Periodontology 2000, Val. 11.

1996, 103-1 11
Printed in Denmark All rights reserved

Copyright 0 Miinksgnnrd 1996

PERIODONTOLOGY 2000
ISSN 0906-6713

Suturing techniques for

periodontal plastic surgery
REGANL. MOORE
& MARGARET
HILL
In periodontal surgery, the most common method
of wound closure uses sutures. The primary objectives of suturing are to stabilize and to secure tissues
in their desired locations. Surgical specialties, both
medical and dental, have many unique methods
and materials for wound closure. Generally, the suturing terminology is universal for all medical and
dental uses, and many of the techniques are useful
in more than one discipline. Of the medical surgical
specialties, plastic surgery techniques and materials are probably the most useful for application in
periodontics. Plastic surgery shares some common
goals with periodontal surgery, such as emphasis
on aesthetics, flap rotation and grafting techniques.
In addition, plastic surgery places strong interest in
scar revision and scar prevention in the process of
reconstruction. Review of the plastic surgery literature shows how the importance of suturing is emphasized in perfecting the final result.
Periodontal surgery incorporates many common
issues with plastic surgery but is complicated in
many cases by the additional challenge of dealing
with the periodontal disease process affecting both
soft and hard tissues. Working in the oral cavity
presents other unique surgical management
challenges. The varied anatomy of the area, the
limited access and the conscious patient with an
active tongue and swallowing reflex make speed
and accuracy important throughout the procedure.
Flap stability and durability can also be a problem
during the postoperative period. The mouth is a
moist, movable, and contaminated environment
where healing must take place. At the same time,
the patient continues to function by eating and
speaking. Many patients also participate in other
destructive behaviors such as smoking or poor oral
hygiene, which may undo surgical efforts. These
unique characteristics of procedures performed in
the oral cavity make suturing techniques even more
important in insuring optimum healing results.

Suturing can often be the most tedious part of a

surgical procedure, and some operators have
proposed techniques to eliminate suturing
altogether (8). However, applying the basic
principles and techniques of plastic surgical
suturing can help make suturing more efficient
and improve surgical results.

Three main features of

periodontal plastic suturing
Intraoral anchor points
A major advantage of performing surgical proce-

dures in the oral cavity is the presence of four main

anchoring structures for use in securing movable
tissues. The teeth are the easiest to use and the
most secure of all the intraoral anchors. Teeth are
used typically for sling, or suspensory, suture anchors (11). Bound down tissue, most commonly
the gingiva affixed to bone via periosteum, is the
second most reliable anchor. This tissue is especially important in securing vertical releasing incisions and in areas adjacent to gingival tissue grafts.
Periosteum, either bound down or elevated, can
also be useful for positioning movable tissues.
Loose connective tissue is the least secure anchorage point in the mouth. Connective tissue in the
vestibule is commonly used for suturing mucosal
tissues in vestibular lengthening procedures and in
securing the apical edge of grafts. The fatty tissue
in the retromolar area is another loose connective
tissue anchor source.
Mattress suturing
One major feature of plastic surgery suturing techniques is the use of various types and combinations of mattress suturing. Mattress sutures pro-

103

vide precise flap edge placement and control. They

are less likely to tear through the tissue because the
tearing forces are directed over several vectors, depending on whether the sutures are vertical or horizontal mattresses. They allow the operator to apply downward (inverting) or upward (everting)
pressure at the flap edge. Plastic surgeons generally
prefer a slightly everted skin wound edge, because
this prevents a depressed scar and prevents skin
appendages such as hair follicles and sweat glands
from becoming entrapped in the scar (4). Both inverting and everting (14) sutures are useful in the
mouth depending on the desired result. Mattress
sutures also allow suture material placement away
from the incision line, thus minimizing wicking of
bacteria into the wound (12).
Continuous suturing
The choice of using interrupted or continuous suturing techniques is usually made by operator preference, and most procedures can be completed using either style. The use of continuous suturing in
both plastic surgery (1) and periodontal surgery
has many advantages. Continuous suturing allows
for placement of fewer knots and enables the operator to avoid tying knots in areas that are difficult
to reach. Knot placement can be planned so that
they occur in the buccal anterior and premolar regions. The operator can elect to use 360" loops
around the teeth during placement of a continuous
suture to stabilize the individual sections of a flap
(Fig. le). Several designs of a continuous crossover
behind terminal molars are useful to avoid knots in
posterior areas of the mouth (Fig. 4a). Fewer knots
also make suture removal easier for the operator
and more comfortable for the patient.
In addition, dental assistants can be trained to
"catch and pass" the needle as it is moved through
the interproximal areas, while at the same time
wiping clean and lubricating the suture with a wet
gauze. The speed and convenience of continuous
suture placement is greatly augmented with a welltrained, attentive assistant. One disadvantage to
continuous sutures is that if one suture becomes
unsecured, adjacent areas may also be affected.
This problem can be decreased by use of
continuous mattress sutures and by use of
additional 360" loops for stability. Rarely, patients
perceive an extra bulk of suture material with their
tongue, especially in the maxillary anterior area
when periodontal dressing is not used. The routine

104

use of continuous suspensory suturing is

extremely useful in precise flap placement and
control (6, 10) especially when combined with
mattressing techniques.

General informational
guidelines
Tissue handling and positioning
Sutures are generally used to hold tissues passively
in the desired position. The movement of flaps either apically or coronally should be primarily accomplished by appropriate flap design and placement of incisions. The use of well-placed vertical releasing incisions and adequate reflection of flaps
will allow the tissues to achieve the desired position
and drape passively (61, without forcing or stretching. Attempts to use sutures to unduly stretch tissues past their passive positions because of poor
flap design or inadequate reflection can result in the
suture materials tearing through the flap edges and
subsequent retraction of the flaps to less desirable
positions. Another complication may be creation of
pressure on the tissues, leading to ischemia, necrosis and subsequent tissue slough. The healing
course can be complicated and the surgical result
may be compromised unnecessarily (4).
Close adaptation of flap edges is sometimes
indicated in areas where scarring must be
minimized or when perfusion of grafts is critical,
but an overly tight closure can create problems. In
particular, hemorrhage control should not be
attempted with tight suturing alone. Hematoma
formation and swelling can result, compromising
healing and flap position. Instead, the source of
bleeding should be identified and controlled with
other methods such as degranulation, bone
swedging, arterial ligation, or application of direct
pressure before wound closure is attempted. If
drainage is compromised by unnecessarily tight or
too closely placed sutures, excessive swelling may
result, causing premature suture loss from suture
pullout, and possible flap displacement. The
postoperative course of healing and the surgical
result may be adversely affected (4,9).
The needle entry points, specific suture
selection, and knot placement are often
overlooked issues in terms of the healing result.
Suture material should not pass through tissue too
close to the wound edge. The flap edges are often

Periodontal plastic siirgery suturing

thin and friable, and any pressure will cause

sutures to tear through the flap edge. One tendency
is to place the suture too close to the papilla tip, an
almost sure guarantee of suture pullout. The use of
mattress sutures minimizes tearing as well as
bagging of the tissues between sutures.
Wicking is the phenomena of bacteria moving
along or within multi-stranded suture materials
into the wound. This can be minimized by using
coated or monofilament materials and by using
inverting mattress sutures that keep the suture
materials on the surface of flaps as much as
possible (13) (Fig. 4b). Attentiveness to knot
placement is also important. Measures should be
taken to keep knots out of incision lines and in
more accessible areas. With advance planning,
knots can be placed toward the anterior and buccal
areas of the mouth for ease of placement and
removal, and to prevent the patient from
manipulating the knot with the tongue.
Sutures can also be used as a tool to retract flaps
for photography or to retrieve free gingival or
connective tissue autografts. This is probably less
traumatic to tissue than handling with tissue
forceps (11).

Suture materials and needles

Suturing materials have a long history. Before
modern materials, for example, horse hair was
commonly used for wound closure. Today, there is
a wide variety of suture materials, and choices are
determined by the particular working characteristics of the material and the intended use (2). Suture
materials vary in size (gauge) from 3 - 0 to 11-0.
They come in precut lengths of 18 inches, 24
inches, 27 inches, 30 inches, or in spools of 100
yards for do-it-yourself needle threaders. Suture
materials are generally grouped into two categories; nonabsorbable and absorbable.
Absorbable materials are useful in many specific
situations in periodontal surgery. Plain or chromic
gut sutures are particularly useful in mucosal
tissues. Nonabsorbable sutures placed into
mucosal tissue are difficult to remove at the
postoperative appointment and may cause
discomfort. Absorbable suture materials are good
choices for palatal donor sites for gingival or
connective tissue grafts. These sutures may be
used to retain collagen material in the wound or
act as a meshwork to help retain cyanoacrylate.
Absorbable sutures are always an appropriate

choice in any situation when suture removal may

be compromised, from management problems
such as very young or uncooperative patients, to
areas that are difficult to reach. Absorbable sutures
are often the suture of choice in tissue grafting
procedures, especially in connective tissue grafts,
when some of the sutures may be buried under
flaps. The speed of disintegration of the suture
material may be another consideration when
selecting an absorbable suture material.
Absorbable sutures create an inflammatory
reaction in healing tissues, which is responsible for
the material breakdown. Absorbable suture
materials vary from 3 days to up to 6 weeks in the
time they remain intact in the mouth (15).Even silk
could be classified as absorbable, even though it
takes several years to complete the process (13).
Nonabsorbable sutures are traditionally the
most commonly used suture materials in the
mouth. Black silk suture is unparalleled in ease of
placement
and
handling
characteristics.
Manipulation is simplified due to the lack of
memory in silk. Knots are easy to tie and are
resistant to slippage after placement. The operator
has more control over exactly how long the sutures
are retained in the mouth. Good visibility of the
black suture also aids in accurate placement and in
insuring complete removal of the sutures. One
obvious disadvantage, however, other than
nonresorbability, is the phenomenon of wicking,
or movement of bacteria along or within suture
material, which occurs particularly with silk, but
also with any multistranded suture material. In
situations where this problem may be particularly
critical, such as bone replacement grafting or
guided tissue regeneration procedures, coated
multistranded sutures or monofilament suture
materials may be more appropriate choices.
Coatings minimize but do not prevent wicking and
also act as lubricants to make the passage of the
material through tissue easier. Nylon and Teflon@
monofilament sutures are possible choices; nylon
monofilament
has minimal inflammation
associated with healing, but is difficult to
manipulate intraorally, especially when tylng
knots. Teflon suture material is much easier to use
in the mouth, and has the unique property of
sliding easily upon itself. Teflon is also very
nonreactive in tissue. The high cost of Teflon@
sutures is probably the biggest disadvantage to
their general use.
Both plain and chromic gut sutures are usually

105

Fig. 1. a. Preoperative view of an altered passive eruption

case prior to aesthetic crown-lengthening surgery. b. Most
mattress sutures can be accomplished by passing the needle through both entry and exit points in one motion. Precision placement of the papilla tip can be accomplished by
making the entry point into the papilla and the exit point
near the mucogingival junction. c. Placement of the combination evertinglinverting horizontal mattress suture to
close the releasing incision. The knot is placed on the papilla for precise papilla tip positioning. d. The papilla distal
to the canine has been secured by piercing the palatal aspect of the papilla with the suture, before suspending

around the canine. Note that by piercing the papilla between the canine and lateral incisor, this papilla area is
mattressed in such a way that the movable portion cannot
shift coronally. e. The buccal flap has been sutured in an
apical position for the purpose of aesthetic crown lengthening. The continuous vertical mattress slings are further
stabilized by completely circling the right central incisor.
f. The process of continuous inverting vertical mattresses
and papilla pinning continues across the anterior and is
terminated at the vertical releasing incision on the distobuccal line angle of tooth 11 with a loop tie incorporated
into an inverting horizontal mattress suture.

packaged in alcohol. It is advisable to remove the

alcohol from the surface of the suture material by
wiping with a saline or sterile water soaked gauze

before use. Additional wipings with the wet gauze

during suturing will remove the blood products
that tend to coat the suture material and cause the

106

Periodontal
plastic surgery suturing
_ _ _ _ _ _ _ _ _ _ ~

Fig. 2. a. On the left are two interrupted through-andthrough sutures which tend to allow wound separation between sutures and provide no flap edge control. All tearing
forces are applied at two points and toward the wound
edge. The middle suture is a vertical mattress that distributes tearing forces over four points and at the same time
everts the wound edge. On the right is a horizontal mattress that nicely approximates while everting the wound
edge. It also diverts tearing forces at the four entry/exit
points away from the wound edge. b. Left is an interrupted
everting vertical mattress. Right is an inverted version,
which is used more commonly intraorally, passing between buccal and lingual flaps over papillae tips. c. The left
side of the figure shows a single horizontal mattress. The
right figure is an inverting version, which can also be mod-

ified to make the surface strands form a criss-cross. d. A

continuous through-and-through suture is useful for closing edentulous areas. It is helpful to start the continuous
run with a vertical or horizontal mattress to prevent tear
out and to keep the knot from rolling over into the incision
line. e. A continuous through-and-through interlocking
suture will prevent the incision line from bagging open in
the middle of the wound. Using intermittent loop ties instead of interlocks will accomplish the same purpose, and
is useful in periodontics in situations such as tying down
the edges of a gingival onlay graft. f. Continuous suturing
can be used with almost any other style of suturing. The diagram shows inverting vertical mattresses sewn continuously. This is the basis for vertical mattress sling sutures
used intraorally.

suture to drag as it is passed through the tissue and

to stick both to itself and to the needle holder. It is
inadvisable to use petroleum products to lubricate
suture materials because this practice may
introduce the petroleum products into connective
tissues, possibly creating an unwanted
inflammatory response. Saline or plain water may
be a more suitable choice.
The choice of needle can also be important. The
nomenclature for identifymg needle types is
extremely confusing and varies from one maker to
another. The FS-2 needle on a 4-0 silk is commonly

used for most periodontal flap suturing

applications. It is adaptable for edentulous areas as
well as long enough to pass the needle
interproximally in posterior areas. McGhan
Medical Corporation of Santa Barbara, CA makes
plastic surgery needles with a laser-drilled hole
into which the suture material is inserted.
Reportedly, this needle produces less drag when
passing through tissues and is less likely to become
unswagged during use (17).
For tissue graft placement, a smaller semicircle
needle, such as the P-2, is easier to manipulate due

107

to the smaller arc of rotation as the needle passes

through the tissue. Regardless of the needle type
used, the needle should not be grasped with needle
holders on the swagged part. Repeated pinching of
the swagged area tends to cause the suture to fray
and detach from the needle. Grasping the needle
with needle holders near the tip will dull the
cutting edges. The angle of the needle as it is
grasped in the needle holder should be at 90.
Attempting to grip the needle at obtuse angles will
result in twisting or bending of the needle as it
passes through tissue. The needle should be
rotated along an arc as it is guided through tissues,
rather than forced to go straight. This arc is
established by the curve of the needle itself and
can be altered slightly but is relatively futed. Many
of the mattressing techniques described involve
passing the needle in one hole and out another
with one pass when possible (5) (Fig. lb). The
direction of the needle movement depends on the
type of mattressing intended, either inverting or
everting, but the easiest passes are made from
epithelium into connective tissues using the bone
to support the flap. Penetration of the flap from
connective tissue toward the epithelial surface is
easier when the flap is supported by a suction tip
or elevator.
Special instrumentation
A wide assortment of instruments have been developed for ease and speed of suture placement. Special tissue pickups and needle holders are made for
the purpose of delicate suture placement. A periosteal elevator with a hole in the wide end is helpful for supporting tissue for needle penetration.
Dermatomes and adjustable scalpels have been
designed to aid in graft harvesting. A simple and
useful tool is a graft holder made bv sharpening the
ends of college pliers. It can be used to secure the
movable tissue against bone, freeing the operators
hands for suturing (2).

Suture placement nomenclature

Interrupted sutures
Interrupted sutures are the basic single suture. The
simplest interrupted suture passes once through
each flap, a surgical knot is placed, and the ends
are trimmed. Interrupted through-and-through
sutures pass through flaps once, a surgical knot is

108

placed, and the ends are trimmed. They are the

first sutures that most students learn to place and
often are the only sutures that they use. Placement
of interrupted sutures is a time-consuming process, requiring placement of multiple knots in areas that may be difficult to access. They allow
movement of flaps when buccal and lingual flaps
are tied to each other, rather than to anchor points.
Also, excessive numbers of knots increase the
chance of the knots getting embedded in the pack
material. The interrupted suture can be done in
many forms, including through-and-through, sling
(suspensory), figure eight, single vertical mattress,
horizontal mattress or periosteal tack.
Continuous sutures
Continuous sutures are a series of sutures placed
without cutting or knot tylng between each suture.
They can incorporate any of the same suture forms
suggested in the interrupted forms above, from
through-and-through to periosteal tacks.
Suspensory sutures
Suspensory sutures attach or suspend the flap
from the teeth. They can be single interrupted or
continuous. They are the most precise way to position a flap because the flap is attached to an immovable anchor (teeth) rather than to another
movable flap (Fig. 1). They are also called sling sutures (11).
Through-and-through sutures
A through-and-through means the suture passes
through the flap in just one direction (Fig. 2a).

Mattress sutures
A mattress means the suture passes through the
flap twice. By using inverting horizontal or vertical
mattress sutures, the material does not pass under
the incision line, thus minimizing wicking. Everting mattress sutures are useful in papilla preservation techniques in anterior areas (Fig. 2a).

Vertical mattress sutures

Vertical mattress sutures can be used when greater
control of the wound edge is needed. There are two
main variations on a vertical mattress. The evert-

Periodontal plastic surgery suturing

~~~~

ing vertical mattress is commonly used in closing

skin wounds because it prevents hair and pores
from being trapped in the scar. The invertingvertical mattress is most commonly used in securing
periodontal flaps because the bulk of the suture
lies on top of the tissue and does not cross under

the wound edge (Fig. 2b). Vertical mattresses are

particularly useful in papillae management (14)
(Fig. 3a, 4c).
Horizontal mattress sutures
Horizontal mattress sutures are used when more
precise apposition of wound edges is needed. Horizontal sutures have less tendency to tear through
tissue. There are also two main variations on the
horizontal, inverting and everting. Everting
mattress are often used in skin wounds (Fig. 2c),
whereas inverting are usually used in intraoral
wounds. Horizontal mattresses, vertical mattresses
and through-and-through distribute tearing forces
in 4, 2 and 1 directions respectively (Fig. 2a). The
use of a criss-cross as the suture passes through the
interproximal provides good control of the flap papilla (Fig. 3b) and keeps the suture out of the healing interproximal sulcus area (16).
Continuous through-and-through sutures
Continuous through-and-through sutures are
sometimes used in periodontics in combination
with other continuous methods, but they are more
commonly used to close edentulous areas. These
are sometimes referred to as running or whipstitch continuous sutures (Fig. 2d).
Continuous locking

Fig. 3. Top. The left figure demonstrates a vertical mattress

used on an apically positioned flap papilla. The suture material passes through the palatal portion, across the papilla
tip, mattresses through the papilla and then back through
the palatal aspect before being tied off or used in a continuous run. On the right figure, an everting mattress is used
to maintain papilla height in an aesthetic papilla preservation application. Center. The criss-cross version of the inverting horizontal mattress is especially useful over extraction sites. In tight interproximal areas it prevents suture
material from falling into the interproximal sulcus areas. It
is also useful in areas of bone replacement grafts to keep
suture material away from the grafted material. Bottom.
One variation of a surgical knot. The double throw is used
first, allowing slippage to adjust tissue position and suture
tension. The second throw in the same direction allows further slippage for additional control of suture tension. The
third throw is in the opposite direction, forming a square
knot to secure the suture. With some materials, a simple
square knot with only two throws in opposite directions is
sufficient to stabilize the suture. With suture materials that
possess memory, additional throws are needed.

Continuous locking is a variation on the continuous

through-and-through (Fig. 2e). These are also
sometimes confusingly referred to as continuous
mattress sutures, but continuous blanketis probably more correct. A double continuous throughand-through vertical figure eight is the classic baseball stitch and is sometimes used for tight closure of
subcutaneous layers in general surgery.
Continuous mattress sutures
Continuous mattress sutures can be done as verticals (Fig. 2f) or horizontals, inverting or everting
and interlocking depending on the need, and all
continuous can be done with intermittent loop ties.
Figure eight and criss-cross sutures
Figure eight and criss-cross allows many variations. A criss-cross single horizontal mattress is

109

Fig. 4. a. When both buccal and lingual flaps are joined by

one continuous suture, some method is needed to make
the transition from one side to the other without the use of
knots. Vertical figure eights, horizontal mattresses or 360'
circles around the terminal teeth are just a few useful tools.
If a knot is needed, a loop tie at the distobuccal corner of
the terminal mandibular molar is an option. b. Horizontal
mattress sutures are used to suspend the palatal flap from
the teeth. The sutures act to invert the flap edge and to po-

sition most of the suture material on the surface of the flap,

minimizing wicking. c. Everting vertical mattress sutures
used to maintain papilla tip height when the palatal portion has been reduced from the treatment of osseous defects. d. Palatal closure on the same patient in Fig. 2 shows
from posterior to anterior, a criss-cross inverting horizontal mattress, an everting horizontal mattress, an inverting
vertical mattress, and a simple through-and through.

good for holding gel-foam or dry socket pack or osseous grafts in place (Fig. 3b).

flap in an apical position by encircling and constricting a quantity of mucosal tissue in the apical
part of the flap. When used in combination with a
suspensory technique, the periosteal suture becomes a variation on the vertical inverting mattress suture. The significant difference is that the
suture material is secured into the mucosal tissues below the mucogingival junction rather than
in the gingival tissues. This supposedly minimizes
the tendency for the flaps to hike up around the
necks of the teeth, which would defeat the purpose of pocket reduction via apically positioned
flaps. The vertical inverting periosteal mattress
suture can be placed as continuous sutures to secure buccal and lingual periodontal flaps independently.

Vertical figure eight sutures

The vertical figure eight suture is useful in periodontics because it will prevent wound edges from
overlapping. It can be used in combination with
other suturing methods such as suspensory, mattress and continuous techniques.
Periosteal sutures
Periosteal sutures are a method of using the periosteum as an anchorage for controlling more
movable tissues. The periosteal tack holds the

110

Periodontal plastic surgery suturing

~

Surgical knots

References

Surgical knots have many variations (7).The essential elements allow for the first part of the knot to
give the operator the ability to adjust the tension
on the suture before placing the second part of the
knot, which is a square knot to secure the entire
knot. It requires that the operator remember which
direction (that is, right hand or left hand throw) the
suture is wound around the needle holder tip each
time. A double throw can be substituted for a slip
knot, but generally the first and second wind go the
same direction (making a slip knot) and the third
throw goes the opposite direction (making a square
knot). The number of throws and extra square
knots may depend on the handling characteristics
of the materials (Fig. 3c). General surgeons also use
hand ties, which are simply surgical knots tied
without the benefit of a needle holder. Hand ties
can be useful when making ties on the bracket table or ligating teeth, but are not generally useful intraorally.

1. Adani R, Castagnetti C, Lagana A, Perretti M, Caroli A.

Proposition for a new continuous suturing technique
for microvascular anastomosis: a comparative study. Br
J Plastic Surg 1988: 41: 506-508.
2. Atkinson LJ. Wound closure materials. In: Berry EC,
Kohn ML, ed. Operating room technique. 7th edn. Philadelphia: Mosby Year Book, 1992: 384-403.
3. Barnes RA. But can s / h e operate?: teaching and learning
surgical skills. Curr Surg 1994: 51:256-258.
4. Cocke WM. Basic techniques of plastic surgery. In:
Cocke WM, McShare RH, Silverton JS, ed. Essentials of
plastic surgery. Boston: Little, Brown & Co., 1979: 1-43.
5. Converse JM. Introduction to plastic surgery. In: Converse JM, ed. Reconstructive plastic surgery. Philadelphia: WB Saunders, 1964: 3-20.
6. Dahlberg WH. Incisions and suturing: some basic considerations about each in periodontal flap suturing.
Dent Clin North Am 1969: 13: 149-159.
7. Gumley GJ. Improved suture tying technique in microsurgery. Br J Plast Surg 1988: 41: 95-97.
8. Hoexter DL. The sutureless free gingival graft. J Periodonto1 1979: 50: 75-78.
9. Kopczck RA, Abrams H. Principles of periodontal surgery. In: Hardin JE ed. Clinical dentistry rev. edn. Philadelphia: J.B. Lippincott Co., 1992: 1-20.
10. Malamed EH. A technique for suturing flaps in periodontal surgery. Periodontics 1963: l: 207-210.
11. Morris ML. Suturing techniques in periodontal surgery.
Periodontics 1965: 3:84-89.
12. Myer RD, Antonini CJ. A review of suture materials. I.
Compendium 1989: 10: 260-265.
13. Myer RD, Antonini CJ. A review of suture materials. 11.
Compendium 1989: 10:360-367.
14. Newel DH, Brunsvold MA. A modification of the curtain technique incorporating an internal mattress suture. J Periodontol 1985: 56:484-487.
15. Robert PM, Frank RM. Periodontal guided tissue regeneration with a new resorbable polylactic acid membrane. J Periodontol 1985: 65:414-422.
16. Schluger S. Principles of periodontal surgery. In:
Schluger S, Yuodelis RA, Page RC, ed. Periodontal disease. Philadelphia: Lea & Febiger, 1978: 461-462.
17. vonFraunhofer JA, Johnson JD. A new surgical needle for
periodontology. Gen Dent 1992: 5:418-420.

Tying a loop tie

Tying a loop tie is essentially the same as a regular

surgeons knot, but it allows the operator to place a
knot at the end of a series of continuous sutures
(Fig. If). A series of loop ties is useful for tying
down the edges of a free gingival autograft. These
are more secure than continuous locking sutures.

Conclusion
The use of intraoral anchors, combination mattressing and continuous sutures can provide the
operator with ease and speed of suture placement
while providing precise and secure tissue control.
This chapter describes and depicts the use of these
techniques for a variety of periodontal surgical applications.

111