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ORIGINAL RESEARCH Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 2  |  Page : 72-77
Healing of periodontal flaps when closed with silk sutures and N-butyl cyanoacrylate: A clinical and histological study


Dept. of Periodontics, S. D. M. College of Dental Sciences and Hospital, Dharwad, India

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Date of Submission20-Jun-2006
Date of Decision27-Oct-2006
Date of Acceptance05-Nov-2006
 

   Abstract 

Background: The closure of the periodontal flaps post-surgery is a necessity for attainment of a primary union between the flap margins and the establishment of a healthy dentogingival junction. N-butyl cyanoacrylate is a tissue adhesive, which can be used for the closure of the incised wounds to overcome the problems associated with conventional suture materials like silk. Objective: The present study was carried out to assess the healing of the periodontal flaps when closed with the conventional silk sutures and N-butyl cyanoacrylate. Materials and Methods: The study was carried out on 24 patients who needed flap surgical procedure for pocket therapy. Results: It was found that healing with the cyanoacrylate is associated with less amount of inflammation during the first week when compared with silk. However, over a period of 21 days to 6 weeks, the sites treated with both the materials showed similar healing patterns. Conclusion: It can be concluded that cyanoacrylate aids in early initial healing.

Keywords: Cyanoacrylate, healing, silk suture

How to cite this article:
Kulkarni S, Dodwad V, Chava V. Healing of periodontal flaps when closed with silk sutures and N-butyl cyanoacrylate: A clinical and histological study. Indian J Dent Res 2007;18:72-7

How to cite this URL:
Kulkarni S, Dodwad V, Chava V. Healing of periodontal flaps when closed with silk sutures and N-butyl cyanoacrylate: A clinical and histological study. Indian J Dent Res [serial online] 2007 [cited 2019 Oct 14];18:72-7. Available from: http://www.ijdr.in/text.asp?2007/18/2/72/32424
Periodontal surgical procedures are routinely carried out for management of disease-induced changes in the periodontal tissues. Close postoperative adaptation of the flap onto the prepared root surface and the maintenance of this adaptation for a period of time holds the key to the reestablishment of a healthy dentogingival unit.[1],[2],[3]

Materials like silk, nylon, steel, catgut and polyglycolic-polylactic acid derivatives are being used for the post-operative closure of the flaps.

Braided silk is the most common suture used for closure of oral wounds. It has the phenomenon of 'wicking,' which makes it a site for retention and ingress of bacteria into the tissues and thus a reservoir of secondary infection. It has been found that silk has maximum amount of inflammatory tissue response (Posthelwaite 1974). So in order to overcome these difficulties, a need for an alternative to sutures is always felt.[3],[4],[5]

Cyanoacrylates[3],[6],[7] are tissue-adhesive materials that were synthesized in 1959 by Coover et al . The cyanoacrylate materials have a chemical formula H 2 C = C (CN) COOR, where R-can be substituted for any alkyl group ranging from methyl to decyl. The earlier methyl homologues were found to be histotoxic and thus were discontinued in clinical practice.[3] N-butyl cyanoacrylate (NBC) is a biocompatible tissue adhesive and is hence used for closure of wounds.

The present study was carried out to evaluate and compare the healing of periodontal flaps when closed with silk sutures and NBC.


   Materials and Methods Top


This comparative clinico-histological study was carried out at the Dept. of Periodontics and Dept. of Oral Pathology, S. D. M. College of Dental Sciences and Hospital, Dharwad. The required ethical clearance was obtained from the college. The test materials used in the study were 3-0 black braided silk and N-butyl-2-cyanoacrylate.

Twenty-four patients, in the age group of 35-50 years with 6-mm or deep periodontal pockets, indicated for periodontal flap surgical procedures were included in the study. Patients' consent was taken prior to inclusion in the study. Uncooperative patients, patients with any systemic condition that might affect the treatment, and patients with habits of smoking, tobacco chewing or any other habits that might influence the disease or the treatment were excluded from the study.

All the patients selected for the study were divided into three groups, eight patients per group: Group A - 7th day group; Group B - 21st day group; Group C - 6th weekday group. In each patient, a split mouth design was employed. The surgical procedure consisted of a full thickness mucoperiosteal flap, elevation, debridement, and root planning. The selection of the site for suture and cyanoacrylate was done randomly. Simple loop interdental ligation was done with 3-0 black braided silk sutures on one half of the surgical area. Closure on the cyanoacrylate site was done with N-butyl-2-cyanoacrylate[8],[9] [Figure - 1]. The cyanoacrylate was placed in a drop-wise manner on the flap margins, which were held in place. The application was done till a thin film of set cyanoacrylate formed. Once the flaps were closed, no periodontal dressings were placed. Postoperative instructions were given. No antibiotics or analgesics were prescribed. All the patients were recalled after 7 days. On the 7th day, the sutures were removed and any cyanoacrylate present was also removed [Figure - 2]. Standardized gingival punch biopsies were taken with a 5-mm diameter punch, from the interdental regions. Care was taken so as to include the area of the suture in the tissue. The patients belonging to groups B and C were recalled on the 21st day and 6th weekday respectively, the study parameters were recorded and the biopsies were taken. The biopsies were then sent, processed and stained with hematoxyllin and eosin stains for histological assessment.

Parameters assessed

The Turesky-Gilmore-Glickman modification of the Quigley-Hein Plaque index and the Loe and Silness gingival index were used to record the respective data.

The biopsy specimens were first observed under the microscope at 10x magnification for assessment of the epithelium. Then, three areas with maximum amount of inflammatory cells were selected and were assessed for the counting of the inflammatory cells and vascularity (endothelial proliferation) at 40x magnification.


   Results Top


In the comparative analysis done between the suture and the NBC sites, the following results were obtained.

Clinical

The clinical results revealed that, plaque index scores of the suture and the cyanoacrylate sites in the 7th day group (Group A) were significantly different ( P < 0.01), as shown in [Table - 1].

The gingival index scores of sutures and cyanoacrylates were compared; the scores showed statistically significant difference in Group A ( P < 0.01), as shown in [Table - 2].

Histological results

The epithelium did not show any signs of atrophy, hypertrophy or dysplasia. Connective tissue appeared disorganized, with high amount of inflammatory cells at 7 days on both the suture and cyanoacrylate sides. But on the 21st day and 6th weekday, the gingival connective tissue had more organized connective tissue fibers, with less number of inflammatory cells.

The cells observed were polymorphonuclear lymphocytes (PMNs), chronic inflammatory cells and fibroblasts. The acute inflammatory cells (PMNs) were present only in the 7th day group (Group A).

The chronic inflammatory cells were present in all specimens. No histiocytes, foreign body giant cells, phagocytes were detected. The chronic inflammatory cells were present on all the three observation days in both the sites. Statistically significant ( P < 0.01) difference between the suture and cyanoacrylate sites was detected only in Group A, as shown in [Table - 3] [Figure - 3],[Figure - 4],[Figure - 5],[Figure - 6],[Figure - 7],[Figure - 8].

When the assessment of the vascularity was done, no statistical difference was found, as shown in [Table - 4].


   Discussion Top


The present study was carried out to evaluate the healing of periodontal flaps when closed with sutures and cyanoacrylate and also to compare the healing and tissue response to both the materials.

NBC and its isoform iso-butyl cyanoacrylate are biocompatible tissue adhesives and have good working properties like flow and fast setting, within 5-10 s. Tissue adhesion is by valence bonding and van der Waal's force (Miller et al. ).[4] NBC sets by polymerization in presence of moisture and even blood, with release of heat. It is also a good hemostat. NBC is found to be bacteriostatic, and reduced postoperative pain has been found in sites closed with NBC. The material is degraded by breaking the C=C bond and is eliminated from the body through urine and faeces. It has good bonding properties and strength to hold the tissue margins together (McGraw and Caffesse),[7] hemostatic property (Greer).[10]

In our study, the increased plaque score at the suture site in Group A can be attributed to the difficulty in oral hygiene maintenance post-surgery. This may be related to suture threads acting as sites of plaque accumulation, which is similar to those reported by Binnie and Forrest,[11] Giray et al.[12] This was absent in Groups B and C; this is because of the absence of the test materials, which were removed at 7 days. This is in concurrence with Binnie and Forrest[11] and Giray et al .[12]

The gingival index is an indicator of inflammation and response of the tissues to both the materials. In the Group A, the significant difference in the scores between the suture and the cyanoacrylate sites can be attributed to the presence of the silk material within the tissue and also to increased plaque accumulation. In a previous study by us (Kulkarni and Chava)[13] done on rabbits, it was found that the clinically appearing redness was more on the suture site than on the cyanoacrylate site. This can be attributed to the fact that silk was present within the tissues, which might have provoked the response, according to Macht and Krizek,[14] whereas Levin[3] attributed the increased inflammatory response to silk, because silk being a foreign protein is treated as such by the body and it has a tendency to fragment the wound. However, Giray et al.[12],[15] attribute it to the trauma during suturing and also to the increased plaque accumulation at the suture site.

The reduced inflammation in Groups B and C can be related to the fact that the sutures were removed on the 7th day. This finding is similar to those reported by Kulkarni and Chava[13] at the end of 21-day period and is in accordance with Giray et al. ,[12],[15] Binnie and Forrest,[10] who attribute it to the removal of sutures resulting in less plaque accumulation.

The standardized punch gingival biopsies were taken from the interdental region to assess the tissue response of the test materials histologically. The histological analysis revealed no alteration in epithelialization in all the groups at both the suture and cyanoacrylate sides, similar to the reports by Giray et al. ,[12] Kulkarni and Chava.[13] However, in studies done by Greer,[10] there was a retardation of the epithelialization with cyanoacrylate, which was attributed to the force of the spray gun and the entrapment of the material within the tissues.

There was certain amount of acute inflammation in the biopsies from Group A. But in the groups B and C, the inflammation was mainly chronic in nature, similar to any wound healing with primary intention. This can be attributed to the fact that acute inflammation is more by 3-4 days and is taken over by chronic inflammation. In all the three groups, healing was uneventful and proceeded in a normal way except for slightly increased inflammatory infiltration on the suture site. This is similar to the findings reported by Giray et al .[12],[15] However, Kulkarni and Chava[13] reported the presence of a few eosinophils at the end of 7-day period in a study on rabbits and attributed it to a mild hypersensitivity response to the test materials.

There was certain amount of acute inflammation in the biopsies from Group A. But in the groups B and C, the inflammation was mainly chronic in nature, similar to any wound healing with primary infection. This can be attributed to the fact that acute inflammation is more by 3-4 days and is taken over by chronic inflammation. In all the three groups, healing was uneventful and proceeded in a normal way except for slightly increased inflammatory infiltration on the suture site. This is similar to the findings reported by Giray et al .[12],[15] However, Kulkarni and Chava[13] reported the presence of a few eosinophils at the end of 7-day period in a study on rabbits and attributed it to a mild hypersensitivity response to the test materials.

When the chronic inflammatory response and the overall cellularity were compared in group A at both the sites, cyanoacrylate site showed less inflammatory cell response as compared to suture site. This finding is in accordance with studies conducted by Bhasker and Frisch,[16] Binnie and Forrest,[11] Greer,[10] Giray et al.,[12] Kulkarni and Chava.[13] This can be corroborated with increased gingival index clinically. In groups B and C, only chronic inflammatory cells were detected without much of difference in the amount of infiltrates. These findings are in conjunction with those reported by Bhasker and Frisch,[16] Forrest,[17] Binnie and Forrest,[11] Greer,[10] Giray et al.,[12] Kulkarni and Chava.[13] Giant cell proliferation or histiocytes were not detected in either of the sites in our study. However, Greer[10] reported presence of microhistiocytes at 6 weeks, and Miller et al.[4] reported some giant cell proliferation on the cyanoacrylate site. However, Giray et al.[12],[15] did not report any giant cells in the cyanoacrylate site but found giant cell proliferation on the suture site on the 14th postoperative day. Bhasker and Frisch[16] said that there would be giant cell reaction, phagocytosis if the cyanoacrylate material were to be implanted deep into the tissue, which was not the case in the study, as the material was placed superficially.

The vascularity was normal to slight hyper-vascularity because of endothelial proliferation in both the sites. This can be attributed to the proliferation of vessels as a part of the normal healing process. This is in agreement with studies conducted by Giray et al.[15]

When the connective tissue was evaluated over the days, the connective tissue was seen getting organized as the healing proceeded.

In our study, there was a correlation between the clinical and the histological findings, i.e., the intensity of the clinical inflammation was reflected in the histological picture with the amount of cellularity, which is similar to the finding by Bhasker and Frisch.[16] However, Javelet et al.[18] did not find any correlation between the clinical and histological features at 3 weeks, but over 10-20 weeks there was correlation between the two.


   Conclusions Top


From this study, following conclusions can be drawn:

  1. Periodontal flaps healed by primary union when closed with sutures and with NBC.
  2. Clinically and histologically, the cyanoacrylate sites appeared less inflamed as compared to the sutured sites at 7 days; however, at 21 days and at 6th weekday, both the sites appeared similar.


The drawbacks of the present study were that the material was tested in the anterior teeth, where it is easier to apply the cyanoacrylate; and also the secondary trauma caused by the biopsy. The future studies should be done so as to assess the materials in the closure of flaps in the posterior areas.

 
   References Top

1.Carranza FA Jr. General principles of periodontal surgery. In : Carranza FA, Neumann M, editor. Clinical periodontology, 8th ed. W.B. Saunders and Company: 1996. p. 569-78.  Back to cited text no. 1    
2.Carranza FA Jr. The surgical phase of therapy. In : Carranza FA, Neumann M, editors. Clinical periodontology, 8th ed. W.B. Saunders and Company: 1996. p. 565-9.  Back to cited text no. 2    
3.Levin MP. Periodontal suture materials and surgical dressings. Dent Clin North Am 1980;24:767-81.  Back to cited text no. 3  [PUBMED]  
4.Miller GM, Dannenbaum R, Cohen WD. A preliminary histologic study of the wound healing of mucogingival flaps when secured with cyanoacrylate tissue adhesives. J Periodontol 1974;45:608-18.  Back to cited text no. 4    
5.Sachs HA, Farnoush A, Checchi L, Joseph CE. Current status of periodontal dressings. J Periodontol 1984;55:689-96.  Back to cited text no. 5  [PUBMED]  
6.Herod EL. Cyanoacrylates in dentistry: A review of literature. J Can Dent Assoc 1990;56:331-4.  Back to cited text no. 6  [PUBMED]  
7.McGraw VA, Caffesse RG. Cyanoacrylates in periodontics. J West Soc Periodontal 1978;26:4-13.  Back to cited text no. 7    
8.Raymond De Bono. A simple inexpensive method for precise application of cyanoacrylate tissue adhesive. Plast Reconstruct Surg 1997;100:447-50.  Back to cited text no. 8    
9.Bhasker SN, Frisch J, Margetis MP, Leonard F. Application of a new chemical adhesive in periodontic and oral surgery. Oral Surg Oral Med Oral Pathol 1966;22:526-35.  Back to cited text no. 9    
10.Greer RO Jr. Studies concerning the histotoxicity of isobutyl-2-cyanoacrylate tissue adhesive when employed as an oral hemostat. Oral Surg 1975;40:659-69.  Back to cited text no. 10  [PUBMED]  
11.Binnie WH, Forrest JO. A study of tissue response to cyanoacrylate adhesive in periodontal surgery. J Periodontol 1974;45:619-25.  Back to cited text no. 11  [PUBMED]  
12.Giray CB, Atasever A, Durgun B, Araz K. Clinical and electron microscope comparison of silk sutures and N-butyl-2-cyanoacrylate in human mucosa. Aust Dent J 1997;42:255-8.  Back to cited text no. 12  [PUBMED]  
13.Kulkarni S, Chava V. Comparison of Cyanoacrylates and sutures on healing of oral wounds: An animal model study. Indian J Dent Res 2003;14(4):254-8.   Back to cited text no. 13    
14.Macht SD, Krizek TJ. Sutures and suturing: Current concepts. J Oral Surg 1978:36:710-3.  Back to cited text no. 14    
15.Giray CB, Sungur A, Atasever A, Araz K. Comparison of silk sutures and N-butyl-2-cyanoacrylate on healing of skin wounds. A pilot study. Aust Dent J 1995;40:40-3.  Back to cited text no. 15    
16.Bhasker SN, Frisch J. Use of cyanoacrylate adhesives in dentistry. J Am Dent Assoc 1968;77:831-7.  Back to cited text no. 16    
17.Forest JO. The use of cyanoacrylates in periodontal surgery. J Periodontol 1974;45:225-9.  Back to cited text no. 17    
18.Javelet J, Torabinejad M, Danforth R. Isobutyl cyanoacrylate: A clinical and histologic comparison with sutures in closing mucosal incisions in monkeys. Oral Surg Oral Med Oral Pathol 1985;59:91-4.  Back to cited text no. 18  [PUBMED]  

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Correspondence Address:
Sudhindra Kulkarni
Dept. of Periodontics, S. D. M. College of Dental Sciences and Hospital, Dharwad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.32424

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4]

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