CASE REPORT

The Triangle Suture for Membrane Fixation in Guided Bone Regeneration

Procedures: A Report of two Cases
Thomas M. Johnson,∗ Sarah M. Vargas,∗ Jennah C. Wagner,∗ Adam R. Lincicum,∗ Brian W. Stancoven∗ and
Douglas D. Lancaster∗

Introduction: Existing evidence supports superior treatment outcomes in guided bone regeneration (GBR) proce-
dures employing membrane fixation. The purpose of this report is to present a specific flap design and suturing method
for stabilizing GBR barrier membranes.
Case Presentation: Two generally healthy patients received GBR using native collagen membranes stabilized with
absorbable sutures. In both cases, we fixed barrier membranes apically using “triangle” sutures. Sling sutures (Case 1)
or triangle sutures (Case 2) secured the crestal and palatal aspects of the membranes. No postoperative complications
occurred, and both sites exhibited favorable alveolar ridge volume for implant placement.
Conclusions: The described triangle suture technique reliably stabilized GBR barrier membranes without the need
for fixation hardware. Compared with suturing methods that limit graft volume and apply pressure over the grafted area,
the triangle suture may offer clinical advantages. Clin Adv Periodontics 2022;0:1–8.
Key Words: Allografts; dental implants; bone regeneration; wound healing; biocompatible materials; sutures.

may enhance space maintenance. Limited evidence

Background
Among the available methods for horizontal alveolar
ridge augmentation (ARA), guided bone regeneration
(GBR) is the most common.1–3 Although GBR techniques
and materials vary considerably, surgeons performing the
procedure must establish several biologic prerequisites
for bone regeneration—space provision, clot stability,
and wound closure for primary intention healing.4,5
Membrane fixation may facilitate graft containment
and contribute to wound stability. Additionally, when
providers utilize semi-rigid barriers, such as dense
polytetrafluoroethylene, fixation at membrane borders
∗ Departmentof Periodontics, Army Postgraduate Dental School, Uni-
formed Services University of the Health Sciences, Fort Gordon,
Georgia, USA
Received November 30, 2021; accepted December 29, 2021
doi: 10.1002/cap.10193
© 2022 American Academy of Periodontology
suggests that GBR protocols involving membrane fixation
achieve significantly greater gains in alveolar ridge
volume.6,7
Because absorbable membranes have demonstrated
superior soft tissue compatibility,8–10 these barriers are
often preferable to non-absorbable membranes for hor-
izontal ARA.11 Dr. Istvan Urban has introduced “the
sausage technique” for horizontal ARA, which involves
the use of an absorbable membrane, a mixture of auto-
genous bone and anorganic bovine bone mineral, and
membrane fixation with multiple titanium pins.11 This
technique assures excellent stability at the membrane
periphery, while the applied graft material generates
tautness in the absorbable barrier. Unfortunately, fix-
ation hardware can add considerable procedural cost,
and hardware retrieval at re-entry surgery may com-
pel more extensive flap reflection than otherwise nec-
essary. In addition, pin/screw fixation offers the poten-
tial for damage to adjacent roots, and placement of
fixation hardware may be taxing or uncomfortable for
patients.
Clinical Advances in Periodontics, Vol. 0, No. 0, January 2022 1
C A S E R E P O R T

FIGURE 1 Case 1. Baseline clinical and radiological assessments. 1a, 1b Buccal and occlusal views of the
horizontal alveolar ridge deficiency in the tooth #4 area. Tooth #3 exhibited buccal gingival recession (RT2A,
recession depth of 2 mm). 1c through 1e Axial, coronal, and sagittal cone-beam computed tomography
images of the site. The treatment plan consisted of guided bone regeneration in the tooth #4 area and staged
implant placement with transalveolar sinus elevation.

FIGURE 2 Case 1. Flap design. 2a Split-thickness dissection beginning ≈ 2 mm apical to the mucogingival
junction resulted in residual submucosa and periosteum attached to the alveolar bone (arrow). We subse-
quently reflected this tissue to establish an inner flap. The inner flap facilitated placement of triangle sutures
and possibly enhanced membrane stability. 2b The attached periosteum and submucosa were also visible in
the occlusal view (arrow).

As an alternative to fixation hardware, clinicians may
utilize absorbable sutures to stabilize GBR barrier mem-
branes. Dr. Rodrigo Neiva and colleagues have presented
the “lasso” GBR method, consisting of a bone substitute
and an absorbable membrane stabilized with internal
sutures.12,13 To fix the membrane, a continuous suture
engages the buccal periosteum and the lingual flap, with
multiple passes over the membrane surface.13 At 76 sites,
the lasso technique resulted in a mean ridge width gain
of 5.9 mm, with 3% of patients experiencing incision line
opening.12 However, internal sutures over the membrane
surface may generate pressure against the graft and limit
space available for bone regeneration.
In this report, we present a “triangle suture” method
applied at the margins of a native collagen membrane
(NCM) and a specific flap design to facilitate api-
cal membrane fixation in GBR procedures. An anima-
tion demonstrating the triangle suture technique (Video
S1) is available in the online Clinical Advances in
Periodontics.
Clinical Presentation, Case
Management, and Clinical Outcomes
Patients in this report presented to the Department of
Periodontics, Army Postgraduate Dental School, Fort

2 Clinical Advances in Periodontics, Vol. 0, No. 0, January 2022 The Triangle Suture
 C A S E R E P O R T

FIGURE 5 Case 1. Stretching of the native collagen membrane over the

applied bone biomaterial. 5a Particulate freeze-dried bone allograft (FDBA)
in place after apical fixation of the membrane. 5b Because the triangle
sutures reliably anchor the membrane apically, the clinician is able to apply
a large volume of FDBA and stretch the barrier over the alveolar crest. In
this case, we applied sling sutures around the adjacent teeth to provide
additional stability and contain FDBA particles.

FIGURE 3 Illustration showing the relationship between the barrier

membrane and the inner flap. In this case, three triangle sutures fixed
the membrane apically. The cutout in this illustration demonstrates
the triangle suture technique. The clinician passes the suture needle
through the base of the inner flap, starting from the superficial aspect.
Next, the clinician engages the membrane ≈ 2 mm from the margin.
Then, starting from the deep aspect, the clinician passes the needle
through the base of the inner flap, keeping the needle position in line
horizontally with the original inner flap entry point. Finally, the clinician
ties a surgeon’s knot to fix the membrane. Unlike a horizontal mattress,
the triangle suture requires only one pass through the membrane—
an advantage when working in a constricted space. This technique
firmly secures the barrier without bunching or distorting the membrane
margin.

FIGURE 6 Sling suture technique. This illustration demonstrates

FIGURE 4 Cross-sectional view illustrating flap design and trian-
gle suture placement. The attached gingiva lacks a submucosa.
Thus, in the attached gingiva, the mucosa is firmly adherent to
the periosteum via dense connective tissue of varying thickness.
Conversely, apical to the mucogingival junction, a distinct sub-
mucosa intervenes between the periosteum and the oral mucosa.
Sharp dissection apical to the mucogingival junction results in
an incision through the periosteum, release of the buccal flap,
and establishment of an inner flap comprising submucosa and
periosteum. The inner flap simplifies the placement of triangle
sutures for membrane fixation and may contribute to membrane
stability.
the precise suture engagement points on the barrier membrane.
These engagement points avoid distorting the membrane margin.
For added stability, the practitioner may apply a triangle suture
to stabilize the palatal aspect of the membrane (not used in this
case). This technique permits alveolar ridge augmentation at the
line angles of adjacent teeth and may promote the establishment
of harmonious osseous contours. The selection of a native colla-
gen membrane may minimize untoward soft tissue responses and
reduce the risk of wound dehiscence.
Gordon, Georgia, and completed an informed consent
process involving verbal and written components. Both
elected GBR prior to implant surgery.

Thomas et al. Clinical Advances in Periodontics, Vol. 0, No. 0, January 2022 3

C A S E R E P O R T

FIGURE 7 Case 1. Sling sutures in place. 7a Buccal view. 7b Occlusal view.

FIGURE 8 Case 1. Wound closure for primary intention healing. 8a Buccal view. 8b Occlusal view.

FIGURE 9 Case 1. Clinical and radiological assessments three months following alveolar ridge augmentation.
9a, 9b Buccal and occlusal views demonstrate favorable ridge volume for implant placement and harmonious
mucosal contours. 9c through 9e Axial, coronal, and sagittal cone-beam computed tomography images of
the site at postoperative month three.

Case 1 at tooth #3, and a pneumatized maxillary sinus (Figure 1).

In August of 2021 a healthy male, aged 32 years, presented The treatment plan included GBR at the tooth #4 area
for implant evaluation to replace missing tooth #4. Clini- and staged implant placement with transalveolar sinus
cal and radiological assessments revealed horizontal ridge elevation. We reflected a full-thickness buccal flap ≈ 2 mm
deficiency at the edentulous site, buccal gingival recession beyond the mucogingival junction with vertical incisions

4 Clinical Advances in Periodontics, Vol. 0, No. 0, January 2022 The Triangle Suture

FIGURE 10 Case 2. Guided bone regeneration, maxillary central incisor area. 10a, 10b Baseline clinical appearance. 10c
Intraoperative view of the alveolar deficiency. A prominent anterior nasal spine aided in space maintenance. 10d Native collagen
membrane fixed apically with triangle sutures. 10e Freeze-dried bone allograft in place. 10f Wound closure for primary intention
healing. In this case, we used two triangle sutures to secure the palatal aspect of the membrane.
FIGURE 11 Illustration showing the technique for stabilizing the palatal
aspect of the membrane using triangle sutures.
at the mesial and distal line angles of teeth #2 and 6,
respectively. Then, we performed split-thickness dissection
to release the buccal flap (Figure 2). We exposed the
alveolar deficiency by reflecting the remaining periosteum
and submucosa, establishing an “inner flap” (Figures 3
and 4). After careful debridement and placement of intra-
marrow penetrations, we trimmed an NCM† to fit the site
and stabilized the barrier apically using triangle sutures‡
(Figures 3 and 4). We applied a 1.2-cc particulate freeze-
dried bone allograft§ (FDBA), stretched the NCM over
† BioGide, Geistlich, Wolhusen, Switzerland
‡ Glycolon 5-0, Osteogenics, Lubbock, TX
§ LifeNet Oragraft, Virginia Beach, VA
Thomas et al.
C A S E R E P O R T
the graft, and stabilized the membrane crestally using
sling sutures (Figures 5–7). Closure involved mattress
sutures at the edentulous site and simple interrupted
sutures interproximally (Figure 8). The patient received
amoxicillin (500 mg) three times daily for seven days
with ibuprofen (800 mg) and acetaminophen (500 mg) as
needed for analgesia. Healing proceeded uneventfully and
no membrane exposure occurred. Three months following
surgery, we noted favorable alveolar ridge volume for
implant placement (Figure 9).
Case 2
A healthy male, aged 23 years, presented in November of
2020 requesting replacement of missing maxillary central
incisors. Clinical and radiological assessments demon-
strated moderate horizontal alveolar ridge deficiency (Fig-
ure 10). We prepared a facial flap, which extended from
tooth #5 to #12, as described in Case 1. Next, we sta-
bilized an NCM apically using triangle sutures, placed a
1.2-cc particulate FDBA, stretched the barrier over the
alveolar crest, and used triangle sutures to fix the palatal
aspect of the membrane (Figure 11). Wound closure and
perioperative medications were as described in Case 1,
and healing was unremarkable. At postoperative month
five, a cone-beam computed tomography volume demon-
strated favorable alveolar ridge dimensions for implant
placement (Figures 12 and 13).
Discussion
Our purpose was to present a suturing technique for
GBR membrane stabilization and a flap design to facil-
itate the placement of these sutures. Many practitioners
 Cytoplast 4-0, BioHorizons, Birmingham, AL
Clinical Advances in Periodontics, Vol. 0, No. 0, January 2022 5
C A S E R E P O R T

FIGURE 12 Case 2. Comparison of baseline and follow-up cone-beam computed tomography

(CBCT) volumes. 12a, 12b Axial and sagittal CBCT images at baseline. 12c, 12d Axial and
sagittal CBCT images at postoperative month five.

FIGURE 13 Case 2. Re-entry for implant placement at postoperative month six. 13a Clinical appearance of healed alveolar ridge.
13b Intraoperative view of alveolar ridge. 13c Direction indicators in place following osteotomy with 2 mm twist drill. 13d Surgical
guide in place during osteotomy preparation with shaping drills. A separate restrictive surgical guide was used for the initial 2-mm
osteotomy. 13e 4.3 × 10 mm implants stabilized in the #8 and #9 positions. Insertion torque ≈ 30 newton centimeters.

include barrier fixation in GBR protocols.6,7,11–13 Mem- we describe in this report involves securing the mem-
brane stability appears biologically relevant,4 and limited brane at its margins. We have consistently observed
clinical evidence supports superior treatment outcomes NCM expansion while stretching the barrier material
when surgeons utilize barrier fixation.6,7 The technique over bone allografts (Figure 5). By avoiding a continuous

6 Clinical Advances in Periodontics, Vol. 0, No. 0, January 2022 The Triangle Suture
 C A S E R E P O R T

periosteal suture over the membrane surface, the described
method may maximize the space available for regenera-
tion and prevent pressure against the graft during early
healing.
Notably, in the presented cases, we did not trim the
barriers to establish a distance between the membranes
and adjacent root surfaces. In contrast, some clinician-
investigators have applied GBR protocols involving
root-membrane separation of ≈ 2 mm, particularly
when employing non-absorbable barriers.1,2,5,9,11 This
approach permits blood supply from the bone and
periodontal ligament to the marginal soft tissue, possi-
bly reducing the risk of wound dehiscence and mem-
brane exposure. However, shifting/trimming the mem-
brane away from tooth roots denies practitioners the
ability to augment the alveolar crest at line angles of
adjacent teeth and may produce less harmonious osseous
contours. Use of an NCM, rather than a non-absorbable
or cross-linked collagen biomaterial, may permit direct
approximation of the barrier against adjacent root sur-
faces (Figures 6 and 7) without untoward effects on the
overlying flap.14 

Summary

Why are these cases new  Securing the barrier peripherally rather than placing sutures over the
information? membrane surface may avoid limiting the graft volume and prevent
generation of apical pressure during early healing.

What are the keys to the
successful management of these
cases?
 The establishment of an inner flap simplifies triangle suture placement
and may contribute to wound stability.
 The simplest method for establishing the inner flap is to begin
partial-thickness dissection ≈ 2 mm apical to the mucogingival junction,
reflecting the inner flap from the alveolar bone secondarily.

What are the primary limitations
to success in these cases?
 Suturing a non-absorbable or cross-linked collagen membrane in direct
approximation with root surfaces may lead to atrophy of the marginal
soft tissue and wound dehiscence.
 Controlled clinical research is necessary to validate the presented
protocol.

Acknowledgments
The authors report no conflicts of interest related to this
report. The views expressed in this manuscript are those
of the authors and do not necessarily reflect the official
policy of the Department of Defense, the Department
of the Army, the United States Army Medical Depart-
ment, or Uniformed Services University of the Health
Sciences. We gratefully acknowledge Ms. Keri L. Jones,
Medical Illustrator and Animator, Dwight David Eisen-
hower Army Medical Center, for the illustrations in this
report.
CORRESPONDENCE
Thomas M. Johnson, 228 East Hospital Road, Fort Gordon, GA 30905,
USA.
Email: thomas.m.johnson34.mil@mail.mil
Supporting Information
Additional supporting information may be found online
in the Supporting Information section at the end of the
article.
References
1. Hämmerle CH, Jung RE. Bone augmentation by means of barrier
membranes. Periodontol 2000. 2003;33:36-53.
2. Benic GI, Hämmerle CH. Horizontal bone augmentation by means of
guided bone regeneration. Periodontol 2000. 2014;66:13-40.
3. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are
the most successful in furnishing bony support for implant placement?
Int J Oral Maxillofac Implants. 2007;22:49-73.

4. Polimeni G, Xiropaidis AV, Wikesjö UM. Biology and principles of
periodontal wound healing/regeneration. Periodontol 2000. 2006;41:
30-47.
5. Wang HL, Boyapati L. “PASS” principles for predictable bone regener-
ation. Implant Dent. 2006;15:8-17.
6. Carpio L, Loza J, Lynch S, Genco R. Guided bone regeneration around
endosseous implants with anorganic bovine bone mineral. A random-
ized controlled trial comparing bioabsorbable versus non-resorbable
barriers. J Periodontol. 2000;71:1743-1749.
7. Phillips DJ, Swenson DT, Johnson TM. Buccal bone thickness adja-
cent to virtual dental implants following guided bone regeneration. J
Periodontol. 2019;90:595-607.
8. Zitzmann NU, Schärer P, Marinello CP. Long-term results of implants
treated with guided bone regeneration: a 5-year prospective study. Int
J Oral Maxillofac Implants. 2001;16:355-366.
9. Zitzmann NU, Naef R, Schärer P. Resorbable versus nonresorbable
membranes in combination with Bio-Oss for guided bone regeneration.
Int J Oral Maxillofac Implants. 1997;12:220-238.

Thomas et al. Clinical Advances in Periodontics, Vol. 0, No. 0, January 2022 7

C A S E R E P O R T
10. Friedmann A, Strietzel FP, Maretzki B, Pitaru S, Bernimoulin JP. His-
tological assessment of augmented jaw bone utilizing a new collagen
barrier membrane compared to a standard barrier membrane to protect
a granular bone substitute material: a randomized clinical trial. Clin
Oral Implants Res. 2002;13:587-594.

11. Urban I. Horizontal ridge augmentation: the sausage technique. In:
Urban I, ed. Vertical and Horizontal Ridge Augmentation. 1st ed.
Quintessence; 2017:117-146.
 indicates key references.
8 Clinical Advances in Periodontics, Vol. 0, No. 0, January 2022
12. Neiva R, Duarte W, Tanello B, Silva F. LASSO GBR–rationale, tech-
nique, and long-term results. Clin Oral Implants Res. 2018;29:447.
https://doi.org/10.1111/clr.332_13358.

13. Silva F, Neiva R. LASSO GBR for lingual alveolar ridge augmentation.
SVOA Dent. 2021;2:10-14.
14. Elgali I, Omar O, Dahlin C, Thomsen P. Guided bone regenera-
tion: materials and biological mechanisms revisited. Eur J Oral Sci.
2017;125:315-337.
The Triangle Suture