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. 2026 Apr 26;12(2):e70345. doi: 10.1002/cre2.70345

Effect of Suturing and Adhesive Fixation on Free Gingival Graft Stability: An Ex‐Vivo Porcine‐Model Study

Kevimy Agossa 1,2, Khushboo Kalani 1, Parham Hazrati 1, Chi‐Fan Chen 1, Chen‐Lin Tsai 1, Dumitru Chele 1,3, Abdusalam E Alrmali 1,4, Hom‐Lay Wang 1,✉
PMCID: PMC13110839  PMID: 42035460

ABSTRACT

Objectives

Clinician expertise influences approach choices, amidst ongoing research on suturing techniques’ biomechanical effects on graft stability. This study evaluated different suturing methods and cyanoacrylate adhesive for FGG fixation with a porcine mandible model.

Material and Methods

Ninety‐four FGG procedures were performed on juvenile pig mandibles. Eight fixation methods were evaluated: seven suturing techniques—Cross Compression (CC), Vertical Circumferential Compression (VCC), Horizontal (H), CC + H, VCC + H, Miller (MIL), Holbrook and Ochsenbein (Chan et al.)—and cyanoacrylate adhesive (GLU). Outcomes measured included marginal tension (vertical displacement force) and lateral tension (horizontal displacement) at the graft margin.

Results

The HOC technique demonstrated the highest marginal stability (3.82 (SD 1.35 N) and compressive resistance (0.76 (SD 0.48 N). CC + H and VCC + H also showed significantly enhanced marginal stability. Compared to MIL, HOC exhibited superior compressive resistance (p = 0.001), while both HOC and CC + H achieved significantly greater marginal tension (p < 0.05). Graft dimensions influenced outcomes: greater graft height improved compressive resistance, while increased length reduced marginal stability with horizontal sutures. Mean suturing time was 4.84 min (SD 1.55); CC was faster than MIL (p = 0.03), whereas HOC, CC + H, and VCC + H required significantly more time (p < 0.01). GLU achieved marginal stability (3.45 (SD 3.2 N) comparable to HOC.

Conclusions

Within the limitations of this ex vivo study, suturing technique and graft dimensions significantly affect the FGG's biomechanical stability. Holbrook and Ochsenbein's suturing technique achieved the highest marginal stability and compressive resistance. Furthermore, tissue adhesive demonstrated comparable performance to conventional sutures, supporting its potential as an alternative fixation method.

Keywords: animal, autograft, models, sutures, swine, tissue adhesives

1. Introduction

Free gingival grafts (FGGs) are autologous soft tissue transplants, typically harvested from the palate with the overlying epithelium, that are entirely detached and repositioned onto a prepared recipient bed within the oral cavity (Zucchelli et al. 2020). FGGs have long been a cornerstone of periodontal plastic surgery and remain the gold standard for augmenting keratinized tissue height around both natural teeth and dental implants (Horning et al. 2008; Jensen et al. 2023; Kim and Neiva 2015; Scheyer et al. 2015; Sullivan and Atkins 1968). Long‐term clinical studies report predictable keratinized tissue gains of 3.1 to 5.6 mm, with stable outcomes maintained over 20 to 30 years (Agudio et al. 2019; Agudio et al. 2016; Wennström 1996).

Graft stabilization is considered as one of the most critical determinants of FGG success (Miller 1987). Mechanically, free grafts lack intrinsic attachment strength to the recipient bed. Biologically, during the initial postoperative period, no blood vessels extend from the recipient bed into the graft, making graft survival entirely dependent on passive plasmatic diffusion through close contact with the periosteal bed (Oliver et al. 1968). Therefore, the technique used to secure and stabilize the graft is crucial to enable adequate perfusion and ensure graft viability (Oliver et al. 1968).

Several methods have been developed to achieve optimal graft stabilization, including suturing techniques (Holbrook and Ochsenbein 1983; Miller 1985), biological tissue adhesives (Hoexter 1979; Jaeger et al. 1987), and, more recently titanium tacks, and stent systems (Korkis et al. 2019; Lee et al. 2023; Zwanzig et al. 2025). Among the suturing techniques, Holbrook & Ochsenbein introduced a sophisticated technique, combining a horizontal stretching suture with vertical circumferential and crossed compressive sutures to maintain close contact between the graft and recipient bed and eliminate dead space (Holbrook and Ochsenbein 1983). In contrast, Miller advocated a more straightforward technique (MIL) that uses individual sutures at each papilla along with two apical sutures to stretch the graft and ensure adaptation to the recipient bed (Miller 1985). This approach minimizes or omits compressive sutures to reduce pressure on the graft, which has been suggested to contribute to graft contraction (Miller 1987). In practice, the choice between these two main approaches—and their intermediate variations—is largely empirical and based on clinician preference, as the biomechanical impact of different suturing techniques on graft stability has not yet been systematically investigated.

The primary aim of this ex vivo porcine model study was to compare the biomechanical performance of different FGG fixation techniques. Specifically, we evaluated graft stability and adaptation across multiple suturing methods. Additionally, we assessed the influence of graft dimensions and suture positioning, and compared conventional sutures to a cyanoacrylate‐based tissue adhesive (GLU), which has been proposed as a user‐friendly and biologically advantageous alternative (Veríssimo et al. 2021; Yilmaz et al. 2022).

2. Material and Methods

2.1. Study Design

Fresh porcine mandibles were sourced from a licensed abattoir (Michigan, USA) after routine slaughter for the food industry. No animals were sacrificed for research purposes. Per institutional policy, the University of Michigan, School of Dentistry IACUC/Ethics Committee reviewed the protocol. It deemed it exempt from animal research oversight because it involved only post‐mortem tissues. The study followed the relevant ARRIVE 2.0 items for transparent reporting of experimental research using animal materials. (Percie du Sert et al. 2020) The primary investigation focused on suturing techniques using 4‐0 silk sutures, with an additional analysis involving 5‐0 resorbable polyglycolic acid (PGA) sutures for comparative purposes.

2.2. Sample Collection

A total of 94 FGG procedures were performed on fresh mandibles harvested from juvenile domestic pigs (Sus scrofa domesticus), aged 6–8 months and weighing between 90 and 110 kg. Specimens were sourced from a licensed abattoir and stored on ice. Only jaws with intact gingiva and alveolar bone structures were included.

2.3. Group Allocation

Procedures were divided into two experimental arms (Table 1).

Table 1.

Overview of the fixation techniques evaluated in the study.

Group Technique Key characteristics n (Silk 4.0) n (PGA 5.0)
1 CC Diagonal cross‐compression (X‐pattern) 10 2
2 VCC Vertical circumferential compression 10 2
3 H Single horizontal stretching suture 10 2
4 CC + H CC combined with horizontal suture 10 2
5 VCC + H VCC combined with horizontal suture 10 2
6 MIL Miller technique: papillary + apical periosteal sutures 10 2
7 HOC Holbrook–Ochsenbein: H + CC + VCC 10 2
8 GLU High‐viscosity cyanoacrylate adhesive 10 —
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Note:Total procedures: 94 (70 silk; 14 PGA; 10 GLU).

Primary Suturing Arm (Silk Sutures 4‐0 ‐ AD Surgical, Rancho Santa Margarita, CA, USA): 80 procedures, 10 per group, across 8 groups (Figure 1A):

  • 1.

    Cross Compression (CC): Diagonal compressive sutures forming an X‐shape over the graft.

  • 2.

    Vertical Circumferential Compression (VCC): Vertical compressive sutures placed across the graft from coronal to apical direction.

  • 3.

    Horizontal (H): A single horizontal suture passed along (or close to) the graft's midline.

  • 4.

    Cross Compression + Horizontal (CC + H): Combination of cross‐compression and horizontal suture.

  • 5.

    Vertical Circumferential Compression + Horizontal (VCC + H): Combination of vertical compressive and horizontal suture.

  • 6.

    Miller Technique (MIL): Based on the protocol proposed by Miller, this method includes interrupted sutures at the mesial and distal papillae, and two apically positioned periosteal sutures, minimizing compressive forces (Miller PD 1985).

  • 7.

    Holbrook and Ochsenbein Technique: A horizontal stretching suture combined with vertical circumferential and crossed compressive sutures (Holbrook and Ochsenbein 1983).

  • 8.

    Cyanoacrylate Adhesive (GLU): High‐viscosity cyanoacrylate (PeriAcryl® 90 HV‐ Glustitch Inc., Delta, BC, Canada) applied in a layered fashion beneath and over the graft, polymerized under moist gauze compression.

Figure 1.

Figure 1

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Illustrations showing (A) the different suture techniques used, including: Miller Technique (MIL)—Cross Compression (CC), Vertical Circumferential Compression (VCC), Horizontal (H), Cross Compression + Horizontal (CC + H), and Vertical Circumferential Compression + Horizontal (VCC + H); and Holbrook and Ochsenbein Technique—a horizontal stretching suture combined with vertical circumferential and crossed compressive sutures (Holbrook and Ochsenbein 1983). (B) Definition of geometric covariates for each suture configuration: horizontal distances between apical or coronal sutures (a, b); vertical distances from the suture crossing point to the graft edge (c, d); and vertical distances from the horizontal suture to the coronal and apical graft edges (e, f).

Additional Suturing Arm (PGA Sutures 5‐0‐ AD Surgical Premium + , Rancho Santa Margarita, CA, USA): 14 procedures (2 per group across the seven suturing configurations, excluding GLU).

Group assignments were randomized by using an online randomization tool and evenly distributed across the anterior mandibular regions.

2.4. Graft and Recipient Bed Preparation

All recipient bed preparation and graft harvesting were performed by a single calibrated operator (CC) using a 15 C blade. Standardized split‐thickness recipient sites were prepared on attached keratinized mucosa extending to the lining mucosa. Harvested grafts were and placed 1 mm coronal to the cementoenamel junction (CEJ). Dimensions were measured with a UNC‐15 probe:

  • Graft Length: 7–10 mm

  • Graft Width 5–7 mm

  • Thickness: 1–2 mm

2.5. Suturing Technique

All suturing was performed by a single operator (KA) under 3.5× magnification. Suturing time was recorded from first needle pass to final knot. All techniques involved mesial and distal papillary stabilization, except for the GLU group.

2.6. Biomechanical Testing

All the biomechanical testing was done by a single investigator (KK), including two biomechanical parameters. Force was applied manually in a slow, continuous, “quasi‐static” manner using a calibrated analog force gauge, avoiding sudden or jerky movements, until the predefined endpoint was reached, consistent with commonly used comparative biomechanical protocols (Lake et al. 2023; Pastor et al. 2024).

  • 1.

    Marginal tension: The suture was passed through the central portion of the graft, approximately 2 mm apical to the coronal graft margin, and the knot was secured around the hook of the force gauge tip, creating a stable and reproducible traction point without slippage or tissue tearing. Tensile force was then applied apically, parallel to the long axis of the tooth, until the CEJ marker became visible (Figure 2A, 2B).

  • 2.

    Lateral compressive tension: The same loop was pulled outward (horizontally) until the graft detached 1 mm from the root surface (Figure 2C, 2D).

Figure 2.

Figure 2

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Schematic representations of the biomechanical testing setup. The parameters assessed included: marginal tension—the graft was pulled apically, parallel to the long axis of the tooth, until the cementoenamel junction (CEJ) marker became visible (A, B); and lateral compressive tension—the graft was pulled horizontally until it detached 1 mm from the root surface (C, D). All measurements were performed using a calibrated analog force gauge.

Each measurement was conducted using a calibrated analog force gauge (Wenzhou Tripod Instrument Manufacturing Co. Ltd, Zhejiang, China) (Yoon et al. 2019; Yoon et al. 2021). Each site was tested in triplicate within a single retraction, and the average was recorded.

2.7. Data Collection

For each procedure, the following variables were recorded: suturing technique, suture material, graft dimensions (length, width, and thickness), and suturing time (in minutes). Suture placement distances were documented. These include:

  • Vertical distances from coronal and apical graft margins,

  • Horizontal distances from the graft center to both the coronal and apical edges,

  • Cross‐suture distances relative to graft margins.

Biomechanical measurements included marginal tension and lateral compressive tension, with three replicates recorded per site and averaged for analysis. Due to graft detachment during marginal tension testing, lateral compressive tension was not assessed in the GLU group.

To evaluate the symmetry of suture placement, a geometric covariate was defined for each configuration (Figure 1B):

  • Cross Compression (CC): Ratio of the longer to shorter vertical distance from the suture crossing point to the graft edge.

  • Vertical Circumferential Compression (VCC): Ratio of the shorter to longer horizontal distance between apical or coronal sutures.

  • Horizontal (H): Ratio of the shorter to longer vertical distance from the horizontal suture (placed at mid‐height) to the coronal and apical graft edges.

A ratio closer to 1 indicates greater geometric symmetry. This covariate was included in the statistical model to account for the potential effects of suture placement consistency on biomechanical outcomes.

2.8. Statistical Analysis

The initial sample size for the primary investigation using 4‐0 silk sutures was selected based on precedents in ex vivo biomechanical studies, which commonly utilize 6 to 12 specimens per condition. (Pabst et al. 2023; Pirc et al. 2025) This choice was also guided by practical constraints related to cadaver tissue availability and the intention to avoid unnecessary use of animal‐derived material. After data collection, a post‐hoc, simulation‐based sensitivity analysis was performed using the fitted mixed‐effects regression model, incorporating the observed fixed‐effect estimates and variance components via a type‐2 F‐test with Satterthwaite degrees of freedom. This analysis indicated that the design achieved power estimates exceeding 85% for detecting technique (primary predictor) related effects for both marginal (92.61%) and compressive (88.28%) tension, supporting the adequacy of the chosen sample size for the primary objective of evaluating the influence of suturing technique. In contrast, the sample size for the comparative 5‐0 PGA group was intentionally limited and was included primarily to illustrate the directional pattern in tension measurements across techniques in a qualitative manner rather than for definitive statistical comparisons. Univariate mixed‐effects linear regression models were used to evaluate each outcome variable (lateral compressive tension, marginal tension, and procedure time). To account for clustering of multiple sites within individual jaws, a random intercept for jaw was included in all models. Suture technique was treated as a fixed effect, along with graft‐related variables (length, width, and thickness) and geometric characteristics of the suture configuration, which were included as potential covariates. Model assumptions were checked through visual inspection of residuals, assessment of homoscedasticity, variance inflation factor (VIF)‐based multicollinearity diagnostics, and evaluation of influential observations. No substantial violations were detected, and sensitivity analyses confirmed the robustness of the findings.

To provide preliminary observations regarding whether the directional pattern of lateral compressive and marginal tension across suturing techniques differed between suture materials, exploratory correlation analyses were conducted separately for silk (4‐0) and PGA (5‐0) groups. Technique was treated as an ordinal numeric variable, based on its predefined factor levels, sorted by average value. Pearson correlation coefficients were computed between technique order and compressive and marginal tension within each material group. To statistically compare these correlations, a Fisher r‐to‐z transformation was applied using Steiger's method for independent correlations. This analysis was intended to explore whether the overall tension profile associated with suturing technique followed a similar trajectory across materials, rather than to estimate individual effect sizes.

All statistical analyses and data visualizations were conducted by one author (P.H.), who was blinded to group allocation, using RStudio (Version 2024.12.1 + 563, PBC) with the lme4, lmerTest, dplyr, psych, simr, and ggplot2 packages. Confidence intervals for the estimates were calculated using the Wald method, and statistical significance was set at α = 0.05 (Bates et al. 2015; Kuznetsova et al. 2017).

3. Results

3.1. Descriptive Analysis

A total of 94 FGG sites were analyzed across seven suturing techniques and one glue‐based control group (Table 2). The mean graft dimensions were as follows: length, 8.48 (SD 0.64) mm; width, 6.15 (SD 0.44) mm; thickness, 1.68 (SD 0.30) mm. The average suturing time was 4.84 min (SD 1.55). Overall, the mean marginal tension was 2.24 (SD 1.48) N, and the mean lateral compressive tension was 0.41 (SD 0.35) N.

Table 2.

Descriptive analysis table.

Material Technique Number Length (mm) Width (mm) Thickness (mm) Time (minutes) Marginal (Fenlon et al.) Compressive (Fenlon et al.)
Silk Cross compression 10 8.6 (SD 0.62 5.95 (SD 0.16 1.6 (SD 0.32 3.42 (SD 0.36 1.75 (SD 0.54 0.41 (SD 0.36)
Cross compression + Horizontal 10 8.4 (SD 0.57 6.15 (SD 0.58 1.7 (SD 0.35 6.11 (SD 1.32 2.58 (SD 0.5 0.51 (SD 0.23)
Horizontal 10 8.7 (SD 0.79 6.15 (SD 0.41 1.7 (SD 0.26 4.38 (SD 0.56 1.63 (SD 0.57 0.3 (SD 0.36)
Miller 10 8.4 (SD 0.39 6.05 (SD 0.44 1.6 (SD 0.32 4.4 (SD 1.25 1.5 (SD 0.66 0.26 (SD 0.19)
Oshsenbein 10 8.35 (SD 0.67 6.4 (SD 0.46 1.75 (SD 0.26 7.41 (SD 1.14 3.72 (SD 1.39 0.76 (SD 0.53)
Parallel compression 10 8.65 (SD 0.82 6.1 (SD 0.62 1.65 (SD 0.34 3.75 (SD 1.03 1.66 (SD 0.58 0.24 (SD 0.25)
Parallel + Horizontal 10 8.35 (SD 0.82 6.5 (SD 0.53 1.6 (SD 0.32 5.81 (SD 0.81 2.25 (SD 0.84 0.52 (SD 0.36)
PGA Cross compression 2 8.5 (SD 0 6.5 (SD 0.71 1.75 (SD 0.35 2.64 (SD 0.13 1.4 (SD 0.57 0.28 (SD 0.08)
Cross compression + Horizontal 2 8.5 (SD 0.71 6 (SD 0 2 (SD 0 4.56 (SD 0.18 1.83 (SD 0.04 0.40 (SD 0.06)
Horizontal 2 9 (SD 0 6 (SD 0 2 (SD 0 3.7 (SD 0.07 1.02 (SD 0.64 0.27 (SD 0.27)
Miller 2 8.75 (SD 0.35 6.25 (SD 0.35 1.75 (SD 0.35 2.98 (SD 0.48 1.28 (SD 0.02 0.13 (SD 0.08)
Oshsenbein 2 8 (SD 0 6 (SD 0 1.75 (SD 0.35 5.72 (SD 0.26 4.34 (SD 1.43 0.75 (SD 0.07)
Parallel compression 2 8 (SD 0 6 (SD 0 1.75 (SD 0.35 3.03 (SD 0.02 1.24 (SD 0.89 0.17 (SD 0.08)
Parallel + Horizontal 2 8.5 (SD 0.71 6 (SD 0 1.5 (SD 0 5.01 (SD 0.36 1.79 (SD 0.37 0.36 (SD 0.27)
Glue Glue 10 8.4 (SD 0.74 6.1 (SD 0.39 1.65 (SD 0.34 4.72 (SD 0.9 3.45 (SD 3.2 NA
Overall Cross compression 12 8.58 (SD 0.56 5.96 (SD 0.14 1.62 (SD 0.31 3.29 (SD 0.44 1.69 (SD 0.54 0.39 (SD 0.33)
Cross compression + Horizontal 12 8.42 (SD 0.56 6.12 (SD 0.53 1.75 (SD 0.34 5.85 (SD 1.34 2.46 (SD 0.54 0.49 (SD 0.21)
Horizontal 12 8.75 (SD 0.72 6.12 (SD 0.38 1.75 (SD 0.26 4.27 (SD 0.57 1.53 (SD 0.6 0.29 (SD 0.34
Miller 12 8.46 (SD 0.4 6.04 (SD 0.4 1.62 (SD 0.31 4.16 (SD 1.27 1.46 (SD 0.6 0.24 (SD 0.18
Oshsenbein 12 8.29 (SD 0.62 6.33 (SD 0.44 1.75 (SD 0.26 7.12 (SD 1.23 3.82 (SD 1.35 0.76 (SD 0.48
Parallel compression 12 8.54 (SD 0.78 6.08 (SD 0.56 1.67 (SD 0.33 3.63 (SD 0.98 1.59 (SD 0.61 0.23 (SD 0.23
Parallel + Horizontal 12 8.38 (SD 0.77 6.42 (SD 0.52 1.58 (SD 0.29 5.68 (SD 0.81 2.18 (SD 0.78 0.49 (SD 0.34
Glue 10 8.4 (SD 0.74 6.1 (SD 0.39 1.65 (SD 0.34 4.72 (SD 0.9 3.45 (SD 3.2 NA
Total Total 94 8.48 (SD 0.64 6.15 (SD 0.44 1.68 (SD 0.3 4.84 (SD 1.55 2.24 (SD 1.48 0.41 (SD 0.35
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Among the suturing techniques, the HOC method demonstrated the highest marginal (3.82 (SD 1.35 N) and lateral compressive (0.76 (SD 0.48 N) tensions. Elevated marginal tensions were also observed in the CC + H (2.46 (SD 0.54 N) and VCC + H (2.18 (SD 0.78 N) groups. The Miller technique, used as the reference, yielded marginal and compressive tensions of 1.46 (SD 0.60 N and 0.24 (SD 0.18 N, respectively. Lower compressive tensions were noted with the horizontal (0.29 (SD 0.34 N), VCC (0.23 (SD 0.23 N), and CC (0.39 (SD 0.33 N) groups.

Regression analysis suggested that suture material (silk vs. PGA) might not significantly influence marginal (p = 0.16) or compressive tension (p = 0.34), regardless of technique; however, these findings should be interpreted as preliminary observations due to the limited sample size of the 5‐0 PGA subgroup (Supplementary Table 1).

3.2. Suture Analysis

3.2.1. Lateral Compressive Tension

According to the univariate model (Table 3), graft width was significantly associated with increased compressive tension (Estimate = 0.31; p < 0.001). Of all techniques, only HOC demonstrated a statistically significant improvement in compressive tension compared to Miller (Estimate = 0.49; p = 0.001) (Figure 4).

Table 3.

Univariate mixed‐effects models were used to assess the influence of graft dimensions, structural configurations, and suturing techniques on lateral compressive and marginal tension.

Univariate mixed‐effects model
Direction Variable Estimate Lower Upper p value Samples
Compressive Graft length 0.13 −0.01 0.26 0.059 70
Graft width 0.31 0.14 0.47 < 0.001 70
Graft thickness 0.11 −0.18 0.40 0.477 70
Structure horizontal 0.78 −0.04 1.61 0.063 40
Structure cross 0.30 −0.38 0.98 0.377 30
Structure parallel −0.53 −2.00 0.95 0.473 30
Technique (vs. Miller) 70
Cross compression 0.14 −0.13 0.41 0.343
Parallel compression −0.03 −0.30 0.25 0.856
Horizontal −0.06 −0.35 0.24 0.697
Cross compression + Horizontal 0.28 −0.01 0.57 0.063
Parallel compression + Horizontal 0.21 −0.05 0.48 0.138
Ochsenbein 0.49 0.21 0.76 0.001
Marginal Graft length −0.04 −0.41 0.33 0.827 80
Graft width 0.41 −0.10 0.91 0.119 80
Graft thickness 0.11 −0.69 0.93 0.785 80
Structure horizontal −1.19 −3.62 1.25 0.330 40
Structure cross 0.54 −1.51 2.59 0.596 30
Structure parallel −0.31 −4.57 3.95 0.883 30
Technique (vs. Miller) 80
Cross compression 0.15 −0.54 0.83 0.686
Parallel compression 0.10 −0.59 0.79 0.782
Horizontal −0.01 −0.71 0.69 0.981
Cross compression + Horizontal 1.00 0.29 1.72 0.010
Parallel compression + Horizontal 0.56 −0.12 1.25 0.120
Ochsenbein 2.20 1.51 2.89 < 0.001
Glue 0.41 −0.30 1.12 0.277
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Note: Estimates, confidence intervals, and p‐values are reported for each variable. Bold font indicates statistical significance (p < 0.05)

Figure 4.

Figure 4

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Association between graft width and lateral compressive tension for three suturing techniques: Vertical Circumferential Compression (VCC); Vertical Circumferential Compression + Horizontal (VCC + H); Holbrook and Ochsenbein Technique. Increased graft width was associated with higher tension values, particularly in HOC and VCC + H configurations. Estimates: VCC = 0.31, VCC + H = 0.53, HOC = 0.64, Overall = 0.31.

3.2.2. Marginal Tension

For marginal tension, both CC + H (Estimate = 1.00; p = 0.010) and HOC (Estimate = 2.20; p < 0.001) were significantly superior to the Miller technique (Figure 3).

Figure 3.

Figure 3

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Comparison of lateral compressive tension (A) and marginal tension (B) across Suturing techniques using silk and PGA sutures. No significant differences were observed between suture materials for either parameter (p > 0.05).

3.2.3. Technique‐Specific Associations

Technique‐specific models (Table 4) revealed that:

  • Graft height was positively associated with compressive tension in the VCC (p = 0.011), VCC + H (p = 0.002), and HOC (p = 0.048) groups.

  • In the horizontal group, graft length was inversely associated with marginal tension (p = 0.034).

  • In the HOC group, graft length was positively associated with compressive tension (p = 0.026).

  • Additionally, in the HOC group, sutures placed closer to the graft's horizontal midline were associated with increased lateral compressive tension (p = 0.048).

Table 4.

Univariate fixed‐effects models evaluating the influence of graft dimensions and structural configurations on compressive and marginal tension within each suturing technique.

Univariate fixed‐effects model
Technique Direction Variable Estimate Lower Upper p value Samples
Miller Compressive Graft length 0.06 −0.34 0.45 0.750 10
Graft width −0.12 −0.47 0.22 0.451 10
Graft thickness 0.01 −0.49 0.49 0.997 10
Marginal Graft length −0.10 −1.45 1.25 0.865 10
Graft width −0.26 −1.46 0.94 0.630 10
Graft thickness 0.16 −1.52 1.84 0.832 10
Cross compression Compressive Graft length −0.12 −0.58 0.34 0.560 10
Graft width −0.66 −2.42 1.09 0.409 10
Graft thickness −0.02 −0.94 0.90 0.961 10
Structure cross −0.02 −1.37 1.33 0.974 10
Marginal Graft length −0.33 −1.00 0.32 0.276 10
Graft width 1.02 −1.64 3.69 0.402 10
Graft thickness −0.52 −1.85 0.81 0.393 10
Structure cross 0.95 −0.92 2.83 0.268 10
Parallel compression Compressive Graft length −0.01 −0.26 0.23 0.920 10
Graft width 0.31 0.09 0.52 0.011 10
Graft thickness 0.25 −0.32 0.82 0.342 10
Structure parallel −0.45 −2.83 1.92 0.671 10
Marginal Graft length 0.42 −0.04 0.89 0.068 10
Graft width 0.44 −0.24 1.12 0.176 10
Graft thickness −0.13 −1.53 1.27 0.835 10
Structure parallel 0.58 −4.96 6.13 0.814 10
Horizontal Compressive Graft length 0.20 −0.13 0.54 0.199 10
Graft width −0.21 −0.91 0.48 0.501 10
Graft thickness −0.29 −1.41 0.83 0.569 10
Structure horizontal −0.62 −2.85 1.59 0.534 10
Marginal Graft length −0.48 −0.92 −0.04 0.034 10
Graft width −0.19 −1.31 0.92 0.702 10
Graft thickness −0.59 −2.33 1.13 0.449 10
Structure horizontal −2.44 −5.40 0.50 0.092 10
Cross compression + Horizontal Compressive Graft length 0.24 −0.01 0.50 0.057 10
Graft width 0.14 −0.15 0.44 0.302 10
Graft thickness 0.20 −0.30 0.70 0.387 10
Structure horizontal 0.02 −1.27 1.32 0.967 10
Structure cross 0.30 −0.37 0.97 0.329 10
Marginal Graft length 0.32 −0.34 0.98 0.299 10
Graft width −0.53 −1.08 0.01 0.055 10
Graft thickness 0.01 −1.15 1.16 0.996 10
Structure horizontal −1.20 −2.44 0.03 0.058 10
Structure cross −0.25 −1.78 1.27 0.712 10
Parallel compression + Horizontal Compressive Graft length 0.17 −0.16 0.50 0.277 10
Graft width 0.57 0.27 0.87 0.002 10
Graft thickness −0.01 −0.94 0.91 0.975 10
Structure horizontal 1.14 −0.50 2.78 0.148 10
Structure parallel 0.33 −2.98 3.64 0.825 10
Marginal Graft length −0.62 −1.28 0.04 0.062 10
Graft width −0.07 −1.37 1.22 0.899 10
Graft thickness 0.08 −2.07 2.24 0.930 10
Structure horizontal −1.84 −4.45 0.77 0.060 10
Structure parallel 2.72 −4.69 10.13 0.422 10
Ochsenbein Compressive Graft length 0.54 0.08 1.01 0.026 10
Graft width 0.73 0.01 1.45 0.048 10
Graft thickness 0.08 −1.54 1.71 0.908 10
Structure horizontal 1.87 0.02 3.71 0.048 10
Structure cross 0.38 −1.88 2.64 0.710 10
Structure parallel 0.32 −2.59 3.24 0.805 10
Marginal Graft length 0.68 −0.92 2.27 0.358 10
Graft width 0.50 −1.93 2.93 0.646 10
Graft thickness 0.58 −3.69 4.84 0.763 10
Structure horizontal 0.51 −5.78 6.81 0.855 10
Structure cross −0.16 −6.18 5.86 0.953 10
Structure parallel 3.34 −3.89 10.56 0.318 10
Glue Marginal Graft length 0.70 −0.72 2.12 0.290 10
Graft width 1.06 −1.66 3.79 0.395 10
Graft thickness −0.34 −3.68 3.00 0.820 10
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Note:Estimates, 95% confidence intervals, and p‐values are presented separately for all configurations. Bold font indicates statistical significance (p < 0.05)

Figure 5 demonstrates the regression estimates of the association between graft length (A) and width (B).

Figure 5.

Figure 5

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Forest plots of regression estimates showing the association of graft length (A) and graft width (B) with lateral compressive and marginal tension.

3.3. Suturing Time

Suturing time varied significantly across techniques (Supplementary Table 2). Compared to the Miller technique (4.16 (SD 1.27 min), CC was significantly faster (3.29 (SD 0.44) min; Estimate = –0.97; p = 0.030). Conversely, longer durations were required for HOC (7.12 (SD 1.23) min; Estimate = 3.00; p < 0.001), CC + H (5.85 (SD 1.34) min; Estimate = 2.58; p = 0.001), and VCC + H (5.68 (SD 0.81) min; Estimate = 2.29; p = 0.002).

4. Discussion

The success of FGG procedures is closely linked to the mechanical stability of the graft during the early healing phase, when survival relies primarily on passive plasmatic diffusion through intimate contact with the recipient bed (Oliver et al. 1968). To our knowledge, this is the first study to quantitatively compare the biomechanical performance of different suturing techniques and cyanoacrylate fixation for FGG stabilization.

Findings indicate that complex suture configurations—including the HOC and CC + H techniques—were associated with significantly improved graft stabilization, requiring 50–100% more force for displacement than simple interrupted sutures. As expected, complex suture configurations were associated with increased procedural time. HOC, in particular, required nearly three times longer than the Miller technique, underscoring the clinical trade‐off between enhanced graft stability and surgical efficiency. Notably, the use of cyanoacrylate adhesive achieved marginal stability (3.45 (SD 3.20 N) comparable to that of the HOC suture (3.82 (SD 1.35 N), suggesting that GLU may offer a clinically viable alternative to sutures in appropriate cases.

Although silk sutures are less commonly recommended in contemporary clinical practice due to their greater propensity for bacterial accumulation and tissue reaction, they were selected for the primary experimental arm because of their favorable handling characteristics and reliable knot security. These properties facilitate the reproducible execution of complex suture configurations in controlled experimental models. The inclusion of 5‐0 PGA sutures was based on a recent review from our group, which identified 5–0 as the most commonly used diameter for FGG fixation (Negre et al. 2025). PGA sutures are extensively characterized in oral surgery, and several studies have contrasted their biological behavior with that of silk, including bacterial adhesion, inflammatory response, and histological features (Racey et al. 1978; Balamurugan et al. 2012; T R et al. 2021). Clinically, PGA demonstrates a median in‐situ survival of approximately 15 days, with tensile strength maintained for 5–7 days—sufficient to support graft stabilization during early healing (Moser et al. 1974; Shaw et al. 1996). As a non‐resorbable material, silk remains in place considerably longer but is associated with increased bacterial accumulation and higher incidence of local tissue reactions (Sortino et al. 2008; T R et al. 2021; Faris et al. 2022). These material‐specific characteristics should be considered in clinical decision‐making even when biomechanical performance appears similar.

Graft dimensions influenced mechanical stability in a technique‐dependent manner. Increased graft height enhanced compressive resistance when VCC, VCC + H, or HOC sutures were used. Conversely, greater graft length negatively affected marginal stability in the horizontal suture group. Although horizontal sutures are primarily described for graft stretching and are not used in isolation in clinical practice, their inclusion in this study was intended to provide a comprehensive biomechanical assessment.

While the role of suturing in flap and graft stabilization is well established, few studies have provided direct biomechanical comparisons of suturing techniques in periodontal plastic surgery. Shammas et al. (2020) reported no significant difference in graft contraction when stretching sutures were used in FGG procedures. At 6 months, graft height reduction was similar in both the test (33.7%) and control (33.2%) groups (Shammas et al. 2020). In a cadaver study, Tavelli et al. (2019) found that sling‐based sutures provided greater marginal stability than interrupted sutures in coronally advanced flap procedures. Recorded marginal tensions ranged from 2.83 (SD 1.02 N to 5.33 (SD 1.02) N (Tavelli et al. 2019). More recently, Pabst et al. (2023) demonstrated superior tensile strength with cyanoacrylate adhesives (GLU: 5.20 (SD 1.47 N); GLU+suture: 8.50 (SD 2.30 N) compared to sutures alone (0.88 (SD 0.61 N) in a porcine CAF model (Pabst et al. 2023). However, comparisons across studies must be interpreted with caution due to differences in suture materials, graft design, models used, and testing protocols.

Although comparison of suture material was not a primary objective of this study, clinical decision‐making should also consider material‐specific biological and handling properties. Polyglactin 910 and monofilament sutures have been associated with superior root coverage outcomes in coronally advanced flap procedures compared to silk or expanded PTFE, particularly when 5‐0 sutures were used (Ariceta et al. 2025). These findings likely reflect differences in plaque accumulation, tissue trauma, and wound healing. Timing of suture removal may also influence outcomes; early removal ( < 10 days) may impair healing, while extending beyond 14 days does not appear to provide additional benefit (Blasi et al. 2025; Tatakis and Chambrone 2016). While these data are derived from coronally advanced flap procedures, careful extrapolation to FGG is clinically reasonable.

Among alternative fixation methods, tissue adhesives offer several advantages over traditional sutures, including reduced tissue trauma, improved hemostasis, antimicrobial effects, and enhanced patient comfort (Veríssimo et al. 2021; Yilmaz et al. 2022). The mechanical performance of cyanoacrylate observed in this study suggests that adhesive fixation may provide measurable initial stability under specific conditions. This may be attributed to the uniform bonding across the graft surface achieved during polymerization, as opposed to the localized fixation provided by sutures. In addition, adhesive interaction with adjacent tooth surfaces may further enhance retention (Pabst et al. 2023). However, it is important to note that in the GLU group, graft detachment consistently occurred during primary marginal tension testing, suggesting a potential inherent weakness of adhesives under tensile stress compared with sutures. This limitation should be carefully considered when extrapolating the clinical stability of adhesive fixation relative to more complex suturing techniques. Due to the application of cyanoacrylate adhesive in two sequential layers, with a necessary setting interval between applications, the overall procedure time was not significantly shorter than that of suturing—likely attributable to the small size of the grafts. However, for larger grafts, the use of adhesive may offer a meaningful reduction in operative time.

The porcine mandibular model offers substantial translational value, as its masticatory mucosa closely approximates human tissue in epithelial thickness, keratinization, collagen architecture, and mechanical behavior (Steigmann et al. 2022; Pabst et al. 2023). However, ex vivo conditions inherently lack vascular perfusion, hemostasis, and fibrin clot formation—biological events that play a decisive role in early graft retention. In particular, fibrin clot adhesion, which contributes significantly to initial graft stabilization (Weisel and Litvinov 2017; Tutwiler et al. 2021), cannot be reproduced in a cadaveric model, thereby limiting direct extrapolation to clinical healing dynamics. These constraints are intrinsic to preclinical biomechanical models and should be considered when interpreting the findings.

Several methodological considerations also warrant acknowledgment. A specific displacement rate (mm/min) was not recorded, which may influence absolute force values due to the viscoelastic nature of soft tissues; however, identical testing conditions were applied across all groups by the same operator in a randomized order, preserving the validity of relative comparisons. Adhesive layer thickness and uniformity were not independently quantified and could have influenced fixation strength. In the cyanoacrylate group, graft detachment during marginal loading precluded lateral compressive testing; therefore, single measurements were obtained for each specimen (n = 10). As a consequence, adhesive‐related data were used solely for descriptive purposes and were not incorporated into the inferential statistical model. Importantly, all samples underwent an identical testing sequence—marginal loading followed by lateral compression when feasible—thereby minimizing the risk of systematic bias.

While mechanical stability is crucial for graft integration, the direct correlation between biomechanical parameters and clinical outcomes—such as graft survival, contraction, or esthetic outcomes—remains to be established. Importantly, this ex vivo study compares the biomechanical performance of fixation techniques; however, what constitutes a ‘clinically relevant’ force threshold is currently unknown. Therefore, it cannot be inferred whether, in specific clinical situations, the higher stability observed with the HOC technique is strictly necessary for biological healing, or whether the lower resistance achieved with the Miller technique may be sufficient. Despite these limitations, this study provides novel and clinically relevant biomechanical data on FGG fixation methods. These findings establish a foundational reference to inform surgical decision‐making and support future translational and clinical investigations.

5. Conclusion

Within the limitations of this ex vivo study, both suturing technique and graft dimensions were found to significantly influence the biomechanical stability of free gingival grafts. Tissue adhesive demonstrated comparable performance to conventional sutures, supporting its potential as an alternative fixation method. These findings may inform clinical decisions for optimizing graft stability.

Author Contributions

Kevimy Agossa: conceptualization, writing – original draft preparation. Khushboo Kalani, Parham Hazrati, and Chi‐Fan Chen: methodology, investigation, data collection. Parham Hazrati: formal analysis, data curation. Khushboo Kalani and Parham Hazrati: writing – review and editing. Chen‐Lin Tsai, Dumitru Chele, and Abdusalam E. Alrmali: investigation, writing – review and editing. Hom‐Lay Wang: supervision, validation, writing – review and editing.

Funding

The authors have nothing to report.

Ethics Statement

This ex vivo study used porcine mandibles obtained post‐mortem from a licensed abattoir (juvenile pigs, 6–8 months, 90–110 kg). No animals were explicitly sacrificed for research. In accordance with institutional policy, the University of Michigan Institutional Animal Care and Use Committee (IACUC) deemed the study exempt from animal research oversight because it involved only post‐mortem tissues. The study adheres to ARRIVE 2.0 guidelines for transparent reporting of experimental research.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supplementary Figure 1: Overview of the experimental arms in the study.

CRE2-12-e70345-s001.pdf (561KB, pdf)

Supplementary Table 1: Univariate Mixed Effect regression analysis regarding suture material. Supplementary Table 2: Univariate mixed‐effects models evaluating the effect of graft dimensions, structural configurations, and suturing technique on time.

CRE2-12-e70345-s002.docx (5.8MB, docx)

Data Availability Statement

De‐identified raw data, analysis scripts, and supporting files are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Figure 1: Overview of the experimental arms in the study.

CRE2-12-e70345-s001.pdf (561KB, pdf)

Supplementary Table 1: Univariate Mixed Effect regression analysis regarding suture material. Supplementary Table 2: Univariate mixed‐effects models evaluating the effect of graft dimensions, structural configurations, and suturing technique on time.

CRE2-12-e70345-s002.docx (5.8MB, docx)

Data Availability Statement

De‐identified raw data, analysis scripts, and supporting files are available from the corresponding author upon reasonable request.

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