España-Tost A, Figueiredo R, Valmaseda-Castellón E.In vitro
tensile strength study on suturing technique and material. J Oral Implantol 2017;43:169-74.
Asvar Z, Mirzaei E, Azarpira N, Geramizadeh B, Fadaie M. Evaluation of electrospinning parameters on the tensile strength and suture retention strength of polycaprolactone nanofibrous scaffolds through surface response methodology. J Mech Behav Biomed Mater 2017;75:369-78.
Gnandt RJ, Smith JL, Nguyen-Ta K, McDonald L, LeClere LE. High-tensile strength tape versus high-tensile strength suture: A biomechanical study. Arthroscopy 2016;32:356-63.
Newman JM, George J, Shepherd JT, Klika AK, Higuera CA, Krebs VE, et al.
Effects of topical antiseptic solutions used during total knee arthroplasty on suture tensile strength. Surg Technol Int 2017;30:399-404.
Myer CM 4th
, Johnson CM, Postma GN, Weinberger PM. Comparison of tensile strength of fibrin glue and suture in microflap closure. Laryngoscope 2015;125:167-70.
Kim JC, Lee YK, Lim BS, Rhee SH, Yang HC. Comparison of tensile and knot security properties of surgical sutures. J Mater Sci Mater Med 2007;18:2363-9.
Nary Filho H, Matsumoto MA, Batista AC, Lopes LC, de Góes FC, Consolaro A. Comparative study of tissue response to polyglecaprone 25, polyglactin 910 and polytetrafluorethylene suture materials in rats. Braz Dent J 2002;13:86-91.
Sanz LE, Patterson JA, Kamath R, Willett G, Ahmed SW, Butterfield AB, et al.
Comparison of maxon suture with vicryl, chromic catgut, and PDS sutures in fascial closure in rats. Obstet Gynecol 1988;71:418-22.
Jing Y, Nakajo S, Xia L, Nakaya K, Fang Q, Waxman S, et al.
Boswellic acid acetate induces differentiation and apoptosis in leukemia cell lines. Leuk Res 1999;23:43-50.
Khoorjestan SM, Rouhi G, Toolabi K. An investigation of the effects of suture patterns on mechanical strength of intestinal anastomosis: An experimental study. Biomed Tech (Berl) 2017;62:429-37.
Lalithakumari K, Krishnaraju AV, Sengupta K, Subbaraju GV, Chatterjee A. Safety and toxicological evaluation of a novel, standardized 3-O-acetyl-11-keto-beta-boswellic acid (AKBA)-enriched Boswellia serrata
extract (5-loxin (R)). Toxicol Mech Methods 2006;16:199-226.
Tonkal AM, Morsy TA. An update review on Commiphora
molmol and related species. J Egypt Soc Parasitol 2008;38:763-96.
Al-Mobeeriek A. Effects of myrrh on intra-oral mucosal wounds compared with tetracycline- and chlorhexidine-based mouthwashes. Clin Cosmet Investig Dent 2011;3:53-8.
Nomicos EY. Myrrh: Medical marvel or myth of the magi? Holist Nurs Pract 2007;21:308-23.
Saeidi M, Azadbakht M, Semnani K, Khandan M. Formulation of herbal toothpaste from chamomile and myrrh, a preliminary clinical evaluation on bleeding gum. J Mazandaran Univ Med Sci 2003;13:61-9.
Bradley PR. British Herbal Compendium. A Handbook of Scientific Information on Widely used Plant Drugs. British Herbal Pharmacopoeia. Vol. 1. Bournemouth, UK: British Herbal Medicine Association; 1992. p. 15-20.
Dolara P, Corte B, Ghelardini C, Pugliese AM, Cerbai E, Menichetti S, et al.
Local anaesthetic, antibacterial and antifungal properties of sesquiterpenes from myrrh. Planta Med 2000;66:356-8.
al-Harbi MM, Qureshi S, Raza M, Ahmed MM, Giangreco AB, Shah AH. Anticarcinogenic effect of commiphora molmol on solid tumors induced by Ehrlich carcinoma cells in mice. Chemotherapy 1994;40:337-47.
Dolara P, Luceri C, Ghelardini C, Monserrat C, Aiolli S, Luceri F, et al.
Analgesic effects of myrrh. Nature 1996;379:29.
Alshehri MA, Baskaradoss JK, Geevarghese A, Ramakrishnaiah R, Tatakis DN. Effects of myrrh on the strength of suture materials: An in vitro
study. Dent Mater J 2015;34:148-53.
Prati JL, Kim DH, Matthewson MJ. Application of static fatigue testing to the behavior of absorbable sutures. J Mech Behav Biomed Mater 2017;74:232-5.
Alsarhan M, Alnofaie H, Ateeq R, Almahdy A. The effect of chlorhexidine and listerine® mouthwashes on the tensile strength of selected absorbable sutures: An in vitro
study. Biomed Res Int 2018;2018:8531706.
Al-Faris EA, Al-Rowais N, Mohamed AG, Al-Rukban MO, Al-Kurdi A, Balla Al-Noor MA, et al.
Prevalence and pattern of alternative medicine use: The results of a household survey. Ann Saudi Med 2008;28:4-10.
] [Full text]
McCaul LK, Bagg J, Jenkins WM. Rate of loss of irradiated polyglactin 910 (Vicryl rapide) from the mouth: A prospective study. Br J Oral Maxillofac Surg 2000;38:328-30.
Ferguson RE Jr., Schuler K, Thornton BP, Vasconez HC, Rinker B. The effect of saliva and oral intake on the tensile properties of sutures: An experimental study. Ann Plast Surg 2007;58:268-72.
Sudhir RV, Salim AF, Maha A, Noor N, Mariam K, Eyas A. Comparison of wicking effects of different sutures: An in vitro
study. Int J Curr Res 2017;9:61469-72.
Khiste SV, Ranganath V, Nichani AS. Evaluation of tensile strength of surgical synthetic absorbable suture materials: An in vitro
study. J Periodontal Implant Sci 2013;43:130-5.
Vasanthan A, Satheesh K, Hoopes W, Lucaci P, Williams K, Rapley J. Comparing suture strengths for clinical applications: A novel in vitro
study. J Periodontol 2009;80:618-24.
Altman GH, Diaz F, Jakuba C, Calabro T, Horan RL, Chen J, et al.
Silk-based biomaterials. Biomaterials 2003;24:401-16.
Banche G, Roana J, Mandras N, Amasio M, Gallesio C, Allizond V, et al.
Microbial adherence on various intraoral suture materials in patients undergoing dental surgery. J Oral Maxillofac Surg 2007;65:1503-7.
Mario K, Bojan T, Aleksandar A, Sebastijan B, Marko C, Marko P, et al
. Tensile strength retention of resorptive suture materials applied in the stomach wall – An in vitro
study. Vet Arch 2018;88:235-43.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]