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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 20-24

Comparative evaluation of two suturing models for preclinical training


Department of Periodontology and Implantology, MGV'S KBH Dental College and Hospital, Panchavati, Nashik, Undergraduate Student, Vidyabharti College of Pharmacy, Amravati, Maharashtra, India

Date of Submission27-Oct-2018
Date of Acceptance07-Jan-2019
Date of Web Publication6-Mar-2019

Correspondence Address:
Shruti Shankarrao Lendhey
Department of Periodontology and Implantology, MGV'S KBH Dental College and Hospital, Panchavati, Nashik
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_27_18

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  Abstract 


Introduction: Demonstration and training on the live subject are not always an optimal means of introducing students to suturing technique. The use of live patient as a test subject is not acceptable with today's ethical standard. It would be advantageous to use a preclinical training model that impersonates real-life conditions, through which manual dexterity and a high degree of psychomotor skill can be achieved. This helps to master the suturing technique under semi-realistic circumstances at an affordable cost. The model most closely resembling the actual condition should be considered.
Materials and Methods: A total of 54 postgraduate students participated in the study. The material required for both the models were distributed among participants and asked to prepare the models. Then, suturing was performed on models, and the questionnaires were given for feedback. Model 1: Require orange peel, alginate impression material, and dental stone. Model 2: Require mackintosh, sponge, alginate impression material, and glass slab. Depending on the questionnaire, response results were calculated.
Results: All participants experienced that glass slab model was more durable than the orange model. Thirty-six participants experienced that orange model is easy to prepare compared to glass slab model. There was a significant linear trend among the ordered categories seen using Chi-square test.
Conclusion: According to the participant's preference orange model was better in all aspects such as ease of preparation, the passage of suture needle, and the time required for suturing compared to glass slab model which was more durable and less gaping experienced with it. Hence, we concluded that orange model was better for preclinical suturing training.

Keywords: Preclinical suturing model, study model, suturing


How to cite this article:
Kale T, Lendhey SS, Ranmare V, Bhartiya G, Hudwekar A, Lendhey P. Comparative evaluation of two suturing models for preclinical training. J Oral Res Rev 2019;11:20-4

How to cite this URL:
Kale T, Lendhey SS, Ranmare V, Bhartiya G, Hudwekar A, Lendhey P. Comparative evaluation of two suturing models for preclinical training. J Oral Res Rev [serial online] 2019 [cited 2019 May 20];11:20-4. Available from: http://www.jorr.org/text.asp?2019/11/1/20/253430




  Introduction Top


Sutures are an essential requirement for optimal healing, following various surgical procedures. If sutures are not placed properly, it will result in delayed healing and more damage to the tissue. Hence, a proper suturing technique is an important skill for any surgeon. Suturing training has been recognized as one of the areas, in which undergraduate dental students and resident trainees feel stressed and technically unconfident.[1] The ability to suture is one of the essential skills required for anyone planning to perform surgery. In addition to the theoretical knowledge, expertise in oral surgery requires a high degree of psychomotor skills, which can be achieved only through proficiency-based training with deliberate practice. The time factor and manpower needed for practical training on patients may not always be possible.[2] Furthermore, the use of live patients as test participants is not acceptable to today's ethical standard. The probable solution for these problems is the use of preclinical training models that impersonate real-life conditions.

Various means of preclinical suture training are followed in the surgery unit worldwide. These include suturing on foam, animal skin, waste meat, self-made suturing models, and commercially available suturing models. Animal skin and waste meat acquisition and storage in the tropical climate may be difficult. Furthermore, microbial contamination and health risk in using animal skin have to be evaluated. Commercially, suturing models are available, but not cost effective.[3] To overcome this problem, our study aimed to develop and compare simple and affordable suturing models used for training.


  Materials and Methods Top


The present study was conducted among 54 postgraduate students at MGV'S KBH Dental College and Hospital, Nashik, Maharashtra, India. All participants were asked to prepare both models as per the following instructions. Materials required for preparation were distributed among participants as per the given list of materials.

Materials used:

  1. Orange
  2. Glass slab
  3. Mackintosh
  4. Sponge
  5. Alginate
  6. Spatula
  7. Dental stone
  8. Adhesive
  9. Cutter
  10. 3–0 silk suture
  11. Swaged needle
  12. Needle holder
  13. Adson forcep
  14. Suture cutting scissor
  15. 15 no blade and BP handle.


Procedure for preparation of preclinical suturing model:

  1. Orange model (model 1):


  2. Orange model was prepared from a fresh orange. First, it was cut into two halves. The pulp of the fruit was carefully removed, thereby separating it from the rind (the thick orange colored outer skin) and mesocarp (the inner porous white tissue) of the fruit. A thin layer of elastomeric impression material was smeared on the inner surface of the orange peel, and the pulp space was filled with dental stone. Subsequently, when the dental stone sets, the suture model becomes ready for preclinical suturing training. Systematic illustrations of the preparation of orange model are shown in [Figure 1].
    Figure 1: Armamentarium for orange model, orange cut into two halves and pulp was removed, alginate mixed, alginate applied on inner surface, dental stone mixed, remaining space filled with dental stone, prepared models, and suturing on model

    Click here to view


  3. Glass slab model (model 2):


  4. In this model, the glass slab was used as a rigid base for the suturing model. Synthetic sponge of 4 mm thickness was cut according to the size of a glass slab. 2–3 mm thin layer of elastomeric impression material is applied on the glass slab. Then, a precut sponge is intently positioned over the impression material before it sets. With the help of adhesive, precut Mackintosh according to the size of a glass slab was glued to the sponge. This prepared model was considered for preclinical training of incisions and suturing. Detailed illustrations of the preparation of the glass slab model are shown in [Figure 2].
    Figure 2: Armamentarium for glass slab model, alginate applied over glass slab, completed alginate application on glass slab, sponge placed, adhesive applied over sponge, Mackintosh glued, lateral view of model, and suturing on model

    Click here to view


Once, the models were prepared by the participants. They were instructed to give the incisions, and suture the incised area on the respective model using interrupted suturing technique as shown in [Figure 3]. They were asked to give 5 cm incision till the rigid base with 15 no BP blade, and suture it. After the completion of the task, a questionnaire was distributed among volunteers and requested to fill it.
Figure 3: Armamentarium required for suturing, before and after suturing both the models

Click here to view


Questions were as follows:

  1. Which model was easy to prepare?
  2. In which model passage of suture needle was easier?
  3. In which model gaping was more?
  4. Which model was durable?
  5. Which model best replicates oral mucosa?



  Results Top


In the case of the orange model, 36 participants experienced that it was easy to prepare, 42 participants found that passage of suture needle through the orange model was fast and easy. On the other hand, 39 participants experienced more gaping with orange model and found it less durable than glass slab model. In the case of the glass slab model, all participants found it more durable. This was shown in [Figure 4]. Chi-square test result for independence among the orange model and glass slab model is 90.136 at P < 0.0001 and 4° of freedom. The row and column variables are significantly associated. Chi-square test result for linear trend among orange model and glass slab model was 13.303 (1° of freedom), P = 0.0003. There is a significant linear trend among the ordered categories. Values are shown in [Figure 5].
Figure 4: Questionnaire-based assessment of both models by total participants

Click here to view
Figure 5: The Chi-square test result for both the models

Click here to view



  Discussion Top


The mastery of basic surgical skills like suturing should be a part of the arsenal of all doctors. The acquisition of these skills occurs on simulation-based training model before any procedures in patients.[4] Suturing training has been recognized as one of the areas, in which undergraduate dental students and resident trainees feel stressed and technically unconfident.[1] In addition to the theoretical knowledge, expertise in oral surgery requires a high degree of psychomotor skills, which can be achieved only through proficiency-based training with deliberate practice.[2],[5] The primary focus of this study was to prepare a preclinical training model for teaching the principles of suturing during medical degree.

In a glass slab model, mackintosh and alginate replicate the oral mucosa, sponge resembles the deeper connective tissue, and glass slab further provides a firm base to the suturing model which acts as a bone. The use of alginate was recommended because of their rubbery nature and good tear strength, simulate the elasticity and texture of oral mucosa. In addition, the low viscosity of the impression material abets the material to flow into the sponge, creating a reliable mechanical bond between them.[3]

In an orange model, the orange peel replicates the human oral mucosa with an outer keratinized texture and a subcuticular layer (mesocarp).[6] The outer layer of model offers suitable resistance to the passage of the surgical needle, and its mild rubbery nature gives good tear strength, thereby preventing the suture material from gaping through the incision margins while placing the knot. The alginate impression material which is applied on inner surface of an orange peel further provides a firm, flexible base to the suturing model. The interface between them is practical to master subcuticular sutures. The basic principles of incision indicate that while giving an incision, oral mucosa should be stretched in a way that the marked line of incision rests on a solid bone, thereby providing a firm base for a clean incision. For this reason, a dental stone was smeared on the inner surface of the orange peel which mimics the bone. This reinforces the bony feel when an incision was placed and forms a firm base for the model. If the suture model is fixed over a curved surface, forms the three-dimensional structure which makes the incised wound to gape and which reflects a realistic situation aiding in understanding the wound tension.[7]

These preclinical models are prepared using easily available materials such as orange, sponge, alginate, mackintosh, glue, and dental stone which makes it at affordable cost. The backstage and latex gloves models are also of low fidelity and low financial cost. However, they do not allow the training of three-dimensional procedures such as subdermal sutures and surgical flaps. There are other industrialized low-fidelity simulators allowing three-dimensional training. However, such models have a higher financial cost.[8] There are also the models having the more fidelity when compared with living human oral mucosa such as pork and chicken skins, ox tongue and surgical specimens discarded in surgical procedures.[9] However, this is made from parts of deceased animals have their use limited or derailed, due to the need for structure, space, and proper conditions for storage and bioethical and legal aspects.[10]

Models are assessed by the participants on basis ease of preparation, ease of needle passage, gaping, durability, and fidelity to human mucosa. Ease of preparation, ease of needle passage, and fidelity to human mucosa were checked by the participants on basis of their experience of suturing on human skin, gapping is checked while suturing, durability is checked by the shrinkage of the material over a period of time. All this parameter was assessed by participant on questionnaire distributed to them after the suturing.

In this study, we found that the orange model is easy to prepare, easier for needle passage, shows more gaping, less durable, and which require less time for suturing. With glass slab model, needle penetration is difficult, shows less gaping, more durable, and requires more time for suturing.


  Conclusion Top


Although the glass slab model was found to be more durable, and less gaping was experienced with it, orange model scored higher with regards to ease of needle passage, the time required for suturing, its resemblance to oral mucosa. Hence, according to the participants, the orange model best replicates the oral soft tissue.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Macluskey M, Hanson C, Kershaw A, Wight AJ, Ogden GR. Development of a structured clinical operative test (SCOT) in the assessment of practical ability in the oral surgery undergraduate curriculum. Br Dent J 2004;196:225-8.  Back to cited text no. 1
    
2.
Dantas AK, Shinagawa A, Deboni MC. Assessment of preclinical learning on oral surgery using three instructional strategies. J Dent Educ 2010;74:1230-6.  Back to cited text no. 2
    
3.
Kumaresan R, Pendayala S, Srinivasan B, Kondreddy K. A simplified suturing model for preclinical training. Indian J Dent Res 2014;25:541-3.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Hammond I, Karthigasu K. Training, assessment and competency in gynaecologic surgery. Best Pract Res Clin Obstet Gynaecol 2006;20:173-87.  Back to cited text no. 4
    
5.
De Win G, Van Bruwaene S, De Ridder D, Miserez M. The optimal frequency of endoscopic skill labs for training and skill retention on suturing: A randomized controlled trial. J Surg Educ 2013;70:384-93.  Back to cited text no. 5
    
6.
Kumaresan R, Karthikeyan P. An inexpensive suturing training model. J Maxillofac Oral Surg 2014;13:609-11.  Back to cited text no. 6
    
7.
Uppal N, Saldanha S. Low-cost suturing training model for use in developing nations. Br J Oral Maxillofac Surg 2012;50:e13-4.  Back to cited text no. 7
    
8.
Denadai R, Souto LR. Organic bench model to complement the teaching and learning on basic surgical skills. Acta Cir Bras 2012;27:88-94.  Back to cited text no. 8
    
9.
Denadai R, Saad-Hossne R, Todelo AP, Kirylko L, Souto LR. Low-fidelity bench models for basic surgical skills training during undergraduate medical education. Rev Col Bras Cir 2014;41:137-45.  Back to cited text no. 9
    
10.
Denadai R, Kirylko L. Teaching basic plastic surgical skills on an alternative synthetic bench model. Aesthet Surg J 2013;33:458-61.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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