The rationale for periodontal therapy is to re-establish and maintain the periodontal health and function. Over the years, periodontal therapy has been influenced by the trends of the times, and consequently treatment approaches have been modified somewhat. ¹

The traditional approach to treating periodontitis includes an initial non-surgical therapy phase followed by a surgical phase as necessary. ^{2 C}lose 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. ³

Establishing a non-tension primary wound closure of various soft-tissue flaps is essential for optimal postsurgical wound healing. Suturing is a common procedure done for this. Materials like silk, nylon, steel, catgut and polyglycolic-polylactic acid derivatives are being used for the post-operative closure of the flaps. When used properly, surgical sutures should hold flap edges in apposition until the wound has healed enough to withstand normal functional stresses. ⁴

Although suturing post-surgically has many benefits, there are some disadvantages. 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. ⁵ In addition, breakdown products from the absorbable suture material itself have been shown to cause an inflammatory reaction in the tissue in certain cases. ⁶ Suturing also requires technical skill and an additional patient visit for its removal. ⁷

In order to overcome these difficulties concept of tissue adhesive came forward as an alternative to sutures. Fibrin sealant is a synthetic substance used to create fibrin clot. It is composed of fibrinogen and thrombin where thrombin acts as an enzyme and converts the fibrinogen to fibrin which can act as a tissue adhesive. Fibrin sealant in addition to adhesive property also has an anti-enzymatic effect which promotes fibroblast aggregation, their growth and adhesion. ⁷

The purpose of the study was to compare the healing of surgical periodontal wound closure using Fibrin glue and Surgical silk suture.

A total of 10 systemically healthy subjects aged 25-54 years (mean age of 37.100 ± 5.238), who visited Department of Periodontology, Yenepoya Dental College, Mangalore participated in this split-mouth randomized controlled clinical trial.

The inclusion criteria were (a) Systemically healthy patients and (b) Patients indicated for periodontal flap surgery. The exclusion criteria were as follows (a) Pregnancy and lactation (b) Patients with habits like smoking, alcoholism and tobacco chewing (c) use of any medication possibly affecting the periodontal tissues.

The study protocol was reviewed and approved by the Institutional Research Ethics Committee, Yenepoya deemed to be University. The purpose of the study was explained to the subjects and an informed consent was obtained prior to their enrollment in the study.

All subjects were divided into 2 groups depending on the treatment provided; Group I where surgical flap closure was done with Fibrin glue -RELISEAL^® (Figure 1) on one sextant and Group II where surgical flap closure was done with Silk Suture -MERSILK^® (Figure 2) on other sextant. The test site and control site were determined using computerised randomization. All subjects underwent scaling and root planning prior to surgical procedure.

The purpose of the present study was to compare the healing of surgical periodontal wound closure using Fibrin glue and Surgical silk suture: 10 subjects were divided into 2 groups depending on the treatment provided; Group 1 (Test) in which surgical flap closure was done with Fibrin glue on one sextant and Group 2 (Control) in which surgical flap closure was done with Silk Suture on other sextant.

The Fibrin sealant used in our study is RELISEAL^® (Reliance Life Sciences. India), which is a commercially available indigenous preparation. The use of Reliseal fibrin sealants has been studied extensively; most of this research pertains to the medical field. Thus, there was a need to judge their performance in dentistry when used for flap approximation after periodontal flap surgery. To evaluate fibrin sealing system in the clinical trial, Ethicon Mersilk 3–0 sutures were used as a control since the latter is the most popular and readily available means of fixing tissues in periodontal surgery. A split mouth trial was employed in our study design where the patient serves as his/her own control, thereby reducing the influence of confounding covariates and also increasing the statistical efficiency.

The results of our study showed that on comparing the time taken for flap closure and pain score, there was a statistically significant difference between two groups. Wound healing index and plaque index showed a statistically significant difference between two groups at the end of 1^st and 4^th week. However, at the end of 12th week, no statistically significant difference was observed in both wound healing index and plaque index between two groups.

The time taken for suturing is critical compared to the surgical procedure itself since suturing consumes extra time which can cause additional trauma to the patient and fatigue to the surgeon during the procedure. In our study, it has been found that the use of fibrin glue saves remarkable amount of time and makes it easier to fix the tissues in difficult inaccessible areas and esthetically critical areas. Our results are in agreement with the study conducted by Pini Prato ⁸, in which the time saved range from 3–19.5 in flap and graft procedures.

Assessing severity of pain is an indicator of patient’s comfort during the post-operative period. In our study, we used Visual analog scale for recording pain score at the end of 1st week for both the groups. The results demonstrated that the pain experienced by group 1 was less as compared to that of group 2. This may be due to better tissue handling and less tissue inflammation in group1. The same was noted by Joshi et al ⁹ where cyanoacrylate group experienced reduced pain when used for wound closure after surgical removal of impacted third molars. Contrary to the present study, Khalil et al ¹⁰ found no statistically significant difference between the pain score when tissue adhesive was compared with suture for intra-oral surgical wound closure.

In our study, the highest plaque index score was observed at 1^st week in Group 2, it 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 several authors. ^{11, 12, 13}

There was a decline in plaque index score in 4th and 12th week in group 2. This is in concurrence with Kulkarni et al ¹¹ and Giray et al ¹² who attributed it to the removal of sutures resulting in less plaque accumulation. In group 1, there was lesser accumulation of plaque because of the smooth adaptation of flaps to the tooth surface when fibrin glue was used which is in consistence with the study results obtained by Pini Prato ⁸ and Bartolucci E ¹⁴.

Healing can be best evaluated by the presence or absence of inflammation and infection. ^{13, 15} In this study we used wound healing index to describe the extent of clinical healing after periodontal surgery which was proposed by Landry, Turnbull and Howley. ¹⁶ At the end of 1^st week and 4^th week, better healing was observed in group 1. This can be correlated with the histological study results obtained by Pulikkotil et al ⁷ and Kulkarni et al ¹¹.

Better wound healing may be related to the presence of factors such as thrombin, fibrin, fibronectin and platelet-derived growth factor, which are known to retain their biologic activities on cell proliferation and differentiation in fibrin adhesives. ¹⁷ Fibrin sealants stimulate early wound healing and connective tissue growth by accelerating revasculariza­tion and facilitating the migration of fibroblasts. ¹⁸

During our procedure, rapid hemostasis was observed as an incidental finding soon after the application of fibrin glue, unwinding its hemostatic property and making it possible to approximate flaps precisely. This could be another beneficial effect of Reliseal. Whereas in those approximated with sutures, there was slight bleeding at the line of suture. The findings of are in concurrence with the study results by several authors ^{8, 13, 14, 16} in which they stated that involvement of physiologic substances in biologic adhesive system appears to augment normal clotting mechanism and therefore has a distinct advantage over suturing and synthetic sealants.

In sutures, it was noticed that there was a marginal fixation of the flap, while fibrin sealant provided a whole surface of adhesion to the underlying tissues. This total adhesion, together with fast hemostasis, helps in preventing flap displacement and hematoma formation. ^{8, 13}

One of the drawbacks of fibrin sealant is that fibrin sealants prepared from donors carry the risk of transmit­ting diseases. ¹⁹ Another limitation of fibrin sealant is its high cost. The overall convenience of the use of fibrin sealing system should be evaluated on the basis of its cost and benefits. ²⁰ On one hand the fibrin sealant kit is expensive; on the other hand, the use of the glue saves time during surgical procedures and avoids time wasted in suture removal. ⁸

There were no adverse effects with the use of Fibrin sealant observed in any of the subjects in our study. In the present study, we only assessed clinical parameters following flap surgery with the use of fibrin sealant. Further studies with large sample size assessing both clinical and histological parameters would yield interesting results.

This study shows the beneficial results of using Fibrin sealant for fixing tissues after periodontal flap surgery. On comparison between the two groups, both sutures and fibrin sealant were effective in bringing about healing following periodontal surgical procedure. However, fibrin sealant was found to be a more favorable approach which enhances wound healing when compared to sutures. Thus, fibrin sealant can be considered as a better alternative to sutures for surgical periodontal wound closure.

We would like to thank Dr. Arun Kumar MDS, Professor, Department of Periodontology, Yenepoya Dental College for his constant support and encouragement for carrying out this study.