J Periodontal Implant Sci.

2016 Dec;46(6):415-425
https://doi.org/10.5051/jpis.2016.46.6.415
pISSN 2093-2278·eISSN 2093-2286

Research Article The hidden X suture: a technical

note on a novel suture technique for
alveolar ridge preservation

Jung-Chul Park,1,* Ki-Tae Koo,2 Hyun-Chang Lim3

1
Department of Periodontology, Dankook University College of Dentistry, Cheonan, Korea
2
Department of Periodontology, Seoul National University School of Dentistry, Seoul, Korea
3
Department of Periodontology, Kyung Hee University School of Dentistry, Seoul, Korea

Received: Oct 7, 2016

Accepted: Nov 25, 2016
ABSTRACT
*Correspondence to
Purpose: The present study investigated the impact of 2 different suture techniques, the
Jung-Chul Park conventional crossed mattress suture (X suture) and the novel hidden X suture, for alveolar
Department of Periodontology, Dankook ridge preservation (ARP) with an open healing approach.
University College of Dentistry, 119 Dandae-ro, Methods: This study was a prospective randomized controlled clinical trial. Fourteen patients
Dongnam-gu, Cheonan 31116, Korea. requiring extraction of the maxillary or mandibular posterior teeth were enrolled and
E-mail: periopark@dankook.ac.kr
allocated into 2 groups. After extraction, demineralized bovine bone matrix mixed with 10%
Tel: +82-41-550-0263
Fax: +82-303-3442-7364 collagen (DBBM-C) was grafted and the socket was covered by porcine collagen membrane
in a double-layer fashion. No attempt to obtain primary closure was made. The hidden X
Copyright © 2016 Korean Academy of suture and conventional X suture techniques were performed in the test and control groups,
Periodontology
respectively. Cone-beam computed tomographic (CBCT) images were taken immediately
This is an Open Access article distributed
under the terms of the Creative Commons
after the graft procedure and before implant surgery 4 months later. Additionally, the
Attribution Non-Commercial License (http:// change in the mucogingival junction (MGJ) position was measured and was compared after
creativecommons.org/licenses/by-nc/3.0/). extraction, after suturing, and 4 months after the operation.
Results: All sites healed without any complications. Clinical evaluations showed that the MGJ
ORCID
Jung-Chul Park
line shifted to the lingual side immediately after the application of the X suture by 1.56±0.90
http://orcid.org/0000-0002-2041-8047 mm in the control group, while the application of the hidden X suture rather pushed the MGJ
Ki-Tae Koo line slightly to the buccal side by 0.25±0.66 mm. It was demonstrated that the amount of
http://orcid.org/0000-0002-9809-2630 keratinized tissue (KT) preserved on the buccal side was significantly greater in the hidden X
Hyun-Chang Lim suture group 4 months after the procedure (P<0.05). Radiographic analysis showed that the
http://orcid.org/0000-0001-7695-1708
hidden X suture had a significant effect in preserving horizontal width and minimizing vertical
Conflict of Interest reduction in comparison to X suture (P<0.05).
No potential conflict of interest relevant to this Conclusions: Our study provided clinical and radiographic verification of the efficacy of the
article was reported. hidden X suture in preserving the width of KT and the dimensions of the alveolar ridge after ARP.

Keywords: Alveolar process; Bone regeneration; Bone resorption; Suture techniques; Tooth
extraction

INTRODUCTION
The substantial reduction of alveolar bone dimension following tooth extraction has been
reported in a number of studies [1,2], and this phenomenon can have negative consequences
for further restorative treatment. To prevent this reduction or at least compensate for the loss

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Novel suture technique for alveolar ridge preservation

of bony dimension, the alveolar ridge preservation (ARP) technique was developed [3-6]. The
initial stages of research into ARP focused on the extent to which hard tissue collapse could be
prevented [7,8], and a clear benefit for counteracting hard tissue resorption was demonstrated
compared to natural healing. However, investigators have recently started to holistically
evaluate the effects of ARP not only on the hard tissue, but also on the soft tissue profile [9,10].

Although a variety of studies of ARP have been published, methodological heterogeneity

has been consistently pointed out in previous systematic reviews [2,11]. The heterogeneity
mainly occurred due to different types of biomaterials and surgical techniques. Numerous
biomaterials and various combinations thereof have been used, but no material or
combination of materials has been established as superior. Surgically, no consensus exists
regarding whether the flap should be elevated, whether primary flap closure is mandatory,
and so on. Moreover, insufficient evidence exists regarding the duration of healing before the
implantation following ARP.

An issue that is usually neglected, but is very important in the opinion of the authors, is the
suture technique following ARP. In most previous studies, the conventional crossed mattress
suture (X suture) [12] was generally applied following ridge preservation, especially when
primary closure was not intended (Figure 1). Other studies used the criss-cross suture, which
is essentially a horizontal external mattress suture (Figure 2) [13]. These suture techniques
take advantage of pulling vectors to the center of socket to narrow the socket entrance and
keep the biomaterial in the socket. However, the authors of the present study have observed
soft tissue profiles following ARP sutured using the criss-cross technique or conventional X
suture with large losses of facial keratinized tissue (KT) and have noted that the mucogingival
junction (MGJ) can be shifted to the lingual side due to the pulling of buccal tissue, especially
when the buccal bone is damaged.

Meanwhile, applying the hidden X suture on the grafted extraction socket may successfully
secure the grafted biomaterials and minimally retract the buccal tissue. The hidden X suture,
which was first presented in a plastic surgery study, is a modification of the conventional X
suture (Figure 3) [14]. In plastic surgery, it has also been reported that the hidden X suture
has certain advantages over the conventional X suture. The latter is more harmful to skin

X suture
Figure 1. X suture or conventional X suture. The needle passes through over the extraction socket twice as if
performing a continuous suture. A large crossed X is created over the socket after suturing. The blue arrows
indicate the pulling vectors created by the X suture.
X suture, crossed mattress suture.

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Novel suture technique for alveolar ridge preservation

Criss-cross suture
Figure 2. Criss-cross suture or crossed horizontal external suture. The needle engages the buccal and lingual
flaps in the same direction (mesial to distal or distal to mesial), then a knot is created. A large crossed X is
created over the socket, as in the X suture.
X suture, crossed mattress suture.

Hidden X suture
Figure 3. Hidden X suture. The needle enters the buccal flap and passes to the opposite side in a diagonal direction,
then it passes again from the buccal to the lingual side, also in a diagonal direction. A crossed X is created under the
flap, unlike the X suture or criss-cross suture. The blue arrows indicate the vectors created by the hidden X suture.
X suture, crossed mattress suture.

healing, leaving a very visible X mark after healing, whereas the hidden X suture has only 2
minor suture scars far apart. To the best of our knowledge, the hidden X suture has not been
discussed in the dental literature, and its benefit in comparison to other suture techniques
has not been properly assessed especially for ARP.

Therefore, the aim of this study was to provide proof-of-concept data about the effects of the
hidden X suture technique in preserving the width of KT and the dimensions of the alveolar
ridge following ARP procedures with a double-layered open healing approach.

MATERIALS AND METHODS

Study population and design
This study was a single-blinded, prospective, randomized controlled clinical trial, and was
carried out from January 2016 to July 2016 at the Department of Periodontology, Dankook
University Dental Hospital, Cheonan, Korea. The research protocol was approved by the
Ethical Committee of Dankook University Dental Hospital, Korea (H-1412/012/002).

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Novel suture technique for alveolar ridge preservation

The inclusion and exclusion criteria were as follows:

Inclusion criteria
• Patients' age between 18 years old and 65 years old
• Presence of a single periodontally compromised molar in the mandible or the maxilla requiring extraction
and expected to be suitable for replacement by a dental implant
• Residual extraction sockets with less than 50% bone loss in all dimensions
• Ability to fully understand the nature of the proposed operation and ability to sign an Ethics Committee-
approved informed consent form

Exclusion criteria
• Uncontrolled or untreated periodontal disease
• History of systemic diseases that would contraindicate surgical treatment
• Allergy to collagen and bone substitute
• Requirement of antibiotic prophylaxis
• Heavy smoking (>10 cigarettes per day)
• Pregnancy or lactation
• Inability to consent to participation in the study and/or to accept the proposed treatment plan

Experimental groups
A total of 14 patients (7 control and 7 test) were enrolled in this study (Table 1). Random
numbers for group assignment were generated by a statistician. A sequentially numbered,
opaque, sealed envelope containing the group allocation was created for each participant.
After the completion of bone substitute filling and membrane coverage, an assistant opened
the envelope to identify the group assignment.

Group 1 (open healing and hidden X suture; test)

The sockets were filled with demineralized bovine bone mineral with 10% collagen
(DBBM-C; Bio-Oss® Collagen, Geistlich Pharma, Wolhusen, Switzerland) and covered with
double-layers of a collagen membrane (DL-CM; Bio-Gide®, Geistlich Pharma). No attempt to
obtain primary closure was made. The hidden X suture was performed.

Group 2 (open healing and X suture; control)

The sockets were filled with DBBM-C (Bio-Oss® Collagen, Geistlich Pharma) and covered
with DL-CM (Bio-Gide®, Geistlich Pharma). No attempt to obtain primary closure was made.
The conventional X suture was performed.

Table 1. Demographic information of the enrolled patients

Parameters  Hidden X suture (n=7) X suture (n=7)
Age (yr) 51.0±6.9 54.3±11.8
Sex (%)
Male 42.9 (3/7) 85.7 (6/7)
Female 57.1 (4/7) 14.3 (1/7)
Jaw bone (%)
Maxilla 14.3 (1/7) 57.1 (4/7)
Mandible 85.7 (6/7) 42.9 (3/7)
Values for age are presented as mean±standard deviation.
X suture, crossed mattress suture.

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Novel suture technique for alveolar ridge preservation

Suture techniques

Hidden X suture procedure

The needle enters one of the flaps, passes under the flap, and reaches the opposing side of
flap in an oblique direction (Figure 3). The needle then enters again on the initial side of the
flap and passes obliquely under the flaps, leaving the opposing side flap. It ends up leaving 2
parallel silk threads over the soft tissue on the mesial and distal sides, with the crossed silk
threads under the flaps.

X suture procedure
The overall process is similar to that of the hidden X suture; however, the needle enters the
buccal flap and engages the opposing flap in a perpendicular direction (Figure 1). The needle
then enters again on the buccal flap and passes the opposite flap again. Essentially, it is
involved 2 turns of interrupted sutures, and the large X is created after making a knot.

Outcomes
The primary outcome was the change of KT width, as measured by the MGJ shift.

The secondary outcomes were as follows:

• Change in ridge width 1 mm (HW1), 3 mm (HW3), and 5 mm (HW5) below the ridge crest
• Change in ridge height at the buccal and lingual crest (VHB and VHL, respectively)
• Vertical reduction measured at the mid-crestal area (VMC)

Surgical procedure
After local anesthesia with 2% lidocaine containing 1:80,000 epinephrine, the teeth were
extracted and meticulous debridement by surgical curettage was performed. For both
groups, the sockets were filled with DBBM-C with gentle pressure. A collagen membrane
was then placed over the bone substitute in a double-layered fashion [15,16]. The flaps were
immobilized with minimal tension using a hidden X suture for the test group and an X
suture for the control group (Ethilon® 4-0, Ethicon, Cincinnati, OH, USA). The membrane
was not engaged with the suture material, and no attempts for primary flap closure, such
as a releasing incision, were made. Immediately after surgery, a cone-beam computed
tomography (CBCT) scan was taken with a resolution of 1 mm (scan time, 17 seconds;
exposure time, 17 seconds; 80 kV, 7 mA) using an Alphard 3030 apparatus (Asahi Roentgen
Ind. Co., Ltd., Kyoto, Japan). Patients were instructed to rinse twice a day with mouthwash
(GUM gargle, Osaka, Japan), and received analgesics (Somalgen, Keunhwa, Seoul, Korea)
and antibiotics (Sultamox, Keunhwa) for 5 days. All patients were recalled 7–10 days later
for a check-up and suture removal. The patients then received follow-up care 2, 4, 8, and 16
weeks post-ARP before implant placement. Four months after the initial procedure, the same
surgeon saw the patients for the measurement and placement of the implant (Figure 4).

The location of MGJ was measured at the facial level immediately after the extraction, after
suturing, and 4 months post-ARP by a single investigator (Jung-Chul Park). Using a rolling
technique, MGJ was determined and marked on a stent with a notch [10]. A negative value
was given if the MGJ has shifted to the lingual side.

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Novel suture technique for alveolar ridge preservation

Extraction DBBM-C DL-CM Suture S-O 4 Mon

Hidden X suture

X suture

Figure 4. The clinical process from baseline to 4 months after ARP.

ARP, alveolar ridge preservation; X suture, crossed mattress suture; DBBM-C, demineralized bovine bone matrix mixed with 10% collagen; DL-CM, double-
layered collagen membrane; S-O, stitch-out.

Re-entry procedure
Four months later, the operation for implant placement was scheduled, and a second CBCT
scan was taken before the implant placement. After local anesthesia, mucoperiosteal flaps
were elevated, and the implants (Luna®, Shinhung, Seoul, Korea) were placed. To maximize
the primary stability after placement, the final drills were one size smaller than the actual
implant diameter. The tissues were sutured with 4-0 nylon (Ethilon®, Ethicon).

CBCT analysis
Two CBCT scans were taken at baseline and at 4 months post-ARP (Figure 5). The data were
processed in the Digital Imaging and Communications in Medicine format. The 2 scans were
superimposed using stable reference points (the cranial base for the maxilla and the inferior
border for the mandible, respectively), and an additional manual correction was performed
in the best-matched cuts. Subsequently, CBCT measurements of the cross-sectional images
were made at baseline and 4 months using the same reference points and lines.

Statistical analysis
The data are presented as mean±standard deviation and median. The Shapiro-Wilk test
was used to test normality. For the KT change, HW1, HW3, and HW5, the data were not
normally distributed (P<0.05), while a normal distribution was found for VHB, VHL, and
VMC (P>0.05). The Mann-Whitney U test was used to assess statistical significance in the
KT change, HW1, HW3, and HW5, and the independent t-test was used for VHB, VHL, and
VMC. All analyses were performed using SPSS version 21.0 (IBM Corp., Armonk, NY, USA).
Statistical significance was set at P<0.05.

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Novel suture technique for alveolar ridge preservation

Baseline 4 Mon

Hidden X suture

X suture

Figure 5. CBCT analysis. The horizontal and vertical dimensional changes were measured by comparing the CBCT
images taken immediately after the graft (baseline) and before implant surgery (4 months). Scale bar=1 cm.
CBCT, cone-beam computed tomographic; X suture, crossed mattress suture.

RESULTS
All patients healed without any adverse events, and no cases of graft loss or infection were
recorded. Rapid epithelial migration was observed in both groups. The patients underwent
implant surgery 4 months after surgery, at which point most sites were covered with thick
and firm KT. Minimal changes were observed in the gingival level or papilla height on the
adjacent teeth. The incision for the implant placement was not compromised at all in any
case, and no invagination of the soft tissue was observed. All implants (Luna®, Shinhung)
were placed in a non-submerged fashion, with satisfactory initial stability.

The MGJ line shifted to the lingual side immediately after the application of the X suture
by 1.56±0.90 mm, while the application of the hidden X suture slightly pushed the MGJ
line to the buccal side by 0.25±0.66 mm (Table 2). The difference between the groups
was statistically significant (P=0.003). At 4 months, the width of the facial KT decreased
in comparison to before the placement of sutures in both groups, but this reduction was
different between the 2 groups to a statistically significant extent (P=0.007).

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Novel suture technique for alveolar ridge preservation

Table 2. Change in KT width from the extraction to 4 months

Parameters  Hidden X suture (mm; n=7) X suture (mm; n=7) P value
Baseline to post-suture 0.25±0.66 (0.0) −1.56±0.90 (−1.5) 0.003a)
Baseline to 4 mon −1.05±1.07 (−1.0) −2.83±1.26 (−2.5) 0.007a)
Values are presented as mean ± standard deviation (median); The Mann-Whitney U test was used to compare differences in KT changes between the 2 groups.
KT, keratinized tissue; X suture, crossed mattress suture.
a)
Statistically significant difference.

Table 3. Horizontal changes of the alveolar ridge

Parameters Hidden X suture (mm; n=7) X suture (mm; n=7) P value
Post-ARP 4 mon Ridge change Post-ARP 4 mon Ridge change
HW1 11.50±2.95 (11.20) 10.97±3.26 (11.00) −0.53±0.66 (−0.35) 13.57±2.70 (13.05) 8.02±6.68 (10.00) −5.55±6.63 (−1.75) 0.016a)
HW3 13.42±2.72 (13.50) 12.67±3.35 (13.20) −0.75±0.78 (−0.45) 15.37±2.35 (15.20) 14.20±2.12 (13.60) −1.17±1.58 (−0.50) 1.000
HW5 13.82±2.78 (14.25) 13.42±3.15 (14.20) −0.40±0.54 (−0.30) 16.27±2.20 (16.40) 15.22±2.97 (15.10) −1.05±1.27 (−0.40) 0.376
Values are presented as mean ± standard deviation (median); The Mann-Whitney U test was used to compare differences in the horizontal changes of the
alveolar ridge between the 2 groups.
X suture, crossed mattress suture; Post-ARP, immediately after alveolar ridge preservation; HW1, change in ridge width 1 mm below the ridge crest; HW3, change
in ridge width 3 mm below the ridge crest; HW5, change in ridge width 5 mm below the ridge crest.
a)
Statistically significant difference.

Table 4. Vertical changes in the alveolar ridge

Parameters  Hidden X suture (mm; n=7) X suture (mm; n=7) P value
VHB −0.30±0.64 (−0.45) −0.50±0.51 (−0.40) 0.699
VHL −0.13±0.85 (−0.10) −0.82±0.81 (−0.70) 0.240
VMC −0.42±1.22 (−0.20) −1.47±1.43 (−1.60) 0.034a)
Values are presented as mean ± standard deviation (median); The vertical difference was measured by superimposing the best-matched images taken
immediately after ridge preservation and 4 months later. The independent t-test was used to assess statistical differences in the vertical changes of the 2 groups.
X suture, crossed mattress suture; VHB, change in ridge height at the buccal crest; VHL, change in ridge height at the lingual crest; VMC, vertical reduction
measured at the mid-crestal area.
a)
Statistically significant difference.

Measurements of dimensional changes of the alveolar ridge after ARP using CBCT images
revealed that the hidden X suture resulted in significantly less resorption in both the horizontal
and vertical aspects than the X suture. Additionally, statistical significance was observed for the
HW1 (P=0.016) and VMC (P=0.034) parameters. While minimal resorption was noted 1 mm
below the crest in the hidden X suture group (−0.53±0.66 mm; median, −0.35 mm), the X suture
group had significantly greater resorption (−5.55±6.63 mm; median, −1.75 mm) (Tables 3 and 4).

DISCUSSION
In the present study, the authors applied an open healing approach following ARP using the
double membrane technique, which has been evaluated and demonstrated to have comparable
or better results than conventional primary closure [9]. Previous studies have consistently
reported that complete preservation was not achieved even after obtaining primary closure
[17], as well as recession and loss of the KT of the adjacent teeth [18]. In contrast to the
common knowledge that bone grafts should be covered by primary intention, Barone et al. [9]
demonstrated that an intentional open healing approach to ridge preservation did not affect the
results of ridge preservation in comparison to closure with primary intention. Moreover, it has
been shown that open healing can substantially increase the width of KT [10].

The results of this study corroborate the finding that the open healing approach for ridge
preservation can successfully preserve the alveolar bone dimension for implant placement.
An interesting finding was that the suture technique significantly affected the soft tissue

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Novel suture technique for alveolar ridge preservation

healing pattern. The conventional X suture is the most common suture following ridge
preservation, and insufficient attention has been paid to the fact that this suture technique
can create a pulling vector along the buccolingual axis, decreasing the width of the KT.
Meanwhile, the hidden X suture can minimize the tension along the buccolingual axis, and it
has been shown that it can comparably secure bone grafts and membranes. The application
of the hidden X suture immediately pushed the KT to the facial side after suturing, and
eventually reduced the loss of KT after a 4-month healing period.

In the comparison of the dimensions of the extraction socket, the horizontal width at 1 mm
from the crest was significantly smaller in the X suture group. It appears that the X suture
created a pulling vector along the buccolingual axis, as well as downward pressure, since
it is a variation of the horizontal external suture. Meanwhile, the hidden X suture did not
apply a significant pressing force on the buccal tissue, which may have prevented horizontal
resorption. The X suture also applied downward pressure onto the grafted material, with
statistically significant results.

The importance of KT in implant dentistry cannot be emphasized enough. First, the presence
of an adequate keratinized zone enables proper incision placement and easy flap reflection.
Additionally, the substantial thickness of KT in natural teeth has long been a controversial
issue, although recent systematic reviews have shown that the presence of keratinized mucosa
around implants is much more clinically significant than the presence of keratinized mucosa
around the natural teeth [19-22]. The presence of KT around implants has been shown to
prevent the accumulation of plaque, reduce inflammation, and result in less marginal bone
resorption. Clinically, maintaining or increasing the zone of KT usually requires a free gingival
graft, an apically positioned flap, or the use of special stents [23]; these techniques are difficult
to perform and involve the possibility of significant morbidity for patients. Moreover, none of
these approaches can be performed concomitantly with tooth extraction. The soft tissue created
by secondary healing over the extraction socket shows satisfactory epithelialization and the
connective tissue has a well-structured network of collagen fibers (manuscript in preparation).

Within the limitations of this study, we demonstrated that the hidden X suturing technique
significantly decreased the reduction of the width of KT in comparison to the conventional X
suture, and showed that the dimensional change of the alveolar ridge after tooth extraction
was minimized by using the hidden X suture after ARP.

ACKNOWLEDGEMENTS
This present research was conducted by the research fund of Dankook University in 2014 (R-
0001-27206).

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