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ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 108-114

Cyanoacrylate: An alternative to silk sutures: A comparative clinical study


1 Department of Oral and Maxillo Facial Surgery, KIMS Dental Collage and Hospital, Amalapuram, Andhra Pradesh, India
2 Department of Oral and Maxillo Facial Surgery, Government Dental College and Hospital, Hyderabad, India
3 Resident Pragna Children Hospital, Hyderabad, India
4 Department of Pedodontics, Malla Reddy Dental College for Women, Surarm, Hyderabad, India
5 Department of Orthodontics, Malla Reddy Dental College for Women, Surarm, Hyderabad, India

Date of Web Publication6-Jun-2018

Correspondence Address:
Dr. Phani Himaja Devi Vaaka
Senior Lecturer, Department of Oral and Maxillo Facial Surgery,KIMS Dental Collage and Hospital, Amalapuram, East Godavari District, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.233838

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  Abstract 


Aim: The aim of the study is to compare silk sutures and n-butyl-2-cyanoacrylate tissue adhesive in intraoral wound closure and contrast the effects through the assessment of time taken to close the wound, time taken for securing hemostasis, postoperative pain, swelling, bleeding, incidence of postoperative wound infection, and wound dehiscence.
Materials and Methods: This study included a total of 20 patients of both genders who required alveoloplasty either bilateral in the same arch or in the upper and lower arches. In the selected patients, the surgical sites were randomly divided into two treatment groups. In group I, surgical wounds closed with n-butyl-2-cyanoacrylate tissue adhesive and silk sutures were used for group II wound closure and the parameters were assessed.
Results: Clinically and statistically, there was significant improvement in cyanoacrylate-treated wounds. The time taken for wound closure with n-butyl-2-cyanoacrylate was lesser. Early hemostasis was achieved with n-butyl-2-cyanoacrylate. The postoperative pain, swelling, and bleeding were less with n-butyl-2-cyanoacrylate. Higher incidence of wound infection and wound dehiscence were observed in wounds treated with silk sutures.
Conclusion: Cyanoacrylate causes less tissue reaction and achieves immediate hemostasis. The procedure is relatively painless and quicker. There are benefits of protection from wound infection and wound dehiscence. So it may be concluded that n-butyl-2-cyanoacrylate can be used for intraoral wound closure effectively.

Keywords: Alveoloplasty, 3-0 black braided silk, n-butyl-2-cyanoacrylate, tissue adhesive


How to cite this article:
Vaaka PH, Patlolla BR, Donga SK, Ganapathi AK, Kurapati V. Cyanoacrylate: An alternative to silk sutures: A comparative clinical study. J NTR Univ Health Sci 2018;7:108-14

How to cite this URL:
Vaaka PH, Patlolla BR, Donga SK, Ganapathi AK, Kurapati V. Cyanoacrylate: An alternative to silk sutures: A comparative clinical study. J NTR Univ Health Sci [serial online] 2018 [cited 2019 Dec 16];7:108-14. Available from: http://www.jdrntruhs.org/text.asp?2018/7/2/108/233838




  Introduction Top


Incision is the basic step for surgical procedures. After a surgical approach, suitable closure and optimum maintenance of the surgical area are the most important factors that affect proper wound healing and the surgical success.[1]

The conventional method of wound closure causes trauma during needle penetration while passing through the tissues and provides a “wick down” through which bacteria can gain access to the underlying tissues and it has been proved that the presence of suture material itself increases the susceptibility to infection. It may also lead to complications such as stitch abscess, epithelial inclusion cysts, and railroad track scar due to invasion of the underlying epithelial layer. Moreover, the wound approximation by suture is time-consuming and leads to more amount of scar formation.[2]

Applications of sutures require the passage of a foreign material through tissue due to which it produces the greatest tissue reactivity. It also provides a pathway for the retention of microorganism into the tissue, which leads to infection.[3] In fact, sutures placed in the gingival and oral mucosa may produce a prolonged tissue response that is most likely a result of the continual influx of microbial contamination along the suture channel.[4] Suture material increases the risk of wound sepsis by serving as an adherent foreign body.[5]

In order to overcome these difficulties, a need for an alternative to sutures is always felt.[3] The use of tissue adhesives as an alternative to or replacement for sutures in wound closure has long been an area of interest. A group of these tissue adhesives are cyanoacrylates.[2]

N-butyl-2-cyanoacrylate has become the standard tissue adhesive as it offers advantages such as effective and immediate hemostasis, bacteriostatic properties, and rapid adhesion to soft and hard tissues. It has a wide range of applications in surgery such as the repair of organs, vessels, skin, and mucosa grafts, closure of lacerations incisions, postextraction dressings, and even in the fixation of mandibular fractures.[6],[7]

It was therefore, decided that the benefits of using n-butyl-2-cyanoacrylate in the closure of intraoral wounds would be evaluated through a clinical study.

The present study clinically evaluated the efficacy of n-butyl-2-cyanoacrylate in the closure of intraoral wounds in 20 patients requiring alveoloplasty in a quadrant either bilateral in the same arch or in a quadrant in the upper and lower arches comparing it with the more conventionally used 3-0 black braided silk suture. The efficiency of n-butyl-2-cyanoacrylate was evaluated in comparison with the black 3-0 black braided silk sutures for closure of intraoral wounds.


  Materials and Methods Top


This clinical study was carried out in the Department of Oral and Maxillofacial Surgery. Ethical approval was obtained from ethics committee of the institution. Consent was taken from the 20 patients requiring alveoloplasty in either bilateral quadrants in the same arch [Figure 1] or in a quadrant in the upper and lower arches. Patients with systemic diseases such as diabetes hypertension, which delays the healing, history of drug allergy, food allergy, or any previous history of allergy to tissue adhesive, chronic smoking habit, poor oral hygiene, and severe dental infections requiring drainage were excluded from the study.
Figure 1: Presence of bony prominences in the mandible on both the right and left sides

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The surgical wounds in the selected patients were randomly divided into two treatment groups. In group I, the wounds were thoroughly debrided and closed with n-butyl-2-cyanoacrylate on one side and black braided silk sutures were used for group II wound closure on the other side in the same patient.

Procedure

After the alveoloplasty procedure in which flaps have been raised intraorally using well-planned incisions [Figure 2] debriding with betadine saline solution was performed. The wounds were isolated with sterile cotton rolls and the tissue surface was dried with gauze sponges. The wound edges were held together either by gentle finger pressure or with toothed tissue forceps and any exudates emerging on the surface was mopped to make sure that the surface remained absolutely dry. Cyanoacrylate adhesive was then applied over the surface of the wound in droplet form all the while maintaining the finger pressure to ensure that the adhesive did not flow between the wound edges. The applied film was extended at least 5 mm on either side of wound. Continued support with digital pressure was maintained till the adhesive polymerized as was evident by transformation of the transparent bioadhesive film into an opaque layer [Figure 3]. The time was noted from the beginning of the wound closure till its completion.
Figure 2: Incising and measuring the length of the incision

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Figure 3: Wound closure on both sides of the mandible

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On the other side or opposite side, after securing hemostasis, Bensilk black braided silk suture material knotted to a no. 18 eyed half circle cutting needle, which was manufactured by ethicon company was used to place simple interrupted sutures for wound closure. Care was taken to ensure that an adequate bite of tissue is enclosed so as to result in an eversion of wound edges. Time was noted from the beginning of wound closure till its completion. A pressure pack was applied.

Patients were advised to bite on cotton role, which was placed over the wounds closed with black braided silk sutures only for 30 min and were advised to take a cold and soft diet for 24 h to maintain good oral hygiene and avoid excessive manipulation of the treated area. All the patients were maintained on standard antibiotic regimen, analgesics, and anti-inflammatory drugs, along with vitamin supplements.

Follow-up

Patients were reviewed on the 1st, 3rd, 5th, and 7th postoperative day and at the end of the 2nd, 3rd, and 4th week. The sutures were removed on the 7th postoperative day. The parameters were evaluated and the findings were recorded on a standardized pro forma.


  Results Top


A total number of 20 patients with bony prominences on either side [Figure 1] were included in the study. N-butyl-2-cyanoacrylate and 3-0 black braided silk sutures were compared for their efficacy and parameters such as the time taken to close the incision, time taken to secure hemostasis, postoperative pain, swelling, bleeding, wound infection, and the wound dehiscence were assessed.

The youngest patient was 40 years old and the oldest patient was 60 years. The mean age of the patients was 51.9 years. Out of 20 patients, 11 were males and 9 were females.

[Table 1] shows the length of the incision taken in 20 patients, time taken to close the incision, and time taken to secure hemostasis in both the case and control groups. In comparison, it can be seen that application of cyanoacrylate could be achieved relatively quicker and cyanoacrylate has hemostatic properties.
Table 1: Mean and frequency distribution of the length of the incision, time taken for closure, and time taken for securing hemostasis

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In group I wounds, which were closed with cyanoacrylate, the average length of incision was 2.57 mm [Figure 2]. The mean time taken for closure using cyanoacrylate was 105.35 s [Graph 1] and the mean time for securing hemostasis was 133.45 s [Graph 2].



In group II wounds, which were closed with black Braided silk [Figure 3] the mean time to close the incision was 232.4 s [Graph 1] and the mean time for securing hemostasis was 270.7 s [Graph 2].

The time difference was directly proportional to the length of incision in both the groups. All the patients were reviewed on the 1st, 3rd, 5th, 7th, 14th, 21st, and 28th postoperative day and parameters such as pain, swelling, bleeding, wound infection, and wound dehiscence were assessed.

Postoperative evaluation of pain

[Graph 1] depicts the findings of postoperative evaluation of pain in 20 patients. The pain score was given as per the visual analogue scale. The readings are given as follows: 0 = no pain, 1-3 = mild pain, 3-6 = moderate pain, >6 = severe pain.

In group I wounds, treated with cyanoacrylate, out of the 20 patients, 14 (70%) had no pain while 6 (30%) had a moderate pain lasting for a couple of days. In group II wounds, 14 (70%) patients had mild pain and the remaining 6 (30%) patients had moderate pain on 1st postoperative day.

On the 3rd postoperative day, in group I wounds, 18 patients (90%) had no pain and the remaining two (10%) patients had mild pain. In group II wounds, out of 20 patients, 14 (70%) patients had mild pain and the remaining 6 (30%) patients had moderate pain.

After the 5th postoperative day, all 20 patients in group I wounds who were treated with cyanoacrylate had no pain. On the 5th postoperative day, out of 20 patients 10 (50%) patients in group II wounds had no pain and the remaining 10 (50%) patients had mild pain. On the 7th postoperative day out of 20 patients, 15 (75%) patients had no pain and the remaining 5 patients (25%) had mild pain in group II wounds. From the 14th postoperative day onward, 20 patients in group II wounds had no pain.

Postoperative evaluation of swelling

[Graph 2] shows the postoperative evaluation of swelling in 20 patients reviewed on the 1st, 3rd, 5th, 7th, 14th, 21th, and 28th day.

On the 1st postoperative day, out of 20 in group I wounds, 5 (25%) patients had mild swelling and there was no swelling in the remaining 15 (75%) cases. In group II wounds, out of 20 patients, 16 (80%) patients had mild mucosal swelling and the remaining four (20%) patients had no swelling.

On the 3rd postoperative day out of 20 in group I wounds, 19 (95%) patients had no swelling. The remaining one (5%) patient had mild mucosal swelling. In group II wounds, 13 (65%) patients had no swelling and the remaining 7 (35%) patients had mild mucosal swelling.

After the 5th postoperative day, no patient had swelling in group I wounds in 20 patients. On the 5th postoperative day in group II wounds, out of 20 patients 16 (80%) patients had no pain and 4 patients (20%) had mild mucosal swelling. On the 7th postoperative day out of 20 patients, 19 (95%) patients had no pain and 1 (5%) patient had mild mucosal swelling. From the 14th day onward, no patient in group II wounds had swelling.

Postoperative evaluation of bleeding

[Graph 3] shows the postoperative evaluation of bleeding in 20 patients reviewed on the 1st, 3rd, 5th, 7th, 14th, 21st, and 28th day.



On the 1st postoperative day, out of 20 patients in group I wounds 18 (90%) patients had no bleeding and 2 (10%) patients had bleeding. In group II wounds 14 (70%) patients had had no bleeding, whereas 6 (30%) patients had bleeding (P value = 0.118).

From the 3rd postoperative day onward in group I wounds, no patient had bleeding. In group II wounds, 16 (80%) patients had no bleeding and 4 (20%) patients had bleeding (P value = 0.037).

On the 5th and 7th postoperative days, in group II wounds, out of 20 patients, 17 patients (85%) had no bleeding and the remaining 3 (15%) patients had bleeding (P value = 0.075). From the 14th day onward, no patient in group II wounds had bleeding.

Postoperative evaluation of wound infection and wound dehiscence

[Graph 4] shows postoperative wound infection and wound dehiscence of 20 patients on the 1st, 3rd, 5th, 7th, 14th, 21st, and 28th day.



In group I wounds, no wound infection and wound dehiscence were seen in all the 20 patients. In group II wounds, in two out of 20 patients wound infection and wound dehiscence were seen on the 3rd and 5th postoperative days.

In cases where wound infection occurred, additional treatment was required in the form of antibiotics and local debridement followed by delayed primary closure.


  Discussion Top


Healing after closure of the wound can be enhanced by proper approximation of the wound edges and proper isolation of the wound. Superficial contamination of the wound occurs postoperatively and often results in delayed epithelialization of the wound surface and the production of excessive granulation tissues. All these factors contribute to failure of the surgery to produce the desired result and lead to greater postoperative pain and discomfort.

Plaque, food debris, and excessive manipulation of tissues during surgery retard the healing. The incidence of infection can be reduced by careful attention to asepsis and gentle handling of the tissues to prevent the implantation of foreign material into them. Postoperatively, the immediate concern is the protection of the tissues and the control of infection while healing is taking place. Healing is improved by immobilization of the healing area. Immobilization of healing area can be achieved by suture and the tissue adhesives.

Adhesives were introduced as a commercial product in 1958. The first tissue adhesive developed was methyl cyanoacrylate, which was studied extensively for its potential medical application and was rejected due to its toxic reactions such as inflammation or local body reaction. The shorter chain monomers attached to the cyanoacrylate were proposed to be the major cause of histotoxicity and the longer chain derivatives were tried with much improved results. Since then, butyl-2-cyanoacrylate has become the standard tissue adhesive with a rapidly broadening spectrum of indications.

Butyl cyanoacrylate fulfills most of the properties required by a tissue adhesive. It is available in sealed containers, which can be stored in a refrigerator. It is a clear, free-flowing fluid with a blue dye added to it so that it can be seen when in use. The blue color of n-butyl-2-cyanoacrylate has given rise to the colloquial term “blue glue.”

Polymerization of the material occurs within 10 s in droplet form. The material can spread easily, wets the surface to which it is applied, and in a thin film, produces very little heat. It will stick virtually any biological or synthetic material but does not have sufficient tensile strength to adhere tissues under significant tension. Swabs, gloves, and instruments should be kept clear of the adhesive or they will stick to the tissues; the material can be removed from the instruments with acetone.

As butyl cyanoacrylate has four alkyl groups in its side chain, its biological degradation is slower than adhesive with shorter side chains. This slow degradation into formaldehyde and cyanoacetate makes the material less histotoxic. Since butyl cynoacryalate is broken down slowly, it is not advisable to place a continuous layer of it between two healing surfaces; the two surfaces should be approximated held in place and the adhesive was placed over the junction. The fluid quickly polymerizes to form a solid film within 1 min.

The incisions are prepared in a manner similar to that used for suturing. Hemostasis is secured and the edges are clean and dry and held in approximation. The monomer is applied as small drops directly on the incision line and it is allowed to dry. during polymerization. The solution may be applied as interrupted drops or as a continuous film extending up to 5 mm from the wound edges.

In dentistry, cyanoacrylates have been used as postextraction dressings, periodontal packs, and dressings for free mucosal grafts, indirect pulp capping materials, dental cement treatment for ulcers of the tongue and in the closure of lacerations and electively incised wounds. Cyanoacrylates have been reported to offer advantages as effective and immediate hemostasis, ease of application, bacteriostatic properties, and rapid adhesion to soft tissues although they pose certain disadvantages such as low tensile strength and neurotoxicity.

It was, therefore, decided that a comparative clinical study would be conducted to evaluate the efficacy of n-butyl-2-cyanoacrylate in the closure of intraoral wounds with the more conventionally used 3-0 black braided silk sutures. The parameters such as postoperative pain and swelling, time taken for wound closure, time taken for securing hemostasis, postoperative wound infection, and wound dehiscence were assessed in the study.

This study consisted of 20 patients who required preprosthetic surgery such as alveoloplasty and the patients were reviewed on the 1st, 3rd, 5th, 7th, 14th, 21st, and 28th postoperative day. Postoperative clinical evaluation in the first 3 days revealed that pain and swelling were significantly higher at the suture site in contrast to the cyanoacrylate treated site. The irritation and trauma at the sutures and collection of food particles on the sutured area may be responsible for this reaction. These results correlate with the clinical findings reported by C.B. Giray et al.,[6] Barnett et al.[8] and Quinnet al.,[9] who stated that wound closure with tissue adhesive was painless and quick.

The time required for wound closure using tissue adhesive was less when compared to using 3-0 black braided silk sutures. These results conform to the studies of Dalvi et al.[10] and Burns et al.[11] who stated that this procedure was quicker and saved precious operating time. According to Richard and Eiferman et al.[12] cyanoacrylate is associated with anti bacterial effect. Hiren D. Armar et al.[13] also stated that the wound closure with cyano acrylate was much faster and significantly associated with lesser pain.

Immediate hemostasis was achieved in patients treated with cyanoacrylates while the oozing of blood for a short period postoperatively was observed on the sutured site. This observation highlights the hemostatic property of cyanoacrylate, which was quoted by Daniel Howard et al.[14] in his study where he used bucrylate to achieve hemostasis in tooth extraction sockets. Sudhindra Kulkarni et al.[15] concluded in their study that healing with cyanoacrylate was associated with less amount of inflammation and cyanoacrylate aids in early initial healing.

M. Suresh Kumar et al.[16] also concluded in their study that the use of cyanoacrylate glue resulted in less postoperative inflammation and good clinical and histological healing when compared to silk sutures.

In the present study, a lower incidence of wound infection was observed in patients treated with cyanoacrylate as compared to those where wound closure was carried out with 3-0 black braided silk sutures. A similar observation has been noted by other investigators such as Quinn et al.[9] and Dalvi et al.[10] Out of 20 patients, in the group II wounds treated with silk sutures, two patients developed secondary wound infection. This difference in the incidence of wound infection between the two groups arises from two facts. One is sutures per se that predispose to infection by breaching oral mucosa; they provide a source of infection through the suture canal, perisutural cuff of dead epidermis, dermis, fat, and the foreign body inflammatory response. Second, cyanoacrylate has been shown to have an inherent bacteriostatic effect (Richard and Eiferman)[12] Quinn et al.[9] demonstrated that opened vials of tissue adhesive did not show any pathogenic growth even at 30 days and may be used multiple times.

In the present study, the first few days of healing was quick and uniform with less inflammatory response in the cyanoacrylate-treated group; this could be due to isolation of the wound from external stimulation by the adhesive layer during the healing process thereby leading to uniform healing of the wound.

Patients' satisfaction was very high in the cyanoacrylate-treated group as the procedure was quick and lacked the need of suture removal.


  Conclusion Top


Perhaps one prohibitive aspect about cyanoacrylate is its cost. However it is associated with superior results in terms of uncomplicated healing, lower incidence of wound infection, and together with the time saved during the wound closure suggest that the monitory aspect should not defer the surgeon from using cyanoacrylate more regularly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Giray CB, Sungur A, Atasever A, Araz K. Comparison of silk sutures and n-butyl-2-cyanoacrylate on the healing of skin wounds. A pilot study. Aust Dent J 1995;40:43-5.  Back to cited text no. 1
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2.
Raj Kumar V, Rai AB, Priyayadav. Comparative evaluation of n- butyl cyanoacrylate and silk sutures in intra oral wound closure-a clinical study. J Adv Dent Res 2010;1:37-42.  Back to cited text no. 2
    
3.
Shah C, Parmar M, Desai K, Budhiraja S, Kumar S. Evaluation and comparison of healing of periodontal flaps when closed with silk sutures and N-Butyl cyanoacrylate: A clinico - histological study. Adv Human Biol 2013;3:7-14.  Back to cited text no. 3
    
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Banche G, Roana J, Mandras N, Amasio M, Gallesio C, Allizond V, et al. Microbial adhesion on various intraoral suture materials in patients undergoing dental surgery. J Oral Maxillofac 2007;65:1503-7.  Back to cited text no. 4
    
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Howell JM, Bresnahan KA, Stair TO, Dhindsa HS, Edwards BA. Comparison of effects of suture and cyanoacrylate tissue adhesive on bacterial counts in contaminated l lacerations. Antimicrob Agents Chemother 1995;39:559-60.  Back to cited text no. 5
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6.
Giray CB, Atasevar A, Durgun B, Araz K. Clinical and electronic microscope comparison of silk sutures and n-butyl-2-cyanoacrylate in human mucosa. Aus Dent J 1997;42:255-8.  Back to cited text no. 6
    
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Javelet J, Torabinejad M, Danforth R. Isobutyl cyanacrylate: 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. 7
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Barnett P, Jarman FC, Goodge J, Silk G, Aickin R. Randomized trial of histoacryl blue tissue adhesive glue versus suturing in the repair of paediatric facial lacerations. J Paediatr Child Health 1998;34:548-50.  Back to cited text no. 8
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Quinn JV, Drzewiecki A, Li MM, Stiell IG, Sutcliffe T, Elmslie TJ, et al. A randomized, controlled trail comparing tissue adhesive with suturing in the repair of paediatric facial lacerations. Ann Emerg Med 1993;22:1130-5.  Back to cited text no. 9
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Dalvi AA, Faria M, Pinto A. Non-suture closure of wound using cyanoacrylate. J Postgrad Med1986;32:97-100.  Back to cited text no. 10
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Bruns TB, Simon HK, McLario DJ, Sullivan KM, Wood RJ, Anand KJ. Laceration repair using a tissue adhesive in a children's emergency department. Pediatric 1996;98:673-5.  Back to cited text no. 11
    
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Eiferman RA, Snyder JW. Antibacterial effect of cyanoacrylate glue. Arch Opthalmol 1983;101:958-60.  Back to cited text no. 12
    
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Parmar HD, Bhatt SD. The sutureless circumcision- an alternative to the standard technique. Natl J Med Res 2012;2:448-51.  Back to cited text no. 13
    
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Howard D, Whitehurst VE, Bingham R, Stanback J. The use of bucrylate to achieve hemostasis in tooth extraction sites. Oral Surg Oral Med Oral Pathol 1973;35:762-5.  Back to cited text no. 14
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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.  Back to cited text no. 15
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Kumar MS, Natta S, Shankar G, Reddy SH, Visalakshi D, Seshiah GV. Comparison between silk sutures and cyanoacrylate adhesive in human mucosa- a clinical and histological study. J Int Oral Health 2013;5:95-100.  Back to cited text no. 16
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


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