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The double-sling suture: a modified technique for primary wound closure

Article  in  European journal of esthetic dentistry : official journal of the European Academy of Esthetic Dentistry, The · February 2006
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The Double-Sling Suture: e ss e n z

A Modified Technique
for Primary Wound Closure
Hannes Wachtel, DDS, PhD, Prof Dr med dent
Clinical Associate Professor, Department of Restorative Dentistry
University School of Dental Medicine, Benjamin Franklin Campus
Charité-University Medicine, Berlin, Germany

Stefan Fickl, DDS, Dr med dent

Private Practice, Munich, Germany

Otto Zuhr, DDS, Dr med dent

Private Practice, Munich, Germany

Markus B. Hürzeler, DDS, PhD, Prof Dr med dent

Clinical Associate Professor, Department of Operative Dentistry and Periodontics
School of Dental Medicine, Albert-Ludwigs University, Freiburg, Germany

Correspondence to: Prof Dr Hannes Wachtel

Institute for Periodontology and Implantology, Center for Dentistry,
Rosenkavalierplatz 18, Munich 81925, Germany; fax: 49 89 91 5475; e-mail: hannes@wachtel.bit.

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Abstract
The attainment of primary wound closure is
one of the major determining factors of
success in oral surgery. Especially when
dealing with regenerative or augmentative
procedures, healing in a submerged envi-
ronment is crucial to achieving the desired
treatment result. In this context, the use of
a microsurgical approach and layered su-
turing techniques is of utmost importance
for precise and meticulous wound closure.
However, microsurgical wound closure us-
ing both mattress sutures and interrupted
i
e ss e n z
sutures is very time consuming and may
be detrimental to wound healing because
of trauma and extended surgical time. The
double-sling suture, a modified suture
technique that combines two interrupted
sutures that have different bite sizes and
engage different tissue layers, is able to
predictably and efficiently close the surgi-
cal site for improved wound healing. This
article describes this new technique and
presents two case examples.
(Eur J Esthet Dent 2006;1:xxx–xxx.)

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Reconstruction of dentofacial harmony has
emerged as a major treatment goal in mod-
ern dentistry. Whereas in recent years much
emphasis was placed on achieving a “white
esthetic,” the main focus of modern treat-
ment strategies is shifting toward the estab-
lishment of harmonious gingival architecture.
Therefore, unfavorable wound healing in the
esthetic zone resulting in fibrosis, scar tissue
formation, and tissue necrosis can scarcely
be tolerated and jeopardizes the esthetic
outcome of any surgical intervention.
The duration and predictability of heal-
ing processes that take place in a sub-
merged environment without any bacterial
colonization seem to be superior com-
pared with those associated with healing
1,2
by secondary intention. Precise flap clo-
sure is one of the major determining factors
in achieving wound healing by primary in-
tention and obtaining the desired treatment
3
result. This is particularly true when regen-
erative or augmentative procedures are in-
volved. Data from clinical trials involving
periodontal regenerative surgery have
demonstrated that tissue regeneration can
predictably be achieved when patient-,
defect-, and procedure-associated factors
are considered, with thorough and precise
closure of the surgical site being the most
influential element.2,4 In addition, it has been
shown that when a microsurgical ap-
proach is chosen, up to 6 mm of periodon-
tal attachment gain can be achieved.4 Sim-
ilar principles also are valid for soft or hard
tissue augmentation.5,6 Postsurgical wound
dehiscence and infections resulting in
membrane or graft exposure are usually
followed by a significant amount of often
irreversible tissue recession5,6 (Fig 1).
This article introduces a modified micro-
surgical suture technique that provides for
improved primary wound closure.
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Basic considerations se nz
Wound healing by primary intention is
achieved when intact wound margins are in
intimate contact without any sign of tension
or pressure. This leads to fast bridging of the
incision wound by fibrin, ingrowths of blood
vessels, and epithelial wound closure over a
period of up to 5 days.7 Intimate contact of the
wound margins keeps the amount of tissue
that has to be replaced by granulation tissue
to a minimum.7 Furthermore, the inflamma-
tory reaction to eliminate necrotic and bac-
teria-contaminated tissue fragments is mini-
mized. Hence a closed environment without
bacterial contamination is established im-
mediately after closure of the wound.
Two fundamental factors are involved in
the establishment of primary wound closure
after surgical intervention: careful handling
of the soft tissues and the use of an ade-
quate tension-free suture technique. These
key elements are tremendously improved
when a microsurgical approach is taken.
Microsurgical approach
Hürzeler and Burkhardt showed a signifi-
cant difference in revascularization when
comparing a macro- and a microsurgical
approach for the coverage of recession
type defects.8,9 This difference was evident
immediately after surgery and after up to 7
days of wound healing.8 In addition, a se-
ries of case reports and a controlled clini-
cal study on periodontal regeneration have
clearly demonstrated the benefits of a mi-
crosurgical approach.1,2,10 Data from clinical
studies convey that primary flap closure
could be obtained in more than 90% of all
presented cases when a microsurgical ap-
proach was used.1,2 Moreover, the data
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clearly show that the microsurgical ap- e ss e n z
proach, including delicate handling of the
tissues and precise wound closure, prima-
rily accounts for the favorable healing re-
sults reported in the cited studies.
In addition to optical magnifying devices
and microsurgical instruments and blades
(Fig 2), the microsurgical approach re-
quires accurate and gentle soft and hard
tissue management and meticulous ten-
sion-free suturing. These seem be indis-
pensable determinants for the achieve- Fig 1 Irreversible loss of tissue following membrane

ment of primary wound closure. In terms of exposure and tissue necrosis.

suturing, the suture technique and the su-

ture itself are both of utmost importance.
The tissue reaction to suturing is deter-
mined by the material, the structure, and the
thickness of the suture.11 It has been shown
that nonresorbable monofilament sutures in
small sizes provoke minimal inflammatory
tissue reactions.11 Hence monofilament
polypropylene and polyvinylidenfluroride su-
tures in sizes 6-0 and 7-0 (eg, Seralene,
American Dental Systems) have been devel-
oped and are used to reposition microsurgi-
cal flaps without any tension and force. The
Fig 2 Microsurgical instruments: (top to bottom)
needles exhibit anterior cutting edges that al-
needle holder, pair of scissors, papilla elevator, and a
low them to slide gently through the tissues pair of pliers.
and are between 8 and 15 mm in length in
a 3/8 circle. Long (15-mm) needles can be
particularly helpful for passing through inter-
dental spaces in molar areas (Fig 3).
In addition to the suture material, the
technique for wound closure has a major
impact on the wound-healing processes.
Especially when using the microsurgical
approach, time-consuming suture tech-
niques are often required. As the duration
of surgery increases, the blood supply of
the surgical area is more and more com-
promised,7 therefore a modified suture
technique has been developed to swiftly Fig 3 Polyvinylidenfluroride suture (7-0) with different
and precisely close the wound margins. needle sizes (left to right): HS 8, DSM 12, DSM 15.

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Double-sling suture esse nz
technique
Precise wound closure of a surgical site is
Bite-size Bite-size achieved by adapting the various layers of
tissue. When suturing in the oral cavity, in-
Epithelium
ner (ie, periosteum and deep connective
Connective
tissue tissue) and outer (ie, superficial connective
Periosteum tissue and epithelium) tissue layers should
be approached in a layer-by-layer fashion.
This type of procedure is a basic principle
Fig 4 Wound closure obtained with interrupted su- of plastic surgery.3
tures of identical bite sizes. When adapting wound areas, tradition-
al interrupted sutures are performed
through the entire tissue thickness, includ-
ing the periosteum. Tissue adaptation is
only successful when an identical bite size,
defined as the distance between the inci-
sion line and the point where the needle is
bite-size
bite-size inserted into or exits the tissue, is respect-
ed on each side of the incision (Fig 4). This
Epithelium is essential to achieving tension-free and
Connective perfect adaptation of the flap tissues. When
Tissue
Periosteum accurate bite sizes cannot be established,
eg, in the interproximal spaces, overlap-
ping and folding primarily at the palatal as-
Fig 5 Detrimental effect when an identical bite size is
pect of the flap results, leading to a com-
neglected.
promised wound healing due to gap
formation and colonization by microor-
ganisms (Fig 5).
Therefore, especially in delicate areas
(eg, papillae), a double-layer approach has
to be accomplished using two different su-
tures: A deep horizontal or vertical mattress
suture, which engages the periosteal struc-
tures and deep layers of connective tissue
Epithelium
and increases the divergence of the super-
Connective
Tissue ficial wound areas (Fig 6), and one or more
Periosteum superficial interrupted sutures to close the
outer tissue layer (superficial connective
tissue and epithelium) (Fig 7). This tech-
Fig 6 Horizontal mattress suture closes the deep
wound areas and increases the divergence of the nique ensures adaptation and closure of
superficial wound margins. the inner and outer tissue layers; however,

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it is time consuming and technique sensi- e ss e n z
tive, particularly in the posterior areas. Fur-
thermore, suture removal, especially of the
deep mattress suture, is often painful for the
patient, and suture remnants can be left in
the tissue, leading to disturbance of the
wound-healing process.
Epithelium
Performing two or more microsurgical
Connective
sutures to attain primary closure in each Tissue
surgical area is time consuming. It there- Periosteum
fore can be unfavorable for wound healing
because the vascular supply of the surgi- Fig 7 Several interrupted sutures placed in addition

cal site decreases as the duration of sur- to the horizontal mattress suture to obtain primary clo-
sure of the superficial wound areas.
gery increases. Moreover, an increased
amount of suture material is located in the
soft tissue, especially in regards to the mat-
tress suture, and more tissue manipulation
has to be performed, which can delay heal-
ing of the surgical site because of the as-
sociated trauma and introduction of for-
eign material. The following modified
microsurgical suture, the double-sling su- Epithelium
ture, can overcome these disadvantages. Connective
tissue
The double-sling suture combines two
Periosteum
interrupted sutures, which are performed in
different tissue layers and with different bite
sizes. The first part of the suture ensures the Fig 8 The first part of the double-sling suture. Note that
the needle is guided through the entire flap with a bite
closure of the deep wound areas, while the
size approximately 150% to 200% of the flap thickness.
second is able to precisely adapt the outer
tissue layers. The starting point of the suture
is located at the buccal aspect with the nee-
dle guided through the entire flap with a bite
size approximately 150% to 200% of the
flap thickness. Just as with an interrupted
suture, the needle exits at the palatal aspect
of the flap with the identical bite size (Fig 8).
The needle then is brought back to the start- Epithelium

ing point and inserted superficially through Connective

the buccal flap with a reduced bite size of
approximately 2 mm. The needle exits at
the palatal aspect with yet again a bite size
of 2 mm, engaging only the superficial lay-
ers of the flap (Fig 9). Care should be taken
tissue
Periosteum
Fig 9 The second part of the double sling suture.
Note that the needle only passes through the superfi-
cial areas of the flap with a reduced bite size.

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Epithelium
Connective
Tissue
Periosteum
Fig 10 Tension-free wound closure achieved using
the double-sling suture.
to engage the identical amount of tissue
when the needle is guided through the buc-
cal and palatal flap. To stabilize the suture,
a surgeon’s knot is performed without us-
ing any tension or pressure. Too much ten-
sion on the tissues can jeopardize the blood
supply and compromise early wound heal-
ing. The flaps should be exactly reposi-
tioned with a perfect adaptation of the inner
and outer tissue layers (Figs 10 and 11).
The technique and results are demon-
strated in the following clinical case se-
quences (Figs 12 to 14).
Discussion
The attainment of primary wound closure is
one of the most important determining fac-
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Fig 11 Completed double-sling suture performed
using a macrosurgical suture material.
tors in achieving predictable treatment re-
sults. In order to achieve healing in a sub-
merged environment, the use of a micro-
surgical approach and precise suture
techniques are of utmost importance. A
layer-by-layer suture technique using a
mattress suture and single interrupted su-
tures requires extended surgery time, is
technique-sensitive, and may traumatize
the tissue, whereas the double-sling suture
technique presented here is able to ac-
complish double-layer closure in a simpli-
fied, predictable, and time-efficient fashion.
In addition, the double-sling suture is easy
to remove because both parts of the suture
are positioned externally, similar to a single
interrupted suture, and can be seized
easily by a microsurgical pair of pliers.
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a b

c d

e f

Fig 12 Clinical sequence of the double-sling suture. (a) Starting from the palatal aspect, the needle is guided
through the complete thickness of the flap. (b) The needle reappears at the buccal aspect, having penetrated the
entire buccal flap. (c) After the first sequence of the double-sling suture is completed, the needle is brought back
to the original point of insertion. The needle is guided only superficially through the flap tissue for the second stage
of the suture. (d) The bite size and the amount of tissue involved in the second part of the suture are reduced. (e
and f) This layer-wise suture approach ensures perfect adaptation of the flap tissues, resulting in primary wound
closure.

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a b

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Fig 13 (a) Presurgical status. Soft and hard tissue augmentation in the area of the left central incisor is planned.
(b) Bone augmentation is performed using xenogenous bone substitute (Bio-Oss, Geistlich Biomaterials) and a
double-layer membrane technique (Bio-Gide, Geistlich Biomaterials; Ossix, 3i Implant Innovations). (c) After soft
tissue augmentation with a subepithelial connective tissue graft, wound closure is established with double-sling
sutures. (d and e) Seven days after surgical intervention, uneventful healing with primary wound closure can be
observed. (f) Since most of the double-sling suture is located externally, the suture can be removed easily and
without trauma.

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Fig 14 (a) Frontal view of the defect site. (b) Bone augmentation is performed using xenogenous bone sub-
stitue (Bio-Oss) and a double-layer membrane technique (Bio-Gide and Ossix). (c) Tissue adaptation in the in-
terdental areas of the horizontal releasing incision with the double-sling suture. (d) Primary wound closure is
reached with multiple double-sling sutures. (e) Seven days after surgery, healing was uneventful. (f) Detailed view
of the interdental areas of the releasing incision. Primary wound closure could be obtained after 7 days of healing.

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References

1. Wachtel HC, Hürzeler MB,
Köttgen C, Bolz W, Zuhr O,
Weng D. A microsurgical
approach to guided tissue
regeneration treatment. J Clin
Periodontol 2003;30(suppl 4).
2. Wachtel HC, Schenk G, Böhm
S, Weng D, Zuhr O, Hürzeler
MB. Microsurgical access flap
and enamel matrix derivate for
the treatment of periodontal
intrabony defects: A controlled
clinical study. J Clin Periodon-
tol 2003;30:496–504.
3. Silverstein LH, Kurtzman GM. A
review of dental suturing for
optimal soft tissue manage-
ment. Compend Contin Educ
Dent 2005;26:163–166,
169–170.
4. Cortellini P, Tonetti MS. Clinical
performance of regenerative
strategy for intrabony defects:
Scientific evidence and clinical
experience. J Periodontol
2005;76:341–350.
5. Murphy K. Postoperative heal-
ing complications associated
with Gore-Tex periodontal
materials. 1. Incidence and
characterization. Int J Peri-
odontics Restorative Dent
1995;15:363–375.
6. Selvig K, Kersten B, Wikesjö U.
Surgical treatment of intrabony
periodontal defects using
expanded healing response. J
Periodontol 1993;64:730–733.
7. Wong MEK, Hollinger JO,
Pinero GJ. Integrated process-
es responsible for soft tissue
healing. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod
1996;82:475–492.
8. Burkhardt R, Lang NP. Cover-
age of localized gingival
recessions: Comparison of
micro- and macrosurgical
techniques. J Clin Periodontol
2005;32:287–293.
i
e ss e n z
9. Burkhardt R, Hürzeler MB. Uti-
lization of the surgical micro-
scope for advanced plastic
periodontal surgery. Pract Peri-
odontics Aesthet Dent
2000;12:171–180.
10. Cortellini P, Tonetti MS. Micro-
surgical approach to periodon-
tal regeneration. Initial evalua-
tion in a case cohort. J
Periodontol 2001;72:559–569.
11. Beauchamp PJ, Guzick DS.
Histologic response to micro-
suture materials. J Reprod Med
1988;33:615–623.

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