Clinical Oral Investigations

https://doi.org/10.1007/s00784-019-03034-4

ORIGINAL ARTICLE

Comparison of four different suture materials in respect to oral

wound healing, microbial colonization, tissue reaction and clinical
features—randomized clinical study
Miroslav Dragovic 1 & Marko Pejovic 1 & Jelena Stepic 1 & Snjezana Colic 1 & Branko Dozic 2 & Svetlana Dragovic 3 &
Milos Lazarevic 4 & Nadja Nikolic 4 & Jelena Milasin 4 & Biljana Milicic 5

Received: 10 May 2019 / Accepted: 16 July 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Objectives Sutures are the most frequently used medical device for wound closure. They support tissue during the early phase of
healing until it regains enough tensile strength. The aim of this study was to compare four different suture materials in terms of the
influence on wound healing, microbial adherence, tissue reaction, and relevant clinical parameters which determine their clinical
value.
Materials and Methods Total number of 32 patients undergoing surgical extraction of four impacted third molars were involved
in the study. Clinical parameters were estimated intraoperatively and during the control check-ups. Soft tissue healing around
sutures were evaluated on the 3rd and 7th day postoperatively. Microbial colonization was assessed by means of qPCR. Also,
histological analysis was done to assess inflammatory reaction.
Results Significantly better soft tissue healing was found around monofilament and synthetic sutures compared to multifilament
and natural ones respectively. Soft tissue healing was significantly better around all sutures on the 7th day than on the 3rd day
postoperatively.
Conclusions Non-resorbable polypropylene suture showed superior clinical characteristics among all sutures. Moreover, the best
healing of soft tissue and the least inflammatory reaction was found around this thread. The poorest soft tissue healing was found
around non-resorbable silk suture. This suture elicited strongest inflammatory reaction and showed the greatest microbial
adherence affinity compared to alternative sutures.
Clinical relevance Monofilament synthetic suture should be used in order to obtain the best soft tissue healing, reduce the risk of
postoperative infection, and alleviate the suturing after oral surgery procedures.

Keywords Sutures . Microbial adherence . Monofilament . Soft tissue healing . Inflammatory reactions . Oral surgery

Introduction

* Biljana Milicic Sutures are the most frequently used medical device for
biljana.milicic@stomf.bg.ac.rs wound closure. Regardless of the suture material origin, its
1
essential role is to support the tissue until continuity of surface
Department of Oral Surgery, School of Dental Medicine, University
of Belgrade, Dr Subotica 8, Belgrade 11000, Serbia
and enough tensile strength is regained during the process of
2
wound healing [1, 2]. Oral wound healing follows the well-
Department of Pathology, School of Dental Medicine, University of
Belgrade, Dr Subotica 8, Belgrade 11000, Serbia
known general principles of wound healing but with certain
3
peculiarities. First of all, oral mucosa is colonized by bacteria
Department of Prosthodontics, School of Dental Medicine,
University of Belgrade, Dr Subotica 8, Belgrade 11000, Serbia
which, in conjunction with food detritus, form biofilm and
4
facilitate wound infection. Secondly, oral wounds cannot be
Department of Human Genetics, School of Dental Medicine,
University of Belgrade, Dr Subotica 8, Belgrade 11000, Serbia
immobilized due to the function of oral tissues. Lastly, these
5
wounds are often in contact with avascular structures (enamel,
Department of Medical Statistics and Informatics, School of Dental
Medicine, University of Belgrade, Dr Subotica 8, Belgrade 11000,
ceramic, metal) and thus devoid of active metabolic exchange
Serbia during the healing process [1]. From a clinical point of view,

there are two types of wound healing. One called healing by
primary intention (per primam intentionem), resulting in re-
generation of specific tissues with the same characteristics as
the tissue prior to trauma. On the other hand, healing by sec-
ondary intention (per secundam intentionem) means that the
tissue is not regenerated but only repaired and replaced with
nonspecific scar tissue [3, 4]. In contemporary oral surgery,
primary healing enabled by the use of sutures along with an
adequate intraoperative handling of soft tissues is an absolute
imperative in order to obtain optimal functional and esthetic
long-term results.
It is widely agreed that all surgical procedures in the mouth
are at risk of postoperative infection which could jeopardize
and delay normal healing. Similarly to other materials being
implanted in the human body, suture materials are also con-
sidered to be a foreign body and factor contributing to a larger
incidence of infections due to its microbial adherence [5–8].
When it comes to surgical site infection, it has been shown that
two thirds of wound infections started around the incision line
and that the number is even greater in the presence of sutures
[8, 9]. Microbial adherence is considered to be one of the key
elements of oral tissue reaction to suture materials [10].
It goes without saying that every material embedded in
human tissues induces some inflammatory reaction deter-
mined by the antigen capacity of various materials and the
sensitivity of host immune system.
There are only a few clinical studies dealing with bacterial
colonization, inflammatory reaction, or influence on healing
of different suture materials [11–16]. In addition, in the field of
oral surgery, there are no clinical studies at all, addressing the
mentioned aspects of suture materials simultaneously.
The goal of this study was to compare four different
suture materials used in oral surgery in terms of their bio-
compatibility, degree of bacterial colonization and inflam-
matory reaction, influence on wound healing, and basic
clinical parameters.
Material and methods
Patients
A total of 32 patients (21 females and 11 males) aged 18–25
indicated for surgical extraction of four totally impacted
wisdom teeth were included in the study. Only healthy pa-
tients, non-smokers without systemic and/or oral diseases,
were included in the study. Using standard surgical protocols,
unilateral upper and lower wisdom teeth have been extracted
at the same time. In the mandible, envelope design for
mucoperiosteal flap was used with sulcular incision going
from the first molar, engaging second molar and extending
buccally along the external oblique ridge. In the maxilla, stan-
dard triangular flap was performed with the vertical releasing
Clin Oral Invest
incision made at the distal part of interdental papilla between
first and second molar. Several interrupted sutures were placed
in order to obtain primary wound healing. After a period of 4–
5 weeks, impacted molars from the other side were extracted
following the described procedure. Each wound was closed
with a different suture material taking care of equal distribu-
tion between jaws. Suture positions for the first patient were
determined by toss of a coin and after that, clockwise rotation
was done until each suture material was placed in every quad-
rant equal number of times. Stitches were removed 7 days
postoperatively. Patients were given uniform postoperative
instructions which included antibiotics regime (amoxicillin
500 mg or clindamycin 300 mg) and rinsing with chlorhex-
idine solution 0.2%, three times a day for 7 days. Patients
were also told to apply cold packs immediately after sur-
gical procedure until bedtime with breaks on every 15 min.
Before the operation and the day after, 4 mg of dexameth-
asone was administered in order to reduce postoperative
swelling and patient discomfort. For pain control, ibupro-
fen 400 mg was prescribed four times a day for the first
2 days postoperatively.
The study was approved by the institutional Ethics
Committee and is in compliance with Helsinki Declaration.
Accordingly, all included patients signed a detailed informed
consent.
The suture materials
The suture materials used in this study were Sofsilk® (non-
absorbable natural multifilament wax coated silk; NA-Multi);
Surgipro® (non-absorbable synthetic monofilament polypro-
pylene; NA-Mono); Polysorb® (absorbable multifilament co-
polymer of glicolide and lactide 9:1—Lactomer® coated with
Ca-stearate and Ε-caprolactone; A-Multi); Caprosyn® (ab-
sorbable monofilament co-polymer of E-caprolactone,
glicolide, trimethylen carbonate, lactide 6:2:2:1—
Polyglytone 6221®; A-Mono). All sutures were 4–0 gauge
with 19 mm, 3/8 circle “reverse cutting” needle produced by
Covidien llc, USA.
Scanning electron microscopy
In order to visualize the surface and the structure of sutures,
samples of all materials used in our study were chosen ran-
domly and analyzed using scanning electron microscopy
(SEM). Specimens were placed on specimen holders and coat-
ed with gold in a gold sputter machine JEOL Fine Coat Ion
Sputter JFC-1100 at 18 mA for 1 min. The specimens were
analyzed and photographed in a JEOL JSM-840A scanning
electron microscope, high vacuum mode using the SE detector
with accelerating voltage.
Clin Oral Invest

MTT assay
In order to assess suture material biocompatibility, MTT
(3-(4,5- dimethylthiazolyl-2)-2,5 diphenyltetrazolium bro-
mide) assay was applied. Gingival fibroblast obtained from a
healthy male patient, 18 years old, was grown in Dulbecco’s
modified Eagle medium supplemented with 10% fetal bovine
serum and 100 U/ml penicillin 100 μg/ml streptomycin
(Sigma-Aldrich, St. Louis, Missouri, USA). The cells were
cultured at 37 °C in humidified atmosphere containing 5%
CO2. The medium was changed every 2–3 days, and the cells
were passaged prior to reaching 70% confluence. Cells used
for the present study were obtained after the third passage.
Ten thousand cells were seeded onto a 96-well plate. After
24 h, four different suture materials were suspended in 100 μl
of growth medium with cells. The growth medium was re-
placed every second day. After 7 days, MTT was added to
each well, incubated for 4 h, and the supernatant with suture
materials was discarded. Precipitates were dissolved in 100 μl
dimethyl sulfoxide (Sigma-Aldrich) by shaking at 37 °C.
Optical density (OD) was measured at 540 nm using an
ELISA reader (RT-2100c, Rayto, China). The percentage of
viable cells was calculated using the following formula: % of
viable cells = OD (sample)/OD (control) × 100. All experi-
ments were done in triplicate.
Microorganisms’ quantification
Knots of all suture materials, obtained from each patient, were
placed into sterile Eppendorf tubes, transferred to the lab and
prepared for microbial analysis. In order to obtain consistent
results, a portion of 4 mm in length of each sample was used
for real-time PCR. Bacterial DNA was isolated using a KAPA
Express Extract DNA Extraction Kit (Kapa Biosystems,
Wilmington, MA, USA) according to manufacturer’s instruc-
tions. DNA extracts were stored at − 20 °C prior to PCR anal-
ysis. Total gene copy number determination was done as de-
scribed by Brajović et al. [17], using Maxima™ SYBR Green/
ROX qPCR Master Mix (Thermo Fisher Scientific) and the
following primers: Fw 5′-TCCTACGGGAGCACAGT′-3 and
Rv 5′GGACTACCAGGGTATCTAATCCTGTT-3′. Real-
time PCR analyses were performed on Line Gene-K
Fluorescence Real-time PCR Detection System (BIOER,
China).
were stained with hematoxylin and eosin (H&E) and exam-
ined under optical microscope. Inflammatory cells were
counted on three different sections of each suture sample
and according to average number, indirect assessment of in-
flammatory reaction was done:
1. NO inflammatory reaction (0 inflammatory cells)
2. MILD inflammatory reaction (< 30 inflammatory cells)
3. MODERATE inflammatory reaction (30–60 inflammato-
ry cells)
4. STRONG inflammatory reaction (> 60 inflammatory
cells)
Clinical parameters
Control check-ups were performed on the first, third, and sev-
enth days postoperatively. Soft tissue healing was judged by
the oral surgeon with the help of healing index (HI) described
by Landry et al. [18] and presented numerically. Using visual
analogue scale (VAS), the operator rated threads with respect
to ease of intraoperative handling immediately after the inter-
vention and ease of removal 7 days later. Patients, using the
same scale, evaluated the discomfort and suture removal pain
for each type of suture. Postoperative amount of slack was
assessed for every suture material with the help of graduated
probe UNC 15. The knot was carefully lifted with cotton
pliers, and the distance from the knot to the tissue was mea-
sured to the nearest 0.5 mm (Fig. 1). In the lower jaw, this
procedure was carried out on the suture which was placed at
the interdental papilla between first and second molar. In the
upper jaw, measuring was done on the suture placed at the
mesial corner of the mucoperiosteal flap.

Histological analysis

One knot of every suture material from each patient was ob-
tained on the day of the removal and immersed in 10% neu-
trally buffered formalin solution. After fixation in ethyl alco-
hol, samples were embedded in paraffin and serial sections,
8 μm in thickness, were made. Only the part of the suture that Fig. 1 Postoperative amount of slack measured by graduated periodontal
was implanted in the tissue was sectioned. Individual sections probe

Statistical analysis
All statistical analyses were done using Statistical Package for
Social Science (SPSS software package, version 24.0; SPSS
Inc., Chicago, IL, USA). Mean, median, standard deviation
(SD), and range were used for description of numeric data.
Descriptive data were expressed as percentage for discrete
measures. Categorical variables were compared using chi-
square test (χ 2 ). Numeric data were analyzed using
Friedman and Wilcoxon test or T test according to p values
obtained by one-sample Kolmogorov-Smirnov test for normal
distribution. Univariate and multivariate linear regression
models were used to assess the relationship between parame-
ters. Dependent variables were microbial adherence, soft tis-
sue healing (seventh day), suture removal pain, suture slack
(seventh day), inflammatory cells, and ease of suture removal.
For each of these dependent variables, separate linear regres-
sion model was done using other relevant observed parame-
ters as explanatory variables. Differences were considered sig-
nificant when the p value was ≤ 0.05.
Results
SEM analysis
All suture threads were analyzed, and substantially more
amount of dental plaque was found on multifilament sutures
compared to monofilament ones as seen on representative
micrographs (Fig. 2).
MTT assay and histological analysis
Microscopic analysis showed more pronounced inflammatory
reaction around multifilament sutures, as a significantly higher
number of inflammatory cells were found around these su-
tures compared to monofilaments (Fig. 3). The highest num-
ber of inflammatory cells was found around NA-Multi
(Sofsilk®) and the smallest number around NA-Mono
(Surgipro®). A statistical difference in the number of inflam-
matory cells was also found between all sutures compared
between them, except between NA-Multi (Sofsilk®) and A-
Multi (Polysorb®). Moreover, incidence and degree of in-
flammatory reaction differed significantly among all sutures
(Fig. 4).
NA-Multi (Sofsilk®) was the suture that attracted gingival
fibroblast the most. Moreover, a statistically significant differ-
ence in percentage of viable fibroblast around this suture com-
pared to NA-Mono (Surgipro®) and A-Mono (Caprosyn®)
(p = 0.023*, p = 0.004* respectively) was observed (Figs. 5
and 6).
Clin Oral Invest
Microorganism quantification
A total of 128 suture samples were examined for microbial
adherence, and significantly lower amount of microbial load
was found on monofilament compared to multifilament su-
tures. Statistically significant differences were found between
suture types compared between them (p = 0.000*) except for
the comparison of NA-Multi (Sofsilk®) and A-Multi
(Polysorb®) (p = 0.243) (Fig. 7).
Clinical parameters
Our findings showed significantly better healing around all
synthetic materials NA-Mono (Surgipro®), A-Mono
(Caprosyn®), and A-Multi (Polysorb®) compared to natural
multifilament NA-Multi (Sofsilk®) both on the third and sev-
enth day postoperatively (Table 1). Further, values for soft
tissue healing obtained on both the third and seventh days
were significantly different between all sutures compared mu-
tually excluding comparison between A-Mono (Caprosyn®)
and A-Multi (Polysorb®) (p = 0.499 on the third day; p =
0.480 on the seventh day).
Significant statistical differences were found between all
sutures regarding the ease of handling and ease of removal
(Table 1). For suture removal pain, statistically significant
difference was found between all sutures but between NA-
Multi (Sofsilk®) and A-Multi (Polysorb®) (p = 0.849).
Although NA-Mono (Surgipro®) caused the greatest discom-
fort to patients among all suture types, the statistical signifi-
cance was found only for the seventh day postoperatively
between this suture and NA-Multi (Sofsilk®) and A-Mono
(Caprosyn®) (p = 0.037*, p = 0.003* respectively) (Table 1).
NA-Mono (Surgipro®) was the suture that exhibited the least
postoperative amount of slack compared to all other sutures
throughout the entire postoperative period (Table 1). When
compared individually, significant difference was found be-
tween all suture types for the 3rd and 7th day postoperatively
excluding the pairwise comparison of NA-Multi (Sofsilk®)
and A-Multi (Polysorb®) (p = 0.819, p = 0.157 respectively).
Intragroup comparison for each type of suture regarding soft
tissue healing, suture slack, and patient discomfort is depicted
in Table 2.
Linear regression analysis
Microbial adherence In the linear regression model in which
microbial adherence was used as dependent variable, the fol-
lowing explanatory variables were found to be independent
predictor of variabilities among patients: suture type, suture
slack (seventh day), ease of suture removal, postoperative in-
fection (Appendix 1 Table 3).
Clin Oral Invest

Fig. 2 Micrographs of knot

region and free end of sutures
after 7 days in oral cavity. a, b
NA-Multi Sofsilk®. c, d NA-
Mono Surgipro®. e, f A-Multi
Polysorb®. g, h A-Mono
Caprosyn®

Soft tissue healing (seventh day) In the linear regression mod-
el in which soft tissue healing (seventh day) was used as de-
pendent variable, only the soft tissue healing (third day) was
found to be the independent predictor of variabilities among
patients (Appendix 2 Table 4).
Suture slack (seventh day) Microbial adherence, suture slack
(third day), and ease of suture removal were found to be in-
dependent predictors of variabilities among patients, in the
linear regression model in which suture slack (7th day) was
used as dependent variable (Appendix 4 Table 6).

Suture removal pain In the linear regression model in which
suture removal pain was used as dependent variable, the in-
flammatory cells and microbial adherence were found to be
independent predictors of variabilities among patients
(Appendix 3 Table 5).
Inflammatory cell number In the regression model in which
inflammatory cells number was used as dependent variable,
ease of suture removal and suture removal pain were found to
be independent predictors of variabilities (Appendix 5
Table 7).

Fig. 3 Microscopic samples
show great number of
inflammatory cells around
multifilament sutures (a, c) and
absence of inflammatory cells
around monofilament sutures (b,
d)
Ease of suture removal Suture type, suture slack (seventh
day), and inflammatory cell number were found to be inde-
pendent predictors of variabilities, in the linear regression
model in which ease of suture removal was used as dependent
variable (Appendix 6 Table 8).
Discussion
The anatomical uniqueness of the oral cavity is responsible for
differences between oral wounds and those in other parts of
human body in terms of propensity to infection occurrence.
The most important physical characteristics of the suture
thread are capillarity and 3D configuration since those factors
directly affect the suture susceptibility for bacterial accumula-
tion and wicking phenomenon (transmission of oral fluids and
bacteria into the wound). In the present study, a significantly
lower quantity of microorganisms was found on monofila-
ment sutures compared to multifilament ones, with the least
bacterial load registered on polypropylene (NA-Mono
Surgipro®) suture. Although there are no clinical studies in-
vestigating the use of polypropylene suture in oral cavity, it
was shown in similar studies that lower microbial amount
populate monofilament nylon and PTFE sutures compared
to silk suture [13, 14, 19, 20]. In the present study, the low
microbial adherence on polypropylene suture is mainly due to
its impeccably smooth surface. This is of great importance
since it is known that bacterial load on the fibers increases
the incidence of infection [13–15, 21]. In our study, the inci-
dence of postoperative delayed infection was registered in 10
out of 128 wounds and 7 out of those 10 infected sites were in
the group of multifilament sutures which is in agreement with
Clin Oral Invest
some other reports [22, 23]. All postoperative infections were
in the lower jaw, and these findings are in accordance with
data from the literature [24, 25]. Although sutures were not
investigated in those studies as important factor affecting de-
layed infection, it was stated that in conjunction with other
factors, sutures may contribute to the onset of postoperative
infection. In our linear regression model, it was found that
suture type, suture slack (seventh day), ease of suture removal,
and incidence of postoperative infection could be used as in-
dependent predictors which describe 34% variabilities among
patients regarding microbial amount. In other words, the ade-
quate choice of suture material is beneficial in order to reduce
the risk for infection.
According to the literature, the ability of suture material to
induce infection corresponds approximately to the degree of
inflammatory reaction caused by sterile suture [23]. The stron-
gest inflammatory reaction in our study was found around NA-
Multi (Sofsilk®) suture. The presence of mild inflammatory
reaction around NA-Mono (Surgipro®) was noticed in 20%
of samples. It is essential to emphasize that a significantly more
pronounced inflammatory reaction was registered around A-
Multi (Polysorb®) suture compared to A-Mono (Caprosyn®)
suture (p = 0.000*). Given that similar tissue reaction was
found around two multifilament sutures in our study (Sofsilk®
and Polysorb®), it appears that physical configuration of the
threads rather than its chemical composition plays a role in
inflammatory reaction, and this is in accordance with the results
of other authors [11, 26–28]. In order to obtain stronger evi-
dence about cell interaction with suture materials, we carried
out in vitro MTT assay using gingival fibroblasts. The percent-
age of viable fibroblasts around sutures indisputably confirms
that polypropylene suture (NA-Mono Surgipro®) is the most
Clin Oral Invest

Fig. 4 Number of inflammatory

cells (mean and std. dev.) and
degree of inflammatory reaction
around different suture types.
*Statistically significant
difference p < 0.05

bioinert suture among all sutures used in our study. This result is minimal damage to the tissue [29–31]. In our linear regression
in accordance with data from literature suggesting that polypro- model, ease of suture removal and suture removal pain were
pylene is a material with extremely smooth surface that induce found to be significantly associated with inflammatory cell

Fig. 5 Percentage of viable

fibroblasts around different types
of sutures (mean and std. dev.).
*Statistically significant
difference p < 0.05

Fig. 6 Micrograph of a gingival fibroblast attached to strands of
multifilament suture (a). Greater magnification of the figure part
marked with black rectangle (b)
number describing 45% of variabilities among patients. Greater
inflammatory reaction will cause greater suture removal pain
while on the other hand, it will have negative impact on the ease
of suture removal.
It can be assumed that minimal tissue damage and absence
of capillarity and wicking effect are the main reasons why the
best soft tissue healing in our study was registered around
polypropylene (NA-Mono Surgipro®) suture. On the other
hand, the poorest tissue regeneration noticed around NA-
Multi (Sofsilk®) suture was probably the consequence of its
rough surface and silk strong antigenic characteristics due to
its natural components. These findings are in accordance with
some previous data [28]. Wounds closed with other two syn-
thetic sutures (A-Multi (Polysorb®) and A-Mono
(Caprosyn®)) showed significantly better soft tissue healing
than those sutured with silk suture. Undoubtedly, primary
Fig. 7 Microbial load on different
suture types (mean and std. dev.)
*Statistically significant
difference p < 0.05
Clin Oral Invest
healing is crucial for the successful postoperative period fol-
lowing oral surgery procedures, particularly those in which
sterile material for the bone and soft tissue augmentation is
used. However, data from the randomized clinical studies
about the influence of sutures on oral wound healing are
scarce. According to our results, it is strongly preferable to
use synthetic monofilament sutures following oral surgery
procedures. Furthermore, on the basis of the results depicted
in Tables 1 and 2, it is the authors’ opinion that is always better
to leave sutures in place for 7 days and not to remove them
earlier. It has been shown in previous experimental studies
using cat model that there is significantly more collagen fibers
in those wounds in which sutures were removed after 7 days
compared to those in which sutures were removed after only
3 days [32]. In line with that, in certain surgical interventions,
the role of sutures is to stabilize and compress the
mucoperiosteal flap against the tissues beneath and not only
to close incisional gap; therefore, sutures should be left in
place for 14 days [33, 34]. Longer tissue support with sutures
could be beneficial in extensive wounds with full thickness
mucoperiosteal flap lying on the avascular tissues such as
tooth, artificial materials, or minimally vascularized cortical
bone. The decision for suture removal should be based on
individual healing response of the tissue, but not too early.
In our linear regression model, it was found that only soft
tissue healing on the third day postoperatively can be used
as independent predictor to describe nearly 50% of variabil-
ities of the soft tissue healing on the seventh day postopera-
tively. Other observed factors, such as suture type, microbial
colonization, and number of inflammatory cells were not
found to be independent predictors of soft tissue healing. It
is most likely that all individuals have unique genetic potential
for oral tissue healing which have greater impact on the
wound healing than mentioned factors. It can be logical ex-
planation why the difference in clinical soft tissue appearance
Clin Oral Invest

Significance
of four similar wounds at each patient is less obvious than the

p = 0.000*
p = 0.000*
p = 0.000*

p = 0.012*
p = 0.001*
p = 0.000*
p = 0.000*
p = 0.000*
p = 0.000*
p = 0.301
p = 0.055
difference between microlocal tissue reaction to various suture
materials or microbial quantity on them.
When it comes to parameters that define the clinical useful-
ness of suture material, the most important, from the surgeon’s
standpoint, is the ease of intraoperative handling. It is generally
86.72 ± 7.21 (84.5; 69–99)
90.47 ± 7.40 (92; 66–100)

10.53 ± 7.11 (9.5; 18–22)

13.75 ± 15.75 (10; 0–58)

accepted that ease of intraoperative handling is a feeling which

9.78 ± 9.78 (5.5; 0–54)

A-Mono (Caprosyn®)

6.34 ± 8.25 (3; 0–29)

0.41 ± 0.50 (0; 0–1)

4.50 ± 0.57 (5; 3–5)

1.13 ± 0.55 (1; 0–2)

4.72 ± 0.46 (5; 4–5)

1.56 ± 0.56 (2; 1–3)
surgeons have during the tying procedure. Minimal tissue-
drag, easiness during knot tying, and a structure that is not
affected by saliva and blood are the main reasons why the
polypropylene suture (NA-Mono Surgipro®) was better than
the alternative ones in our study (Table 1). Very close to poly-
propylene suture was the A-Mono (Caprosyn®) which is the
monofilament suture with exceptional pliability and ease of
intraoperative handling. The color of this suture (undyed) and
20.66 ± 15.78 (16.5; 0–63)
12.56 ± 14.96 (7.5; 0–53)
17.50 ± 18.00 (11; 0–60)

somewhat greater elasticity were the negative sides in compar-

62 ± 9.15 (60.5; 48–86)
68.5 ± 9.02 (70; 50–87)

7.63 ± 9.52 (2.5; 0–30)

0.63 ± 0.71 (0.5; 0–2)
A-Multi (Polysorb®)

ison to polypropylene suture. Undyed sutures are extremely

1.84 ± 0.77 (2; 1–3)

4.41 ± 0.61 (4; 3–5)

4.66 ± 0.54 (5; 3–5)
2.41 ± 0.62 (2; 1–3)

acceptable by patients as they appear to be less traumatic, but

it can be frustrating finding it in the oral cavity. On the other
hand, polypropylene suture is less elastic and gives more pre-
cise information during knot tying which helps surgeons to
dose the force in order to passively approximate wound edges
without excessive pressure on the tissue. Multifilament sutures
imbibe the oral fluids and blood which coagulate and makes
96.47 ± 4.70 (98; 80–100)

them sticky and less controllable in the oral cavity. However, it

19.25 ± 17.42 (13; 0–60)
22.47 ± 14.20 (23; 0–51)
92 ± 5.17 (92.5; 78–100)

12.06 ± 11.04 (10; 0–36)

NA-Mono (Surgipro®)

should be emphasized that A-Multi (Polysorb®) suture was

7.22 ± 5.65 (6; 0–18)

0.13 ± 0.34 (0; 0–1)

0.66 ± 0.48 (1; 0–1)

4.75 ± 0.44 (5; 4–5)

4.94 ± 0.25 (5; 4–5)
0.94 ± 0.25 (1; 0–1)

significantly easier to handle than NA-Multi (Sofsilk®) suture,

so it can be said that both the nature of the suture thread and its
Type of suture (Sample X ± SD (Med; min-max))

coating are elements with significant impact on the suture han-

dling features.
Comparison of different suture types in relation to basic clinical parameters

Tensile strength loss is the second most important factor

that influences clinical convenience of suture material. In our
study, significantly greater postoperative amount of slack was
54.10 ± 10.10 (52.5; 38–76)

found in the group of multifilament sutures. The least tensile

18.38 ± 17.69 (15.5; 0–60)
56.22 ± 13.36 (56; 22–92)

20.19 ± 11.80 (18; 0–56)

strength loss was found for polypropylene (NA-Mono

16.53 ± 21.58 (7; 0–75)

7.81 ± 9.78 (3.5; 0–36)

NA-Multi (Sofsilk®)

Surgipro®) suture and the greatest for silk NA-Multi

0.66 ± 0.70 (1; 0–2)
1.88 ± 0.66 (2; 1–3)

4.09 ± 0.69 (4; 3–5)

2.59 ± 0.62 (3; 2–4)
3.78 ± 0.61 (4; 3–5)

(Sofsilk®). This can be explained by the chemical composi-

tion of these materials. It is known from the literature that in
the fibroin structure of silk suture, 10% of water is found
compared to 0% of water in polypropylene suture structure.
*Statistically significant difference, Friedman test

Consequently, competitive water uptake from the saliva in

case of silk suture leads to disintegration of strands [35, 36].
Interestingly, A-Mono (Caprosyn®) is found to have signifi-
3rd day

3rd day
3rd day

cantly less tensile strength loss after 7 days in oral cavity than
7th day

7th day
7th day
1st day
1st day

A-Multi (Polysorb®). The rationale for this finding is based

Ease of intraoperative handling

not only on the unique chemical composition but is also relat-

ed to plasticity as a physical feature. A-Mono (Caprosyn®) is
the only suture made out of two hard and two soft blocks
Suture removal pain

Soft tissue healing

Patient discomfort

compared to other absorbable sutures mostly comprised of

Ease of removal

Slack of suture

one soft and one hard compositional block. These blocks are
Parameter

responsible for the control of hydrolysis process and loss of

Table 1

tensile strength [37]. On the other hand, multifilament sutures

(NA-Multi (Sofsilk®), A-Multi (Polysorb®)) due to its

Table 2 Intragroup comparison of obtained values for different clinical parameters
Parameter Type of suture
NA-Multi (Sofsilk®)
VS. (p value) 1st day 3rd day
Soft tissue healing 7th day – 0.004*
Slack of suture 3rd day 0.000* – 0.000*
7th day 0.000* 0.000*
Patient discomfort 3rd day 0.367 – 0.330
7th day 0.067 0.000*
*Statistically significant, Wilcoxon test
plasticity are more susceptible to structure changes, deter-
mined by rate of elongation. Rate of elongation is the maximal
elastic stretching after which irreversible structure changes in
the inner material composition occurs. It has been known from
the literature that rate of elongation is between 10 and 15% for
multifilament silk and polyglactin sutures while for the mono-
filament polypropylene and poliglecaprone sutures, it is
around 20–25% [38–40]. Therefore, it can be expected that
multifilament sutures are more prone to irreversible changes
of the material structure due to postoperative edema and con-
sequent suture stretching. Our findings are in line with other
studies in which it was found that polypropylene is the suture
with highest potential of re-adaptation to tissue after swelling
reduction [41]. In our linear regression model, microbial load,
amount of suture slack on the third day postoperatively, and
ease of suture removal were found to be independent predic-
tors which describes almost 70% of variabilities regarding
suture slack on the seventh day. The greater the microbial load
and the greater the amount of suture slack on the third day
means the greater amount of suture slack on the seventh day
postoperatively. On the other hand, lesser ease of suture re-
moval is associated with greater suture slack on the seventh
day postoperatively.
The nature of the material is important when it comes to
ease of suture removal from the tissue. In our study, the easiest
for removal was NA-Mono (Surgipro®) suture and the most
difficult was the NA-Multi (Sofsilk®) suture. It is in accor-
dance with other studies which revealed that the required force
for removal of polypropylene suture is 50% lower than the
force required for removal of silk suture and for about one
third lower than the force required for removal of nylon suture
[42, 43]. In our linear regression model, suture type, inflam-
matory cell number, and suture slack (seventh day) were
found to be independent predictors which describe 65% of
variabilities among patients regarding ease of suture removal.
Thus, it should be taken into account that certain suture types
which induce minor inflammatory reaction and have smaller
suture slack are easier for removal.
Clin Oral Invest
NA-Mono (Surgipro®) A-Multi (Polysorb®) A-Mono (Caprosyn®)
1st day 3rd day 1st day 3rd day 1st day 3rd day
– 0.014* – 0.005* – 0.020*
– 0.000* – 0.000* –
0.000* 0.003* 0.000* 0.000* 0.000* 0.002*
– 0.208 – 0.097 –
0.045* 0.000* 0.079 0.000* 0.210 0.000*
Significantly greater suture removal pain in our study was
related to multifilament sutures compared to monofilament
ones. Probably, the main reason for that is peri-sutural tissue
ingrowth. Other authors reported that greater peri-sutural tis-
sue ingrowth is found in multifilament sutures [44, 45]. In our
linear regression model, it was found that microbial load on
the sutures and number of inflammatory cells are significantly
associated with suture removal pain explaining 20% of vari-
abilities among patients. Therefore, the greater pain during
suture removal could be expected in one fifth of treated pa-
tients when used sutures which elicit greater inflammatory
reaction and have greater microbial adherence.
Our results showed that A-Mono (Caprosyn®) suture was
the most acceptable suture from the patients’ point of view
regarding their discomfort with significantly lower mean values
compared to alternative sutures. According to intragroup com-
parisons, it appears that sutures cause the greatest discomfort in
the first 3 days postoperatively, which is logical as the soft
tissue swelling is the most noticeable during this period.
Although this was the randomized clinical study, some data
may not be absolutely objective as it was not possible to avoid
surgeons’ preferences regarding all clinical features of sutures.
Also, linear regression models could not explain two thirds of
differences among patients when it comes to microbial adher-
ence and one half of variabilities regarding soft tissue healing.
Relatively small sample size may be the reason why certain
outcomes have not been obtained more often through linear
regression analysis, or it may be due to some other factors
which could explain greater percentage of variabilities and
need to be taken into consideration in future research.
Conclusion
Based on our results, it can be said that whenever it is possible,
monofilament synthetic suture should be used in order to obtain
the best soft tissue healing, reduce the risk of postoperative in-
fection, and alleviate the suturing after oral surgery procedures.
Clin Oral Invest

Funding This work was supported by the Ministry of Education, Science
and Technological Development, Republic of Serbia. Grant number: 175075.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.

Appendix 1

Table 3 Linear regression analysis of association of microbial adherence and observed parameters

Univariate model Multivariate model bR2adj = 0.34

a a
Parameters B (95%CI) Sig. B (95%CI) Sig.

Suture type − 13.52 × 106 p = 0.000* − 6.81 × 106 p = 0.050*

(− 20.62 × 106 to (− 6.41 × 106)) (− 13.64 × 106–0.01 × 106)
Soft tissue healing (7th day) − 17.47 × 106 p = 0.014* 7.91 × 106 p = 0.243
(− 31.31 × 106 to (− 3.63 × 106)) (− 5.45 × 106–21.28 × 106)
Patient discomfort (7th day) − 0.09 × 106 p = 0.832
(− 0.95 × 106–0.76 × 106)
Suture slack (7th day) 25.89 × 106 p = 0.000* 14.25 × 106 p = 0.016*
(17.13 × 106–34.65 × 106) (2.75 × 106–25.76 × 106)
Ease of suture removal − 1.36 × 106 p = 0.000* − 0.74 × 106 p = 0.021*
(− 1.76 × 106 to (− 0.96 × 106)) (− 1.36 × 106 to (− 0.11 × 106))
Suture removal pain 0.98 × 106 p = 0.004* 0.04 × 106 p = 0.899
(0.32 × 106–1.64 × 106 (− 0.60 × 106–0.68 × 106)
Postoperative infection 53.24 × 106 p = 0.001* 46.72 × 106 p = 0.000*
(83 × 106–23.47 × 106) (21.09 × 106–72.36 × 106)

*Statistically significant difference

a
Unstandardized coefficient B
b
Adjusted coefficient of determination

Appendix 2

Table 4 Linear regression analysis of association of soft tissue healing (seventh day) and observed parameters

Univariate model Multivariate model bR2adj = 0.46

a a
Parameters B (95%CI) Sig. B (95%CI) Sig.

Suture type 0.159 (0.071–0.248) p = 0.001* − 0.049 (− 0.197–0.010) p = 0.509

qPCR − 2.702E−9 p = 0.014* 1.599E−9 p = 0.379
(− 4.843E−9 to (− 5.623E−10)) (− 2.051E-9–5.248E−9)
Soft tissue healing (3rd day) 0.655 (0.547 to (0.763)) p = 0.000* 0.475 (0.248–0.701) p = 0.000*
Patient discomfort (7th day) 0.004 (− 0.006–0.015) p = 0.409
Suture slack (3rd day) − 0.181 (− 0.308 to (− 0.055)) p = 0.005* 0.100 (− 0.159–0.359) p = 0.436
Suture slack (7th day) − 0.265 (− 0.379 to (− 0.151)) p = 0.000* − 0.026 (− 0.298–0.246) p = 0.846
Ease of suture removal 0.015 (0.010–0.021) p = 0.000* 0.008 (− 0.005–0.022) p = 0.226
Suture removal pain − 0.005 (− 0.014–0.003) p = 0.214
Postoperative infection 0.327 (− 0.057–0.711) p = 0.094
Inflammatory cells − 0.004 (− 0.006 to (− 0.001)) p = 0.002* − 0.002 (− 0.004–0.000) p = 0.109

*Statistically significant difference

a
Unstandardized coefficient B
b
Adjusted coefficient of determination
 Clin Oral Invest

Appendix 3

Table 5 Linear regression analysis of association of suture removal pain and observed parameters

Univariate model Multivariate model bR2adj = 0.20

a a
Parameters B (95%CI) Sig. B (95%CI) Sig.

Suture type − 1.553 (− 3.457–0.350) p = 0.109

qPCR 6.466E−8 p = 0.004* 8.114E−8 p = 0.038*
(2.086E−8 to 1.085E−7) (4.685E−9 to 1.576E−7)
Soft tissue healing (7th day) − 2.281 (− 5.898–1.336) p = 0.214
Patient discomfort (7th day) 0.145 (− 0.073–0.363) p = 0.191
Suture slack (7th day) 5.700 (3.371–8.028) p = 0.000* −0.346 (−4.945–4.254) p = 0.880
Ease of suture removal − 0.312 (− 0.419 (− 0.205)) p = 0.000* 0.093 (−0.164–0.350) p = 0.468
Inflammatory cells 0.061 (0.020–0.103) p = 0.005* 0.060 (0.009–0.113) p = 0.024*

*Statistically significant difference

a
Unstandardized coefficient B
b
Adjusted coefficient of determination

Appendix 4

Table 6 Linear regression analysis of association of suture slack (7th day) and observed parameters

Univariate model Multivariate model aR2adj=0.68

# #
Parameters B (95%CI) Sig. B (95%CI) Sig.

Suture type − 0.163 (− 0.293 to (− 0.032)) p = 0.015* 0.045 (− 0.041–0.130) p = 0.306

qPCR 8.246E-9 p = 0.000* 2.320E−9 p = 0.030*
(5.456E−9 to 1.104E−8) (2.258E−10 to 4.415E−9)
Soft tissue healing (7th day) − 0.546 (− 0.780 to (− 0.312)) p = 0.000* − 0.160 (− 0.324–0.005) p = 0.057
Patient discomfort (7th day) 0.000 (− 0.015–0.015) p = 0.997
Suture slack (1st day) 0.697 (0.485–0.909) p = 0.000* 0.077 (− 0.103–0.257) p = 0.398
Suture slack (3rd day) 0.805 (0.683–0.926) p = 0.000* 0.506 (0.346–0.666) p = 0.000*
Ease of suture removal − 0.0333 (− 0.039 to (− 0.027)) p = 0.000* − 0.013 (− 0.021 to (− 0.005)) p = 0.001*
Suture removal pain 0.028 (0.016–0.039) p = 0.000* 0.004 (− 0.004–0.012) p = 0.295

*Statistically significant difference

a
Unstandardized coefficient B
b
Adjusted coefficient of determination
Clin Oral Invest

Appendix 5

Table 7 Linear regression analysis of association of inflammatory cells number and observed parameters

Univariate model Multivariate model aR2adj=0.45

# #
Parameters B (95%CI) Sig. B (95%CI) Sig.

Suture type − 18.850 (− 38.489 to 0.789) p = 0.059

qPCR 4.9757E−7 p = 0.049* − 1.249E−7 p = 0.604
(2.319E−9 to 9.9283E−7) (− 6.104E−7 to 3.606E−7)
Soft tissue healing (7rd day) − 61.354 (− 98.442 to (− 24.265)) p = 0.002* − 32.578 (− 68.600 to 3.444) p = 0.075
Patient discomfort (7th day) 0.147 (− 2.003 to 2.298) p = 0.890
Suture slack (7th day) 33.397 (5.157 to 61.636) p = 0.022* 1.129 (− 26.177–28.434) p = 0.934
Ease of suture removal − 2.550 (− 3.609 to (− 1.492)) p = 0.000* − 1.822 (− 3.283 to (− 0.361)) p = 0.016*
Suture removal pain 3.094 (0.992 to 5.197) p = 0.005* 2.320 (0.430 to 4.210) p = 0.018*
Postoperative infection − 11.570 (− 98.894–75.753) p = 0.790

*Statistically significant difference

a
Unstandardized coefficient B
b
Adjusted coefficient of determination

Appendix 6

Table 8 Linear regression analysis of association of ease of suture removal and observed parameters

Univariate model Multivariate model aR2adj=0.65

# #
Parameters B (95%CI) Sig. B (95%CI) Sig.

Suture type 6.788 (4.231 to 9.344) p = 0.000* 4.913 (1.501 to 8.325) p = 0.006*
qPCR − 1.936E−7 p = 0.000* − 7.409E−8 p = 0.119
(− 2.506E−7 to (− 1.366E−7)) (− 1.683E-7 to 2.008E−8)
Soft tissue healing (7th day) 14.209 (9.491 to 18.927) p = 0.000* 5.194 (− 2.061 to 12.448) p = 0.155
Patient discomfort (7th day) 0.172 (− 0.149 to 0.493) p = 0.291
Suture slack (7th day) − 14.845 (− 17.492 to (− 12.198)) p = 0.000* −8.129 (− 13.382 to (− 2.875)) p = 0.003*
Suture removal pain − 0.672 (− 0.902 to (− 0.442)) p = 0.000* 0.127 (− 0.279 to 0.533) p = 0.530
Inflammatory cells − 0.151 (− 0.214 to (− 0.088)) p = 0.000* − 0.069 (− 0.134 to (− 0.005)) p = 0.036*

*Statistically significant difference

a
Unstandardized coefficient B
b
Adjusted coefficient of determination

References 4. Polimeni G, Xiropaidis AV, Wikesjo UME (2006) Biology and

1. Siervo S, Lorenzini L (2008) Suturing techniques in oral surgery.
Quintessenza Edizioni, 223 p. [ISBN: 9788874921201]
2. Silverstein LH, Kurtzman GM, Shatz PC (2009) Suturing for opti-
mal soft-tissue management. J Oral Implantol 35(2):82–90. https://
doi.org/10.1563/1548-1336-35.2.82
3. Zuhr O, Hürzeler M (2012) Plastic-esthetic periodontal and implant
surgery: a microsurgical approach. Quintessence Publishing 858 p.
[ISBN: 978-1-85097-226-6]
principles of periodontal wound healing/regeneration. Periodontol
2000 41:30–47. https://doi.org/10.1111/j.1600-0757.2006.00157.x
5. Alexander JW, Kaplan JZ, Altemeier WA (1967) Role of suture
materials in the development of wound infection. Ann Surg
165(2):192–199
6. Edlich RF, Panek PH, Rodeheaver GT, Kurtz LD, Edgerton MT
(1974) Surgical sutures and infection: a biomaterial evaluation. J
Biomed Mater Res 8(3):115–126. https://doi.org/10.1002/jbm.
820080312

7. Sugarman B, Musher D (1981) Adherence of bacteria to suture
materials. Proc Soc Exp Biol Med 167(2):156–160
8. Chu C-C, Williams DF (1984) Effects of physical configuration and
chemical structure of suture materials on bacterial adhesion. Am J
Surg 147(2):197–204. https://doi.org/10.1016/0002-9610(84)
90088-6
9. Favero MS, Gaynes RP, Horan TC, Emori TG, Stroud LA,
Archibald LK et al (1996) National Nosocomial Infections
Surveillance (NNIS) report, data summary from October 1986–
April 1996, issued May 1996. Am J Infect Control 24(5):380–
388. https://doi.org/10.1016/S0196-6553(96)90026-7 [ISBN:
01966553 (ISSN)]
10. McCaul LK, Bagg J, Jenkins WMM (2000) Rate of loss of irradi-
ated polyglactin 910 (Vicryl Rapide) from the mouth: a prospective
study. Br J Oral Maxillofac Surg 38(4):328–330. https://doi.org/10.
1054/bjom.2000.0301
11. Sortino F, Lombardo C, Sciacca A (2008) Silk and polyglycolic
acid in oral surgery: a comparative study. Oral Surg Oral Med
Oral Pathol Oral Radiol Endodontol 105(3):e15–e18. https://doi.
org/10.1016/j.tripleo.2007.09.019
12. Pons-Vicente O, López-Jiménez L, Sánchez-Garcés MA, Sala-
Pérez S, Gay-Escoda C (2011) A comparative study between two
different suture materials in oral implantology. Clin Oral Implants
Res 22(3):282–288. https://doi.org/10.1111/j.1600-0501.2010.
01993.x
13. Banche G, Roana J, Mandras N, Amasio M, Gallesio C, Allizond V,
Angeretti A, Tullio V, Cuffini AM (2007) Microbial adherence on
various intraoral suture materials in patients undergoing dental sur-
gery. J Oral Maxillofac Surg 65(8):1503–1507. https://doi.org/10.
1016/j.joms.2006.10.066
14. Leknes KN, Røynstrand IT, Selvig KA (2005) Human gingival
tissue reactions to silk and expanded polytetrafluoroethylene su-
tures. J Periodontol 76(1):34–42. https://doi.org/10.1902/jop.2005.
76.1.34
15. Otten JE, Wiedmann-Al-Ahmad M, Jahnke H, Pelz K (2005)
Bacterial colonization on different suture materials - a potential risk
for intraoral dentoalveolar surgery. J Biomed Mater Res B Appl
Biomater 74(1):627–635. https://doi.org/10.1002/jbm.b.30250
16. Dragović M, Pejović M, Stepić J, Dragović S (2017) Microbial
adherence affinity and clinical characteristics of polypropylene ver-
sus silk sutures in oral surgery. Srp Arh Celok Lek (Online First
October 10):1–9. https://doi.org/10.2298/SARH170428184D
17. Brajovic G, Popovic B, Puletic M, Kostic M, Milasin J (2016)
Estimation of total bacteria by real-time PCR in patients with peri-
odontal disease. Srp Arh Celok Lek 144(1–2):10–14. https://doi.
org/10.2298/SARH1602010B
18. Landry RG, Turnbull RS, Howley T (1988) Effectiveness of
benzydamyne HCl in the treatment of periodontal post-surgical
patients. Res Clin Forums 10:105–118
19. Katz S, Izhar M, Mirelman D (1981) Bacterial adherence to surgical
sutures. A possible factor in suture induced infection. Ann Surg
194(1):35–41
20. Asher R, Chacartchi T, Tandlich M, Shapira L, Polak D (2018)
Microbial accumulation on different suture materials following oral
surgery: a randomized controlled study. Clin Oral Investig 23:1–7.
https://doi.org/10.1007/s00784-018-2476-0
21. Leknes KN, Selvig KA, Boe OE, Wikesjo UM (2005) Tissue reac-
tions to sutures in the presence and absence of anti-infective thera-
py. J Clin Periodontol 32(2):130–138. https://doi.org/10.1111/j.
1600-051X.2005.00647.x
22. Sharp WV, Belden TA, King PH, Teague PC (1982) Suture resis-
tance to infection. Surgery. 91(1):61–63
23. James RC, MacLEOD CJ (1961) Induction of Staphyloccocal in-
fections in mice with small Inocula introduced on sutures. Br J Exp
Pathol 42(3):266–277
Clin Oral Invest
24. Monaco G, Cecchini S, Gatto MR, Pelliccioni GA (2016) Delayed
onset infections after lower third molar germectomy could be relat-
ed to the space distal to the second molar. Int J Oral Maxillofac Surg
46(3):6–11. https://doi.org/10.1016/j.ijom.2016.09.011
25. Figueiredo R, Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda
C (2007) Delayed-onset infections after lower third molar extrac-
tion: a case-control study. J Oral Maxillofac Surg 65(1):97–102.
https://doi.org/10.1016/j.joms.2005.10.063
26. Javed F, Al-Askar M, Almas K, Romanos GE, Al-Hezaimi K
(2012) Tissue reactions to various suture materials used in oral
surgical interventions. ISRN Dent 2012:1–6. https://doi.org/10.
5402/2012/762095
27. Postlethwait RW (1979) Five year study of tissue reaction to syn-
thetic sutures. Ann Surg 190(1):54–57. https://doi.org/10.1097/
00000658-197907000-00012
28. Abi Rached RS, de Toledo BE, Okamoto T, Marcantonio Júnior E,
Sampaio JE, Orrico SR et al (1992) Reaction of the human gingival
tissue to different suture materials used in periodontal surgery. Braz
Dent J 2(2):103–113
29. Goel A (2016) Surgical sutures - a review. Delhi J Ophthalmol (26):
159–162. https://doi.org/10.7869/djo.161
30. Tobias KM, Johnston SA (2013) Veterinary surgery: small animal.
Elsevier Health Sciences. 2332 p. [ISBN: 9780323263375]
31. Ratner BD, Hoffman AS, Schoen FJ, Lemons JE (2004)
Biomaterials science: an introduction to materials in medicine,
2nd edn. Elsevier Inc. 851 p. [ISBN: 0125824637]
32. Selvig KA, Torabinejad M (1996) Wound healing after
mucoperiosteal surgery in the cat. J Endod 22(10):507–515.
https://doi.org/10.1016/S0099-2399(96)80008-2 [ISBN: 0099–
2399]
33. Lindhe J, Wennström J (2015) Periodontal surgery: access therapy.
In: Lindhe J, Lang NP (eds) Clinical periodontology and implant
dentistry, 6th edn. John Wiley & Sons, Ltd., pp 767–804 [ISBN:
978-0-470-67248-8]
34. Chambrone L (2015) Evidence-based periodontal and peri-implant
plastic surgery. Springer International Publishing, Switzerland 323
p. [ISBN: 978-3-319-13975-3]
35. Robson RM (1985) Silk: composition, structure and properties. In:
Lewin M, Pearce E (eds) Fiber chemistry, handbook of fiber science
and technology, vol IV. Marcel Dekker, Inc
36. Lewin M, Pearce E (2007. 505–576 p) In: Lewin M, Pearce E (eds)
Handbook of fiber chemistry, Handbook of fiber chemistry, 3rd
e d n . C R C P r e s s , I n c . h t t p s : / / d o i . o rg / 1 0 . 1 0 0 2 / 1 5 2 1 -
3773(20010316)40:6<9823::AID-ANIE9823>3.3.CO;2-C]
[ISBN: 0824794710]
37. Chu CC (2013) Materials for absorbable and nonabsorbable surgi-
cal sutures. In: King MW, Gupta BS, Guidoin R (eds) Biotextiles as
medical implants. Woodhead Publishing Limited, pp 275–334.
https://doi.org/10.1533/9780857095602.2.275 [ISBN:
9781845694395]
38. Kim JC, Lee YK, Lim BS, Rhee SH, Yang HC (2007) Comparison
of tensile and knot security properties of surgical sutures. J Mater
Sci Mater Med 18(12):2363–2369. https://doi.org/10.1007/s10856-
007-3114-6
39. Zhang X (2017) Science and principles of biodegradable and bio-
resorbable medical polymers materials and properties. Elsevier Inc.
458 p. [ISBN: 9781782420163]
40. Naleway SE, Lear W, Kruzic JJ, Maughan CB (2015) Mechanical
properties of suture materials in general and cutaneous surgery. J
Biomed Mater Res B Appl Biomater 103(4):735–742. https://doi.
org/10.1002/jbm.b.33171 [ISBN: 1552–4981]
41. Hochberg J, Meyer KM, Marion MD (2009) Suture choice a nd
other methods of skin closure. Surg Clin NA 89(3):627–641.
https://doi.org/10.1016/j.suc.2009.03.001
42. Freeman BS, Homsy CA, Fissette J, Hardy SB (1970) An analysis
of suture withdrawal stress. Surg Gynecol Obstet 131(3):441–448
Clin Oral Invest
43. Homsy CA, McDonald KE, Akers WW, Short C, Freeman BS
(1968) Surgical suture-canine tissue interaction for six common
suture types. J Biomed Mater Res 2(2):215–230. https://doi.org/
10.1002/jbm.820020205
44. Ordman LJ, Gillman T (1966) Studies in the healing of cutaneous
wounds. I. the healing of incisions through the skin of pigs. Arch
Surg 93(6):857–882. https://doi.org/10.1001/archsurg.1966.
01330060001001
45. Homsy CA, Fissette J, Watkins WS 3rd, Williams HO, Freeman BS
(1969) Surgical suture-porcine subcuticular tissue interaction. J
Biomed Mater Res 3(2):383–402. https://doi.org/10.1002/jbm.
820030216
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