Bimanual instrument suturing technique for periodontal and implant microsurgery: A technical note

In the traditional suturing technique, the dominant hand (DH) holds a needle holder, and the non-dominant hand (NH) performs manual ties without the aid of an instrument. In periodontal and implant microsurgery, finer sutures and needles, e.g., 7-0 in International Organization for Standardization units, are used, which could be more difficult to handle with this technique.

The bimanual instrument suturing technique (BIST) emphasizing the use of microsurgical instruments in both the DH and NH for tying finer sutures is narratively described, and visualized by a video animation. With BIST, the DH and NH grasp the microsurgical needle holder and tying forceps, respectively. The three-point "tripod" support in the hands stabilizes the instruments to improve suture placement precision and reduce hand tremors. Meticulous bimanually coordinated motions assist in stabilizing the flap and control the suture movement with precision and minimal trauma. The primary technical differences and advantages of BIST, compared to the traditional instrumentation technique, are discussed. Wound closure using the BIST principles was demonstrated in three commonly performed periodontal and implant surgeries: guided tissue regeneration, tunneling with connective tissue graft for root coverage, and guided bone regeneration.

Structural and standard step-by-step demonstration of BIST is introduced as an efficient method for handling fine needles and sutures during periodontal and implant microsurgery.

This technique, utilizing both the dominant and non-dominant hands to tie knots, could potentially enhance the precise placement of the microsutures by allowing better vision and psychomotor coordination and the use of fine finger-wrist motions. It requires hand stabilization and specific needle and suture grasping positions, as well as a specific sequence of needle holder/tying forceps transfers between the hands. As with most new surgical skills, there is a learning curve involved in order to develop finesse. Eye-hand coordination in using two instruments must be developed. The learning curve can be shortened via laboratory technique exercises. Additional instrumentation, i.e., microsurgical tying forceps, is needed.

Structured and step-by-step technical standardization and clinical illustration of the bimanual instrument suturing technique were introduced for periodontists to perform minimally invasive microsurgery efficiently. This technique is beneficial for handling hair-thin biotextiles and fine needles by applying both hands to construct surgical knots. This technique could facilitate better visual and psychomotor coordination, delicate wrist/finger motion, and reduce mental fatigue and distraction. This technique requires intentional practice and adherence to standardized steps to build muscle memory for consistently reproducing desirable knots that are essential for wound stability and successful clinical outcomes.