otto zuhr wound closure and wound healing. suture ...a wide range of diﬀerent suture materials are...

VOLUME 48 • NUMBER 8 • SEPTEMBER 2017 647

Q U I N T E S S E N C E I N T E R N AT I O N A L

Wound closure and wound healing. Suture techniques

in contemporary periodontal and implant surgery:

Interactions, requirements, and practical considerations

Otto Zuhr, Dr med Dent1/Dodji Lukas Akakpo2/Markus Hürzeler, Prof Dr Med Dent3

In contemporary reconstructive periodontal and implant sur-gery, attaining uncomplicated wound healing in the early post-operative healing phase is the key to achieving a successful treatment outcome and is of central interest, from the clinical as well as the scientific perspective. The realization of primary wound healing is the central challenge in most cases. Two of the evidence-based factors that affect postoperative wound healing can be influenced by the surgeon: the blood supply to the surgi-cal site and postoperative wound stability. The surgical suture is a key determinant of whether adequate wound stability is achieved in this context without complicating the course of

wound healing by exerting unnecessary trauma or excessive tensile strain on the wound edges. Therefore, the inclusion of anchors in the suturing process that make it possible to achieve the best wound stability possible is often an important key to success. This article provides an overview of the principles of successful wound closure that are relevant to postoperative wound healing in order to equip dentists with the tools needed for the correct, indication-specific selection and performance of surgical suturing techniques in daily practice. (Quintessence Int 2017;48: 647–660; originally published (in German) in Implantologie 2016;24:281–294; doi: 10.3290/j.qi.a38706)

Key words: microsurgery, suture anchoring, suture material, suturing technique, wound closure, wound healing

ORAL SURGERY

Otto Zuhr

the key to success is to achieve fast and uncomplicated

wound healing. The successful integration of graft and

augmentation materials commonly used in this context

depends on a range of factors, such as, and in particu-

lar, the good blood supply to the surgical site, the pre-

vention of bacterial infections, and the achievement of

maximal wound stability. The realization of primary

wound healing is therefore the measure of all things in

the majority of these cases.1,2 From a biologic perspec-

tive, wound healing by primary and secondary inten-

tion leads to the same result: wound closure. However,

the two processes differ significantly in terms of the

chronology of the different phases of wound healing

and the tissue quality at the end of the healing period.3

Reconstructive hard and soft tissue augmentation pro-

cedures in periodontal and dental implant surgery are

increasingly shaping the treatment spectrum of den-

tistry. More and more emerging evidence shows that

1 Private Practice, Hürzeler & Zuhr Joint Dental Practice, Munich, Germany; and Asso-

ciate Professor, Center for Dentistry, Oral and Maxillofacial Surgery (Carolinum),

Johann Wolfgang Goethe University, Polyclinic for Periodontology, Frankfurt,

Germany.

2 Dentist, Hürzeler & Zuhr Joint Dental Practice, Munich, Germany.

3 Private Practice, Hürzeler & Zuhr Joint Dental Practice, Munich, Germany; and

Associate Professor, Albert-Ludwigs University, Department of Conservative Den-

tistry and Periodontology, Freiburg University Hospital, Freiburg, Germany.

Correspondence: Dr med dent Otto Zuhr, Hürzeler & Zuhr Dental Practice, Rosenkavalierplatz 18, 81925 Munich, Germany. Email: [email protected]

VOLUME 48 • NUMBER 8 • SEPTEMBER 2017648


Zuhr et al

From a surgical point of view, smooth, well-vascu-

larized, tension-free, and precisely adapted wound

edges are the most important prerequisites for primary

intention healing. After primary wound closure in this

manner, a thin but stable blood clot forms between the

wound margins, and little to no local tissue ischemia

occurs. Consequently, it is virtually impossible for bac-

teria to infiltrate the wound, particularly the deep tissue

layers. The blood supply to the wound is rapidly

restored, and a provisional matrix quickly forms to

cover the wound. Under favorable conditions, a wound

can close within a few days of primary wound closure in

the absence of clinically detectable inflammation,

wound secretion, and granulation tissue. There is very

little to no scar tissue formation after wound healing by

primary intention. The outcome of primary wound

healing can thus be described as wound tissue regen-

eration in the sense of “restitutio ad integrum”, ie res-

toration of the tissue to more or less its original intact

condition.

Secondary wound healing, on the other hand, is

associated with the formation of repair tissue. To

quickly close the wound and restore the integrity of the

epithelial lining of the oral cavity, the body produces

low-grade scar tissue to bridge over the gap resulting

from tissue damage or removal. When suture closure

results in excessive tension on flap edges, or when

suture loosening occurs due to improper suture tying,

or a restricted local blood supply leads to wound edge

necrosis, healing by secondary intention often occurs in

spite of primary wound closure.4 Especially in the intra-

oral cavity, such wounds are associated with a high risk

of bacterial contamination. In many cases, this results in

a compromised treatment outcome characterized by

the development of volume defects, fibrotic tissue, and

hypertrophic scars.5

Against the background of this knowledge, it is

evident that the successful performance of any recon-

structive-surgical procedure requires a deep under-

standing of the importance of wound healing as well

as the identification and control of factors influencing

the wound healing process. From the clinical per-

spective, these are basic keys to success. Prognostic

factors associated with wound healing have been

investigated in research on the treatment of gingival

recession in the context of reconstructive periodontal

and implant surgery.6 Risk factors for failure can be

divided into three broad categories: patient-related,

defect-related, and technique-related. It seems feasi-

ble to transfer the knowledge gained in the context

of gingival recession treatment to other settings.

While both patient-related factors (eg, general

health) and defect-related factors (eg, the defect con-

figuration) are primarily controlled by appropriate

patient selection, it is mainly via technique-related

factors that the clinician can have a positive influence

on wound healing and, thus, a direct effect on the

outcome of treatment. Surgical soft tissue manage-

ment is therefore a key determinant of the success or

failure of treatment. Careful preoperative planning of

all parts of the procedure (from the first incision to

flap elevation to wound closure) is needed to ensure

optimal wound stability and an optimal blood supply

to the surgical site.7,8 Surgical suturing techniques

play an important role in this context.9

The aim of this article is therefore to equip practic-

ing dentists with the tools needed to correctly select

and perform the various suturing techniques used in

oral surgery in an indication-specific manner. Clinical

examples are provided to illustrate a range of aspects,

from the indication-specific selection of appropriate

suture materials and suturing techniques and practical

tips on how to perform them. It is our hope that this

will contribute to a better understanding of the impor-

tance of achieving wound closure based on biologically

sound principles for successful wound healing in the

oral cavity.

MACRO OR MICROSURGERY?

Thanks to the availability of optical magnification and

special microsurgical instrument kits, it is now possi-

ble to perform surgical procedures in the oral cavity

with relatively little trauma and high precision. More

and more scientific evidence is emerging to support

the clinical observation that the consistent use of a



Zuhr et al

microsurgical approach not only leads to superior early

wound healing with significantly less morbidity, but

also significantly improves the clinical results of oral

surgery.10-12 Microsurgical approaches to reconstructive

periodontal and implant surgery were originally intro-

duced in the early 1990s,13,14 and the ensuing develop-

ment of suitable microsurgical instruments and suture

materials has been a decisive driver of advances in this

field.

In contrast to the classic microsurgery disciplines

such as neurosurgery or ophthalmic surgery, the micro-

surgical techniques used in periodontal and implant

surgery must be adapted to meet the very special

requirements of the oral cavity: they must be delicate

enough to ensure the atraumatic and precise adapta-

tion of sometimes very fragile oral mucosa under opti-

cal magnification yet sturdy enough to withstand high

mechanical stresses, especially in the gingiva or palatal

masticatory mucosa.

Regarding the suture materials, it has proven to be

advantageous to use needles of sufficient length and

stability. Ideally, the needle should be sturdy enough to

penetrate the intraoral tissues smoothly and without

bending, long enough to cross the interdental space in

a single pass, and fine enough to be combined with

fine sutures.

In light of these instrument requirements, it does

not seem absolutely necessary to use an operating

microscope. Loupes with 4.5- to 6-fold magnification

have proved to be an adequate and easy-to-use alter-

native. In terms of the range of optical magnification

and instruments used today, microsurgical interven-

tions in the oral cavity fall somewhere between the

realms of classic microscopic surgery and traditional

macroscopic surgery. This development increasingly

raises two reasonable questions:

• Will strict differentiation between macro- and

microsurgery still be useful in the future?

• Should surgical interventions in the oral cavity gen-

erally be performed via a microsurgical approach

with adequate magnification, using instruments

and suture materials developed specifically for this

purpose?

BIOLOGIC AND PHYSICAL REQUIREMENTS OF SUTURE MATERIALS

A wide range of different suture materials are available

for oral surgery today. Sutures may be classified on the

basis of their structural and physical properties.15 Struc-

turally, sutures are defined in terms of their size (diam-

eter), number of filaments (monofilament vs multifila-

ment/braided), and surface texture (smooth vs rough).

In terms of their physical properties, suture materials

are classified based on their biodegradability (absorb-

able vs nonabsorbable), stiffness, tensile strength, and

knot security.

The ability of a suture to withstand mechanical stress

depends on its combination of physical and structural

properties.16 Equipped with a wide base of knowledge

about the specific properties of different suture mater-

ials, surgeons can not only correctly choose an appropri-

ate suture for a specific case, but are also able to enhance

the healing process to a certain extent. There are very

high requirements that an “ideal” suture material must

meet.17-19 Regarding factors related to the manufacturing

process, the ideal suture material should be easily steril-

izable and precision-fabricated so as to ensure a uniform

and consistent thread size. High tear and tensile

strength, good handling properties, and high knot secu-

rity are other requirements it should meet. Moreover, the

ideal suture material should cause minimal trauma

during tissue passage and minimal immunologic tissue

reactivity with no capillarity tendencies associated with

the so-called “wick effect.” Capillarity is a process by

which fluids and microorganisms are drawn into the

wound via the filaments of sutures, multifilament mater-

ials in particular, which act like the wick of a candle due

to their rough and braided surface.20 The tendency for

biofilm formation and the risk of patients injuring them-

selves on stiff suture edges during the healing phase

should be as low as possible, and the duration of func-

tion of absorbable sutures must be clearly defined. Last

but not least, manufacturing costs should be low

enough to ensure a reasonable sales price appropriate

for the large volume of sutures used in daily practice.



Zuhr et al

Absorbable and nonabsorbable sutures are classi-

fied on the basis of their in-vivo biodegradability.

Absorbable sutures may be either natural or synthetic

in origin.15 Natural absorbable sutures are broken down

by proteolytic enzymes, while synthetic absorbable

sutures are degraded by hydrolysis. The degradation

process by which sutures are absorbed triggers an

inflammatory reaction in the surrounding tissues.21,22

Therefore, it seems advisable to limit the use of absorb-

able sutures to deep tissue layers that are no longer

accessible after wound closure and healing. Because

natural sutures generally elicit a greater degree of tis-

sue reaction than synthetic sutures,23,24 they are no

longer recommended for use in oral surgery. The

inflammatory response associated with the absorption

of polyglycolic acid (PGA)-based synthetic sutures is

relatively small.25 PGA sutures are absorbed over a

period of 60 to 90 days.26 However, they appear to have

a maximum of 50% of their original tensile strength

after an implantation period of 60 days.26

Synthetic nonabsorbable sutures made of poly-

amide polymer, polyolefin, polypropylene, or poly-

vinylidene fluoride feature outstanding tissue compat-

ibility.2,27 These monofilament sutures have a much

lower degree of capillarity than multifilament sutures.28

In line with this, there is evidence suggesting that

monofilament sutures are associated with a lower risk

of wound infection.29-31 This advantage, however, is

offset by certain disadvantages: monofilament sutures

are somewhat stiff and inflexible, which results in

poorer handling properties and knot security.23

For the surgeon, the challenge is to choose a suture

material that provides an optimum balance between

the advantages of monofilament and multifilament

sutures.

Smooth polyvinylidene fluoride-based synthetic

monofilament sutures appear to be the suture materials

that offer the best compromise at present.32 Evidence

suggests that the aforementioned disadvantages with

respect to handling properties and knot security no lon-

ger apply from a suture size of 6-0 and 7-0.33 However,

precise knot-tying technique is still needed to achieve

secure wound closure with monofilament sutures.

Expanded polytetrafluoroethylene (ePTFE) is a spe-

cial type of nonabsorbable synthetic suture material.

Expanded PTFE fibers form monofilament sutures with

“pockets of air” incorporated in the material. They have

excellent tissue compatibility, but their porosity (air

content of 50% to 60%) and porosity-related swelling

capacity result in increased bacterial biofilm coloniza-

tion of the thread surface. These are major drawbacks,

but ePTFE also offers some great advantages, such as

excellent glide characteristics. Therefore, ePTFE suture

material can now be recommended as a standard ma-

terial for macrosurgical sutures in oral surgery. How-

ever, because of their porous surface, ePTFE sutures

should not be used in cases where the suture material

must be left in place for long periods of time.2

Proper surgical needle selection is not only import-

ant for successful wound closure, but also for prevent-

ing additional tissue trauma. Surgical needles must

have high flexural strength: they must be rigid enough

to resist bending when passed through tough tissues,

yet ductile enough to keep from breaking as soon as

they encounter resistance. Furthermore, a good surgi-

cal needle must be sterilizable and corrosion-resistant.

The material that best meets these requirements is

high-quality stainless steel, which is usually nickel- or

chrome-plated to make it easier to polish.

Curved needles are easier to control in confined

spaces. They guide the path of the thread through the

tissue such that pulling on the free ends of the suture

brings the edges of the wound into apposition with

slight eversion. Straight needles, on the other hand,

result in inversion of the wound edges, which gener-

ally should be avoided in periodontal surgery. When

making interdental sutures, it should be possible to

insert the needle through the interdental space in a

single pass. This requires the use of longer needles,

especially in the molar region. Needles with a ⅜ or ½

curve and an arc length of 8 to 15 mm are preferen-

tially used in periodontal and dental implant surgery

for this reason. Needles with a triangular cutting blade

have proved effective in periodontal microsurgery.

Only the front third (tip) of the needle should be

sharp, and the middle third (shaft) should be flattened



Zuhr et al

for better retention in the needle holder. A polished

surface enhances the ability of the needle to glide

through tissues. Round-bodied needles are not recom-

mended because they bend more easily and are more

difficult to pass through periodontal tissues. The junc-

tion between the needle and the thread is another

important factor. Eyed needles are reusable. The eye

of the needle and the doubled strand of thread in that

region produce in a relatively broad suture footprint,

which causes substantial tissue trauma. Atraumatic

suture needles were developed for this reason. Unlike

eyed needles, the suture thread is glued or welded to

the blunt end of the eyeless atraumatic suture needle,

creating a smooth junction (swage) between the

needle and the thread. Because these are disposable

needles designed for single use only, they are always

new and sharp. Consequently, atraumatic suture nee-

dles results in a tremendous reduction of tissue

trauma. All of these are good reasons why atraumatic

suture needles should be used in oral surgery in gen-

eral and oral microsurgery in particular.

PRINCIPLES OF SUTURE CLOSURE

Because complete immobilization of wounds in the oral

cavity during the postsurgical period is rarely possible,

precise and stable suture closure is crucial to successful

wound healing following oral surgery. The surgeon

should always keep the goal of suturing in mind: Surgi-

cal sutures must passively secure the flap in the pos-

ition established during surgery, keep the edges of the

wound in intimate contact (this is especially important

for grafts depending on initial nutrition by diffusion),

and stabilize the wound during the early healing phase.

The selected suture materials, suturing techniques, and

soft tissue management must ensure that suture knots

do not come undone and that both the suture mater-

ials and the soft tissues are able to resist the mechanical

stresses exerted upon them during the early healing

phase. All of these conditions must be met in order to

achieve healing by primary intention and, most impor-

tantly, good cosmetic results without scarring, espe-

cially in the esthetic zone.

Incisions should be placed in keratinized tissue

whenever possible because this makes it easier to

achieve precise suture closure. The selected incision

technique and flap design should ensure that the

edges of the flap are held in the desired position with-

out tension and that they can be coapted with sutures

without excessive pulling force. This is essential for

achieving the required stability of wound closure

without the sutures tearing out of the skin during

healing. If mobile and immobile flap components are

to be connected, then suturing should always be per-

formed from movable to non-movable tissue to pre-

vent the sutures from tearing through the edges of

the immobile flap. Gently mobilizing the edges of the

immobile flap can make it easier to achieve precise

suturing.

As a general rule, the needle should be inserted at a

90-degree angle to the tissue to minimize trauma. The

force used to guide the needle should always be

applied in the direction of the needle curvature. The

use of needle holders with a round handle cross-sec-

tion facilitates controlled and precise rotational move-

ment of the fingers. As a rule, the needle is held per-

pendicular to the incision line. The general rule is: the

fewer sutures needed to achieve precise and stable

approximation of the flap margins, the better.

The needle holder should be sturdy enough to

grasp fine needles of different sizes securely, yet small

enough to allow easy access into interdental spaces.

Needle holder jaws with a round cross-section prevent

damage to the sutures as well as trauma to the sur-

rounding tissues during suture placement. Needle

holders with a ratchet lock normally are not used in

conventional microsurgery, but have proven very help-

ful in periodontal and implant surgery. They are

designed to hold the needle securely and enable con-

trolled passage of the needle through the often coarse

periodontal soft tissues without excessive pressure on

the instrument handle.

To ensure sufficient knot security, each suture knot

consists of multiple loops. The first loop determines the

position and tension of the suture and, thus, the exact

position of the wound edges. The second loop (and



Zuhr et al

third loop, if necessary) serves to secure the position

of the first loop. Simple reverse-direction knots can be

tied using microsurgical suture materials of size 7-0

and smaller. First, a double loop is formed, followed

by a second single loop in the opposite direction. The

short end travels in the opposite direction. It should

be noted that once the second loop has been made, it

is not possible to tighten the first loop by pulling on

the second. Therefore, it is important to ensure that

the first loop is securely placed in precise position

before making the second. After making the first loop,

it can be helpful to turn the suture ends 180-degrees

before making the second loop. If it is not possible to

check loop position during suturing, a third single

loop should be made in the opposite direction. The

same rule applies when using size 6-0 microsurgical

suture material. Macrosurgical sutures made of ePTFE

should be tied using a square knot with an additional

third throw to ensure adequate knot security. This

knot is constructed with three consecutive single

loops, each in the opposite direction of the preceding

throw. Due to the excellent gliding capacity of ePTFE,

the first loop can still be tightened after the second

loops have been made. The third loop is needed to

ensure knot security.

To guarantee that the blood supply to the wound is

not impaired during healing, it is important to ensure

that the sutures are not pulled too tightly. The surgical

knot should be as small as possible, and the cut ends of

the knot should never be longer than 3 mm. To avoid

irritation of the wound edges and to minimize plaque

accumulation in the wound, knots should not be

placed on the incision line, but lateral to the wound

edges.

To prevent impairment of healing, the sutures

should be removed with sharp instruments, with as

little trauma as possible, 5 to 7 days after the pro-

cedure.

In oral surgery, sutures are tied either completely

with instruments (needle holder and forceps) or partly

with instruments (needle holder and fingers). Instru-

ment tying enables better control of loop position,

especially in poorly accessible sites.34,35

SUTURING TECHNIQUES AND THEIR CLINICAL APPLICATION

The main objective of the commonly used suturing

techniques described below is the constant clinical

challenge of achieving the most stable wound closure

possible without significantly affecting the blood sup-

ply to the surgical site. Clearly, sufficient wound stability

cannot be achieved if the suture only passes through

mobile tissue flaps alone. Therefore, the availability of

suitable anchors for the sutures is a decisive factor in

the successful selection and execution of a suturing

technique that meets the requirements of the specific

clinical situation. Natural structures (such as the teeth,

gingiva, masticatory mucosa of the hard palate, and

periosteum) as well as artificial structures (such as com-

posite resin anchors) can provide sufficient anchorage.

Single interrupted sutures

Optimal adaptation of two surgical flap edges is the

central focus of suturing. Compared with continuous

sutures, the advantage of interrupted sutures is that

the loss of an individual suture does not mean the com-

plete loss of suture closure. Although it can be assumed

that the use of as few sutures as possible has a benefi-

cial effect on wound healing in the oral cavity, inter-

rupted sutures are relatively time-consuming. This is a

major disadvantage, even if they are used sparingly. If

wound closure is performed using single interrupted

sutures, the distance between the incision line and the

needle entry and exit points (bite size) should be kept

as equal as possible. The closer to the surface the

suture passes through the tissue, the smaller the bite

size should be. However, the bite size should never be

less than 1 to 2 mm (minimum bite size). Ideally, the

suture should cross the incision line at right angles and

should only deviate from this course in selected cases

(Figs 1 to 3).

Tension-relieving sutures

Tension-relieving sutures are always used in combina-

tion with closing sutures to achieve tension-free adap-

tation of the flap edges before the actual suture closure.



Zuhr et al

The use of closing sutures alone leads to punctiform

flap adaptation, whereas the combination of closing

and tension-relieving sutures results in broader and

intimate adaptation between the flap edges. This

enhances the precision and mechanical stability of

wound closure, which is particularly important in cases

where increased wound tension or mechanical stress

during the postoperative healing phase is likely to

occur due to postoperative edema or to talking and

chewing movements. Tension-relieving sutures are

placed before closing sutures. They may have a crossed

or parallel suture pattern and can be positioned hori-

zontal or vertical to the incision line. Tension-relieving

sutures may be placed externally or internally, above or

below the incision line.2 The internal horizontal mat-

tress suture is the most commonly used tension-reliev-

ing suture in periodontal and implant surgery. It may

run parallel to or cross over the incision line (Figs 4 to 6).

Bite-Size Bite-Size

Fig 1 Schematic illustration of “bite size.”

Fig 2 Suture closure of a vertical relieving incision in conjunc-tion with a coronally advanced flap (suture material: Seralene Blue 7/0 DS-12).

Fig 3 Schematic representation of a single interrupted suture used for flap stabilization (arrow): the suture passes from the mobile flap to the stationary anchor point, in this case, the gingiva in the immobile part of the second flap (A, anchor; MF, mobile flap).

A MF



Zuhr et al

Single sling sutures

Regenerative periodontal therapy for deep infra-alveolar

bone defects often requires the simplified papilla preser-

vation technique in interdental spaces, which runs

obliquely through the papilla, from buccal to lingual.36 As

the interdental space generally does not provide enough

access for correct single interrupted suture placement,

the single sling suture is a useful tool for achieving pre-

cise flap adaptation in these cases (Figs 7 to 9).

MBF

A

MPF

Fig 4 Clinical example: An internal hori-zontal mattress suture was used for wound closure after a subepithelial connective tis-sue graft was harvested from the lateral palate for soft tissue ridge augmentation (suture material: Seralene Blue 6/0 DS-15).

Fig 5 Schematic representation of an internal horizontal mat-tress suture (occlusal view).

Fig 6 Schematic diagram demonstrating the use of an internal horizontal mattress suture for flap stabilization (arrow): the palatal masticatory mucosa is used for anchorage (A, anchor; MBF, mobile buccal flap; MPF, mobile palatal flap).



Zuhr et al

Double sling sutures

The double sling suture, a combination of single

interrupted suture and tension-relieving suture,

makes it possible to achieve very good and stable

flap adaptation with relatively little time and effort.37

The first part of the suture achieves tension-free clo-

sure of deeper tissues while providing wound edge

eversion. This facilitates the second part of the

suture to ensure precise wound closure. The double

sling suture is passed through the palatal mastica-

Fig 7 Single sling suture used to close a microsurgical access flap after regenerative periodontal therapy in the maxillary anter-ior region (suture material: Seralene Blue 7/0 DS-15).

MBFA

MPF

Fig 8 Schematic representation of a single sling suture (sagittal view).

Fig 9 Schematic representation of the single sling suture tech-nique for flap stabilization (arrow): the palatal masticatory muco-sa (included in the second pass of the suture) is used for anchorage (A, anchor; MBF, mobile buccal flap; MPF, mobile palatal flap).



Zuhr et al

tory mucosa or the gingiva of the lingual mucosa to

stabilize the wound (Figs 10 to 13).

Suspension sutures

Suspension sutures are used with repositioned flaps to

secure the surgically established flap position if in cases

where the periosteum or attached gingiva does not allow

for sufficient wound stabilization. The teeth or artificially

created retention areas serve as anchors, eg for horizon-

tal or vertical double-crossed sutures, respectively.

The double-crossed suture is a commonly used sus-

pension suture.38 As its name implies, it crosses the

interdental space twice. Horizontal double-crossed

sutures use the circumference of the tooth as an anchor

MBFA

MPF

Figs 10 and 11 Use of two double sling sutures for suture closure after implant placement in the maxillary anterior region (suture material: Seralene Blue 6/0 DS-15), with three additional single interrupted sutures (Seralene Blue 7/0 DS-12).

Fig 12 Schematic representation of a double sling suture tech-nique (sagittal view).

Fig 13 Schematic representation of the double sling suture technique of flap stabilization (arrow): the palatal masticatory mucosa, which was included in the first pass of the suture but was not mobilized, is used for anchorage (A, anchor; MBF, mobile buccal flap; MPF, mobile palatal flap).



Zuhr et al

point. It is used, for example, for donor site closure after

harvesting a free connective tissue graft from the lateral

palate. Additional anchorage of the suture to the pala-

tal masticatory mucosa apical to the harvest site results

in simultaneous wound compression (Figs 14 to 16).

Vertical double-crossed sutures are anchored by

composite resin bonded to the interdental space, coro-

nal to the wound. They are used, for example, after

plastic reconstructive surgery performed by tunneling

technique and entirely without superficial buccal inci-

sions. Vertical double-crossed suture placement allows

for ideal coronal stabilization of augmented tissue as

well as for compression and stabilization of the wound

(Figs 17 to 20).

Fig 14 Horizontal double-crossed sutures used for wound clo-sure after harvesting a subepithelial connective tissue graft from the lateral palate (suture material: Gore-Tex CV5).

Fig 15 Schematic representation of a parallel and a crossed horizontal double-crossed suture (occlusal view).

MF

A1

A2

Fig 16 Schematic representation of a parallel and a crossed horizontal double-crossed suture used for flap stabilization (arrow): a tooth and the palatal masticatory mucosa serve as anchors (A1, anchor 1; A2, anchor 2; MF, mobile flap).



Zuhr et al

DISCUSSION

Perspectives for the future

Various developments and trends toward improving

the currently used wound closure techniques can be

found in the literature. Antimicrobial/antibiotic-coated

sutures as well as suture materials that deliver drugs to

the surrounding tissue have been developed to reduce

the risk of postoperative infection. They offer certain

advantages over conventional suture materials but are

still relatively expensive.39,40

“Smart” sutures made of shape-memory polymers

(SMP) are already being used in minimally invasive car-

diovascular surgery.15,41 They facilitate deep wound

Figs 17 and 18 Vertical double-crossed sutures used for suture closure after the treatment of gingival recession with a modified tunnel technique (suture material: Seralene Blue 6/0 DS-15).

Fig 19 Schematic representation of the vertical double-crossed suture technique (sagittal view).

MF+G

A1

A2

Fig 20 Schematic representation of the vertical double-crossed suture technique for flap and graft stabilization (arrow): Anchor-age is provided by composite resin bonded to the interdental space and the palatal masticatory mucosa (A1, anchor 1; A2, anchor 2; MF+G, mobile flap plus graft).



Zuhr et al

closure because they shrink up to form self-tightening

knots when external energy is applied.

“Barbed sutures” with sharp projections (barbs) on

the material surface are currently used in plastic sur-

gery for closure of deeper tissue layers.42-44 They allow

for knotless wound closure after minimally invasive

surgery; the omission of knots eliminates friction and

thus helps to prevent wound irritation.45 Because these

sutures have a relatively strong tendency to develop

large biofilms when left in place for long periods of

time, they seem to be unsuitable for surgical proced-

ures in the oral cavity.40

In cases where immediate hemostasis is not

needed, wound closure with surgical staples is a

time-saving alternative to suture closure.46 Surgical

staples are still mainly used to close macrosurgical

wounds outside the facial region, and the quality of

wound closure is strongly dependent on the nature of

the tissue involved.39

The use of thrombin, fibrin, and cyanoacrylate glues

that cure on contact with weakly basic fluids, such as

water or blood, is an extremely atraumatic and

time-saving method of wound closure.47 Fibrin glues

are now mainly used in general medicine for endo-

scopic procedures; one of their main advantages is

elimination of the need for postoperative suture

removal.48,49 As evidence suggests that glues do not

result in any significant increase in the tensile strength

of closure,50 their hemostatic effect is clearly the main

emphasis. However, tissue adhesives are rarely used in

periodontal and implant surgery today.

The described developmental approaches show

that current and future surgical suture materials devel-

opment tends to be aimed at making simple and

time-saving wound closure possible, even under diffi-

cult conditions, and at accelerating the pace of healing

more actively than in the past. It remains to be seen

which of these new developments will play a role in

reconstructive periodontal and implant surgery in the

future and will translate into clinical applications that

benefit patients.

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otto zuhr wound closure and wound healing. suture ...a wide range of diﬀerent suture materials are...

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