Comparative Clinical Evaluation of Internal Mattress Sutures vs Continuous Independent Sling Sutures on Interdental Papilla Height and Periodontal Healing in Esthetic Zone: Randomized Clinical Study

In the last decade, esthetics has become a major concern in the periodontal therapy. Modern aesthetic dentistry involves not only the restoration of lost teeth, but increasingly the management and reconstruction of the encasing gingiva. Interdental papilla not only acts as a biological barrier in protecting the periodontal structures but also plays a critical role in aesthetics. Numerous risk factors lead to the development of open gingival embrasures or black triangle. These factors include periodontal disease, length of embrasure area, root angulations, interproximal contact position, triangular shape crowns, and consequence of post periodontal surgery.

Interproximal soft tissue craters formation are the consequences of periodontal surgeries like modified widman flap procedures, osseous surgery. Study shows higher percentage of interproximal soft tissue craters in modified widman flap surgery as compared to osseous surgery at six weeks. This creates difficulty for the therapist and patients in performance and plaque control procedures, leading to persistent soft tissue inflammation and black triangle formation.

Primary closure of interdental area is technically more demanding. In periodontal surgery, the most common method of wound closure uses sutures. The primary objectives of suturing are to stabilize and to secure tissues in their desired locations. Therefore choosing an appropriate suturing technique, thread type, thread diameter and surgical needle as well as using proper surgical knot for each thread material are also critical.

Proper management of supracrestal soft tissue flap along with interdental papilla during suturing appears to be of critical importance in ultimate outcome of surgical periodontal pocket management. Wound healing after periodontal flap surgery is achieved through four precisely and highly programmed phases; hemostasis, inflammation, proliferation and remodelling. Wound stability and undisturbed maturation of a fibrin clot adhering to root surface is one of the prerequisite for optimum periodontal regeneration. Wound stability is achieved by close approximation of wound margins for primary intention healing by proper suturing. Wound integrity during the early healing phase rest primarily on the stabilization of the gingival flaps offered by suturing with primary closure of the wound edges inter-proximally while being maintained in maximum passive contact with the root to minimize the intervening blood clot and to prevent wound contamination Mattress sutures are used for greater flap security and control. They permit more precise flap placement, especially when combined with periosteal stabilization. They also allow for good papillary stabilization and placement. These mattress sutures can be internal or external. The internal mattress sutures are used when it is desirable to have the papilla position more upright in the embrasure space. Literature suggests that these sutures may be used in the anterior region when esthetics ideally required that the papilla fill the entire interdental area Continuous independent sling suture are used when multiple teeth are involved, provides greater distribution of forces on the flaps, minimize need for multiple knots, and allow independent placement of buccal and lingual flaps and permits precise flap placement and also secure multiple interproximal papillae of one flap independently of the other flap.

Thus the most suitable suturing technique to achieve healing by primary intention and connective tissue reattachment/ periodontal regeneration and preservation of interdental soft tissue needs to be explored.