Cyanoacrylate glue application in oral surgery: a mini-review

INTRODUCTION

A substantial part of surgery treatment is a suitable patient dressing after a procedure. Regarding oral surgery with incisions and soft tissue detachment, suture application is the gold standard. Possession of this ability is a foundation in everyday dental surgeon’s practice. The availability of products on medical material market, which might serve as an effective alternative to classic surgical sutures in selected cases, is worth noting. Representatives of this group include tissue adhesives based on cyanoacrylates [1].
Cyanoacrylate glues are biocompatible materials, which are biodegradable and exert a bacteriostatic effect. Furthermore, they do not exhibit genotoxic activity or systemic toxicity, and they do not cause mucosal irritation or cutaneous sensitivity [2]. Their use in surgical wound management is of considerable significance.
Because of these features and efficacy, cyanoacrylates have a long history of utilization in other fields of medi­cine, as hemostatic agents or substances used in emboli­zation [1, 3].
Cyanoacrylates undergo hydrolytic attack of carbon-carbon bonds to produce metabolites, such as formaldehyde and cyanoacetate [4]. Animal model experiments, using lab rats who orally received a dose of an adhesive (6.2-6.4 mg ethyl-2-cyanoacrylate), showed the pre­sence of metabolites derived from cyanoacrylates in serum up to 54 hours and urine at 78 hours. Despite the afore-mentioned metabolite occurrence, the authors indicated no toxicity symptoms [5]. Another study assessed the influence of cyanoacrylate intake on bioche­mical parameters, such as blood urea nitrogen (BUN), creatinine (CRE), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBI), total protein (TP), albumin (ALB), and amylase (AML). This animal model-based study (lab rats) involved animals’ mucosa incisions, with subsequent wound closure using an N-butyl-2-cyanoacrylate glue. The researchers controlled the chosen parameters 2, 14, 21, and 65 days post-procedure. Additionally, pathomorphological tests were done on the 65th day of the experiment after sacrificing the study group. Considering biochemical and autopsy examinations, there were no deviations in the function and structure of the kidneys and livers of the studied rats. The authors emphasized the potential physical (thermal) risk of mucosa injury as a result of applying a cyanoacrylate agent. Its polymerization reaction is exothermic, leading to cell death in cell culture conditions [6].

OBJECTIVES

This article aimed to demonstrate possible clinical applications of cyanoacrylate adhesives in daily oral surgery practice, such as post-extraction socket dressing, impacted third molar surgery, closure of oroantral communications or alveoloplasty as well as various procedures in endodontic or periodontal surgeries.

MATERIAL AND METHODS

Material for the review was obtained from the PubMed database. Search formula included “cyanoacrylate glue” and “oral surgery”, and was applied to all papers published between 2003 and August 2024. Based on these criteria, 54 records were obtained. After excluding articles not addressing dental surgery issues or ex-ceeding the field, a group of 11 articles was determined (Figure 1).
These studies present various applications of cyanoacrylate adhesives in dental surgery.

RESULTS AND DISCUSSION

Based on various study designs and procedures, the current review highlighted the potentials of cyanoacrylate adhesives as an alternative, or complementing conventional sutures in oral surgery. The research included clinical trials, experimental studies on animal models, and case reports. Key procedures explored post-extraction socket dressing, closure of oroantral communications, impacted third molar surgery, alveoloplasty, free gingival grafts (FGG), apicoectomy, and bone graft fixation. Split-mouth studies were particularly prominent, allowing for direct comparisons of outcomes with and without adhesive utilization in the same patients. The detailed results are presented in Table 1.

POST-EXTRACTION SOCKET DRESSING AND IMPACTED THIRD MOLAR SURGERY

According to researchers, post-extraction suture application may be supplanted by tissue adhesion using N-ethyl-2-cyanoacrylate. In a study by Maia et al. [7], an experiment on lab rats was conducted, with bilateral first upper molar extractions. Left-hand side sockets were managed with a single 5-0 nylon suture, whereas right-hand side ones with an N-ethyl-2-cyanoacrylate. Among the animals, several groups were distinguished. They had autopsies in the span of 3, 7, 15, and 30 days after teeth removal. Taking that into account, the healing of surgery sites in both the groups was compared. The results revealed that cyanoacrylates ap-plication slowed the recovery process and bone formation, as opposed to suture application. However, in a comprehensive view of the post-operative period (30 days after the procedure), there was no difference in healing and bone tissue development after implementing the adhesive [7].
In terms of providing care for individuals after surgical removal of an impacted wisdom tooth, the literature also indicates that suturing the wound can be successfully replaced with bonding. Regarding lower impacted third molars, split-mouth studies have been published, in which patients underwent bilaterally impacted third molar extraction in the mandible. Study group consisted of 30 individuals aged 20 to 32 years, with the exact position of the impacted eighth teeth on both sides. Selected criteria were being healthy, no nicotine addiction, no allergies, and no chronic diseases. Firstly, the lower left third molar was removed, the wound was closed with sutures, and the patient’s condition was monitored for 7 days. Two weeks later, the lower right third molar was also extracted using the same operation technique, but an iso-amyl-2-cyanoacrylate was applied for bonding of the edges of a flap instead of sewing. The outcomes showed that after using the glue, the patients reported statistically weaker pain sensations during the first three days following the procedure, compared with surgical sutures. Although the difference intensity of post-extraction bleeding was statistically irrelevant, the participants subjectively notified less bleeding while using the adhesive. Nevertheless, the researchers highlighted some limitations in bonding agent usage, as they did not perform well with significant lateral forces, there was an issue in maintaining dryness of the wound edges during formula application, the surgical area was affected by infection, and there was ample space beneath the lesion edges [8].
The replacement of sutures by cyanoacrylates in impacted upper third molar surgery was also described in a split-mouth study, in which the researchers used glue as a new technique for accessing impacted upper eighth teeth. The experiment was based on a group of thirty systemically healthy patients with bilaterally impacted upper wisdom teeth located in the same position on both sides. The aim was to compare a classic operation technique with a new surgical access. Conventional method required an elevation of a full-thickness flap from an incision running along the crest of the alveolar ridge, with closure using surgical sutures. While a new technique proposed by the authors involved performing an oblique incision running from the front and distal buccal cusp area of the upper second molars to the back, towards the end of the maxillary tuberosity. Then, the wound was bound together with a tissue adhesive based on a N-butyl-2- and N-octyl-2-cyanoacrylate. The findings showed that the cyanoacrylate method was significantly less painful. However, the choice of a technique was not statistically significant for edema intensity, bleeding, and bruising [9].

ALVEOLOPLASTY AND OROANTRAL COMMUNICATION CLOSURE

Split-mouth studies comparing the healing process after alveoloplasty in toothless patients, have led to simi­lar conclusions by the authors of three publications. The research was conducted on 20-, 25-, and 30-person groups, each without comorbidities, in good shape, edentulous, and requiring an alveoloplasty procedure bilaterally in an upper or lower arch. Simple dorsal incisions used as surgical access were closed on one side with 3-0 silk sutures, while cyanoacrylate adhesives were applied on the other side. Both the papers are in accordance with the conclusions. Using cyanoacrylates reduced the time needed to complete the procedure and limited post-operative bleeding; patients reported less discomfort, reduced swelling, and better healing after the procedure [1, 10, 11]. Moreover, the researchers of another project performed a comparative histopathological analysis of wounds. The results proved a lower inflammatory response in a cyanoacrylate-managed wound than with suture application. The density of forming connective tissue was similar in both the groups [10]. One of the included studies presented the use of a cya­noacrylate adhesive for the closure of oroantral communication after upper molar extraction, and described two cases. The glue formula was based on N-butyl cyanoacrylate with metacryloxisulfolane. In the first case, an oral sinus tract was developed during the upper left second molar extraction, which was performed in an author’s dental office. The second patient was referred to the author’s entity 48 hours after upper left second molar removal in a different place due to an oroantral communication. Both instances met with a decision of an immediate junction surgery, followed by various steps. Radiological diagnostics were performed to exclude contraindications for closing the connection. Maxillary sinus was rinsed with 15-20 ml of clindamycin solution 600 mg/2 ml and dexame-thasone 4 mg/1 ml, diluted in saline solution while maintaining drainage through the nasal cavity. After-wards, the sockets were curettaged, and by using a drop-by-drop technique, a plug of cyanoacrylate adhesive was formed in the alveoli. Patients were provided standard guidelines for the procedure, took antibiotics, and were under observation. Both cases managed to yield proper operation site recovery without fistula formation. The period of complete epithelialization of the sockets was 23 days for the one dressed immedi-ately post-extraction, and 25 days for the socket managed 48 hours after tooth removal. Two months post-closure, check-up showed no maxillary sinus or oral cavity pathologies. The author suggests that cy-anoacrylate glue usage as an alternative to a flap procedure is the most suitable for OAC within 3 to 5 milli-meters [12].
Cyanoacrylates’ hemostatic advantages can be applied to assist in treating patients on oral anticoagulants. There have been articles published covering this topic. The authors compared the efficiency of two dis-tinct ways of post-extraction management with additional flap elevation and alveoloplasty. Thirty individuals were using warfarin, and their anticoagulant therapy was not modified because of surgical procedures. Additionally, a group of 10 patients did not take such medications. Study group was divided into two sub-groups. The first one included 15 participants who were conventionally treated with gelatin sponges and catgut sutures applied. The second sub-group consisted of 15 patients treated with absorbable sutures, and N-butyl-2-cyanoacrylate bonding agent was used as a wound coverage. The results showed that both the methods were equally effective [3].
Within the methods for regenerating the alveolar bone of the maxilla, the standard technique for securing bone blocks involves using dedicated screws. Based on animal model research results, one should assume that these types of procedures might bring an opportunity to use a cyanoacrylate glue as an addition or a complete substitution for block fixation using screws. An experimental study was performed, in which two bone blocks were attached to rabbits parietal bones. On the right side, conventional screws were employed, while on the left side, the segments were connected using an N-ethyl- 2-cyanoacrylate adhesive. In the span of 5, 15, 30, 60, and 120 days from the surgery, four rabbits were se-quentially euthanized and subjected to histopathological examinations. The results showed that in the cyanoacrylate agent group, better stability and adherence to the recipient site were achieved. Apart from that, discrete inflammatory reactions lasted longer, bone re-modeling occurred slower than with a screw ap-plication, and bone graft integration appeared much later. The differences in integration and re-modeling of the blocks were the most relevant between 15 and 120 days post-procedure. The authors indicated using cyanoacrylates with short ester chains to gain greater adhesive strength (preferably ethyl groups) because it decreases chain extension. The disadvantage of short-chain agents is that they have a higher potential for toxicity. As stated by the researchers, using this technique in humans necessitates further tests and approval of N-ethyl-2-cyanoacrylate utilization in humans [13].

PERIODONTAL AND ENDODONTIC SURGERY

According to the research, muco-gingival surgeries with free gingival grafts (FGG) may successfully utilize cyanoacrylate glues instead of surgical sutures. In the context of split-mouth studies, a 12-patient group with bilateral gum recessions in one dental arch was subjected to FGG treatment. By means of a random draw, a recipient site was chosen for adhesive application, whereas the opposite side was managed with 5-0 nylon sutures. The results showed that patients dressed with cyanoacrylates reported less complaints of severe pain during the first three days after the procedure, bone graft shrinkage was significantly more minor, and the graft healed one month faster (1 month for the bonding agent vs. 2 months for stitches) [14].
Another split-mouth experiment involved a group of 10 individuals who needed bilateral apicoectomy of the incisors in the maxilla or mandible. The study showed the applicability of cyanoacrylate adhesives in endodontic surgery. Patients requiring simultaneous resection of both upper and lower medial incisors underwent a procedure involving development of a full-thickness trapezoidal flap. The right side of the wound was sewed with 3-0 silk sutures, whereas the left wound edge was treated with a N-butyl-2-cyanoacrylate. Considering clinical observations from the procedure and histopathological tests performed on the 1^st, 2^nd, 3^rd, and 7^th days, the authors came to certain conclusions. Similarly to other methods, inflammation was reduced after using the glue, healing proceeded faster, and patients reported less severe pain sensations. Moreover, the suture-managed side was characterized by more significant scarring [15].

ADVANTAGES AND DISADVANTAGES OF CYANOACRYLATES IN DENTAL SURGERY

The presented material shows numerous advantages of cyanoacrylate application in dental surgery. It is a considerably more manageable way, contrary to classic surgical sewing that requires much greater skills and dexterity, especially in a small and limited space, such as the oral cavity. Owing to the glue’s biodegradability, another visit is not required for stitches’ removal. The post-operative period after using cyanoacrylate glue is less burdensome for the patient than a similar procedure involving surgical suturing. This is due to bacterio-static and hemostatic effects as well as reduced inflammatory response.
Apart from the wide range of advantages of bonding agents, there are limitations which need to be acknowledged. The first condition of proper wound adhesion is to obtain dryness, a particularly problematic condition in the oral cavity environment. Because of chemical properties and polymerization reaction parameters (exothermic reaction), there is a risk of potential cytotoxic activity, thermal cell damage within the bonded tissue, and delayed healing [16, 17].
While beneficial in oral surgery, cyanoacrylate glues are not suitable for all cases due to specific limitations associated with their use, such as highly mobile areas (e.g., areas of high masticatory forces or tongue mobility), deep or high-tension wounds, infect-ed/contaminated wounds, or large surface defects. The adhesive strength of cyanoacrylates diminishes over time as the polymer degrades, which is unsuitable for cases requiring long-term stability [18]. Multidirectional studies on cyanoacrylate glues should be implemented to exploit their assets, and to minimize or eliminate flaws. Firstly, they require research to evaluate their impact on oral cavity tissues, and to establish their safety profile. Subsequently, lab and clinical trials should be performed on the broadest possible range of surgical procedures, comparing the efficacy of dressing wounds in oral surgery with sutures and the studied adhesives. The final results should determine clear indications and contraindications for using this form of wound management in clinical practice of oral surgeons. The summary is presented in Table 2.

STUDY LIMITATIONS

While the current review highlights promising applications of cyanoacrylate adhesives in oral surgery, several drawbacks should be mentioned. Most evidence is based on small-scale clinical trials, split-mouth studies, and animal models. The findings, while informative, require validation through larger, randomized clinical trials with more diverse populations. Moreover, heterogeneity in study protocols, adhesive formulations, and application techniques limit the comparability of the outcomes across the studies. Many studies report on favorable pain reduction, healing, and inflammation results, but comprehensive reporting on failures or complications as well as long-term safety data on humans are lacking.

CONCLUSIONS

Based on the presented material, cyanoacrylate glues offer significant potential in dental surgery as an effective alternative to traditional sutures. These adhesives provide notable benefits, including reduced pain, minimized bleeding, and the elimination of suture removal, leading to effective wound healing. Their ease of application makes them particularly suitable for using in confined spaces, such as the oral cavity, complementing the skills of dental surgeons. Additionally, their biodegradability and bacteriostatic proper-ties enhance patients’ post-operative experience by reducing inflammation and discomfort. However, cyanoacrylate glues are not without limitations. Their efficacy depends on achieving a dry surgical environment, which can be challenging in the oral cavity. Furthermore, the exothermic polymerization reaction poses a risk of thermal damage to the tissue, and their application is unsuitable for wounds under significant tension or above large empty spaces. These constraints underscore the need for careful case selection and surgeon expertise when utilizing these adhesives.
Further research is essential to integrate cyanoacrylate glues into standard dental practice fully. Studies should focus on their long-term effects on oral tissues, optimal application techniques, and safety profiles. While traditional sutures remain indispensable, cyanoacrylate adhesives expand the range of options available to oral surgeons, providing a versatile tool for tailored patient care.

DISCLOSURES

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: The authors declare no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

References