Step by Step: External Vertical Mattress Suture

A CLINICAL GUIDE TO PRECISION
SOFT-TISSUE CLOSURE IN SURGICAL IMPLANT DENTISTRY

The external vertical mattress (EVM) suture is one of the most reliable and versatile suture types used in implant dentistry. By keeping the needle perpendicular to the skin surface during placement, the clinician can ensure accurate skin edge approximation, controlled suture end tension, and optimal flap eversion—key factors for predictable soft-tissue healing.

Video Demonstration of a External Vertical Mattress (EVM) Suture

By Dr. Michael A. Pikos 

The accompanying Pikos Institute video illustrates these steps in real time, highlighting needle angles, bite depths, and hand positioning. Watching the technique performed live reinforces the importance of controlled wrist motion and consistent spacing. This video demonstrates the vertical mattress suture procedure that is taught in implant dentistry by Pikos Institute.

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At the Pikos Institute, this technique is taught as part of several core surgical implant courses, including Mastering Implant Dentistry Fundamentals, Soft Tissue Grafting for Implant Reconstruction, and Mastering Implants in the Esthetic Zone: A Perio-Prosthodontic Approach. While the method itself appears straightforward, proper execution is a fine art that separates acceptable closure from optimal outcomes.

This guide presents the EVM technique step-by-step as demonstrated in the accompanying video. It also discusses when and why to use it, common pitfalls, and how it integrates into modern implant surgery protocols.

THE ROLE OF THE VERTICAL MATTRESS IN IMPLANT SURGERY

In contemporary implant therapy, soft-tissue management is inseparable from surgical success. While we often focus on osseointegration and prosthetic design, it is the peri-implant soft tissue that determines the long-term esthetic and biologic stability of an implant restoration. A healthy, well-adapted mucosal seal resists bacterial ingress and maintains tissue architecture.

The external vertical mattress suture provides excellent tissue eversion and secure margin adaptation. It distributes tension deeper in the flap, away from the incision line, allowing the edges to meet without inversion or gapping. This is especially important in procedures such as:

• Flap advancement or coronal repositioning, where margin stability is essential to maintain coverage.
• Soft-tissue grafting around implants, where the flap must adapt precisely over the graft without compression.
• Esthetic zone implant placement, where delicate tissue control is critical for predictable contour and color match.

At the Pikos Institute, clinicians are trained to select suturing techniques based on the biological and mechanical needs of each case—understanding not just how to suture, but why each movement and millimeter matters.

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STEP-BY-STEP EXTERNAL VERTICAL MATTRESS TECHNIQUE

1. Starting the Suture – “Outside In” at 6 mm from the Margin

Begin the suturing process from the external aspect of the flap, entering the tissue approximately 6 millimeters from the incision line. This first bite must be deep enough to engage the connective tissue layer beneath the epithelium, providing anchorage and distributing tension.

2. Second Bite – “Inside Out” at 6 mm

The second needle pass mirrors the first: enter on the opposite flap margin at approximately 6 millimeters from the incision, but this time from inside out. If you were to tie the suture here, you would simply have a simple interrupted suture—adequate for basic closure, but lacking vertical reinforcement. Instead, resist tying at this point; we’re setting up for the vertical mattress configuration.

3. Third Bite – “Outside In” at 3 mm from the Margin

Re-enter the tissue on the same side as your first entry point, but now move closer to the incision—about 3 millimeters from the margin. This bite controls the fine adaptation of the wound edge and initiates the eversion process.

4. Fourth Bite – “Inside Out” at 3 mm from the Margin

Mirror the previous step on the opposite flap, 3 millimeters from the margin, moving inside out. The two narrower bites now sit directly superficial to the deeper ones, creating a vertical “loop” of suture across the incision line.

5. Tie the Suture Adjacent to the Tooth

At this point, tie the suture in the space adjacent to the tooth or implant site. This placement provides lateral tension control and positions the knot where it will not irritate the incision line. Observe the gentle eversion of the flap margins—the hallmark of a correctly placed vertical mattress.

6. Repeat as Needed

Repeat the EVM sutures strategically along the incision, especially at points where precise margin control is required. Commonly, a clinician will place one EVM at each papilla or embrasure, depending on the length of the incision.

7. Supplemental Sutures

Between EVMs, it is often advantageous to add a horizontal mattress suture to reinforce tension distribution and improve adaptation across broader spans. In many full-arch or multi-unit cases, the closure can be finalized with a continuous interlocking suture, ensuring uniform compression and sealing of the flap edges.

And that completes the external vertical mattress suture—a small, elegant maneuver that contributes disproportionately to the overall success of implant surgery.

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KEY PRINCIPLES OF THE EXTERNAL VERTICAL MATTRESS

Tissue Eversion

The most important objective is to achieve flap edge eversion. Inverted or flat edges predispose the incision to delayed healing or scar formation. The dual-level bite of the EVM pulls deeper tissue upward as the superficial edges approximate, creating a convex margin that heals by primary intention.

Tension Distribution

By taking the initial bites 6 mm from the incision, the suture tension is distributed across a broader area. This reduces the risk of tissue ischemia or tearing at the incision margin. Proper tension distribution is particularly beneficial in coronally advanced flaps and ridge augmentation procedures, where flap mobility is limited.

Edge Approximation

The closer 3 mm bites provide fine control of the wound edges, ensuring accurate adaptation without compression of the underlying tissues. This promotes capillary continuity across the incision line and minimizes dead space.

Knot Positioning

Always position the knot away from the incision line to avoid irritation and bacterial contamination. The lateral tie near the tooth ensures the knot remains accessible for removal while keeping the incision area undisturbed during early healing.

PRACTICAL APPLICATIONS IN IMPLANT SURGERY

The external vertical mattress is particularly useful in the following clinical scenarios:

1. Implant placement in the esthetic zone, where precise soft-tissue positioning and contour preservation are critical.
2. Socket preservation and ridge augmentation, where graft materials require secure coverage without tension.
3. Soft-tissue grafting procedures, especially when stabilizing connective tissue or acellular dermal matrices.
4. Flap advancement or coronal repositioning, ensuring margin stability and full coverage of regenerative materials.
5. Peri-implant maintenance procedures, where minor flap access is needed without compromising soft-tissue architecture.

Surgeons at the Pikos Institute frequently combine EVMs with other closure techniques—such as horizontal mattress or continuous interlocking sutures—to achieve optimal tension relief and adaptation in complex multi-site cases.

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CLINICAL TIPS FOR PREDICTABLE RESULTS

Needle Control:

Maintain a perpendicular angle on entry to engage sufficient connective tissue without exiting too superficially.

Depth and Spacing:

The 6 mm and 3 mm distances are not arbitrary; they balance strength and precision. Larger bites may cause tissue distortion, while smaller ones risk tearing.

Suture Material:

For implant cases, a 4-0 or 5-0 monofilament non-resorbable suture (such as PTFE or nylon) offers strength with minimal tissue reaction.

Avoid Over-Tightening:

The EVM is designed to approximate, not strangulate. Overly tight knots can lead to ischemia and delayed epithelialization.

Confirm Eversion:

Before final knot tying, observe the margin from multiple angles. Adjust as needed to achieve gentle outward curvature of the edges.

Sequence Matters:

Begin with central sutures to establish alignment, then proceed laterally. This prevents distortion along the incision.

Remove Timely:

Typically, EVM sutures remain for 10–14 days in implant cases; removal should occur once epithelial continuity is established.

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COMMON PITFALLS

Even experienced surgeons can overlook small details that compromise outcomes:

Shallow First Bites:

Failing to engage deep connective tissue reduces strength and defeats the purpose of tension redistribution.

Inverted Edges:

This results from reversed needle angles or tying with excessive force.

Unequal Bite Depths:

Asymmetry leads to margin misalignment and poor adaptation.

Improper Suture Material:

Braided sutures can wick bacteria; non-resorbable monofilaments are preferred in implant contexts.

Ignoring Tissue Biotype:

Thinner mucosa demands gentler handling and finer suture material.

These nuances are emphasized repeatedly in Mastering Implant Dentistry Fundamentals and Advanced Soft Tissue Grafting courses, where clinicians perform these closures in simulated and live environments.

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INTEGRATING THE TECHNIQUE INTO THE FULL SURGICAL WORKFLOW

The external vertical mattress is not an isolated maneuver—it’s a component of a comprehensive surgical strategy. Integration should occur at each phase of the procedure:

1. Flap Design and Reflection – Plan incision lines with closure in mind. The EVM performs best with well-vascularized, tension-free flaps.
2. Implant or Graft Placement – Execute atraumatic procedures that minimize flap stress.
3. Flap Advancement and Repositioning – Assess whether flap release or periosteal scoring is necessary to achieve passive closure before suturing.
4. Suture Placement – Place EVMs at key tension points first, typically near the papillae or adjacent to implants.
5. Supplemental Closure – Add horizontal mattress or interlocking sutures between EVMs to stabilize broader flaps.
6. Postoperative Evaluation – Check for blanching, verify margin approximation, and ensure the patient receives clear care instructions.

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Each Pikos Institute course reinforces the concept that soft-tissue management is an anatomic discipline, not a cosmetic afterthought. Understanding when to employ each suture type transforms surgical predictability.

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Teaching Context: The Pikos Institute Surgical Implant Curriculum

At the Pikos Institute, the external vertical mattress suture is introduced early and revisited frequently throughout the implant curriculum:

Mastering Implant Dentistry Fundamentals introduces suturing fundamentals, flap design, and basic closure concepts.  It also builds competence with techniques like the EVM, interrupted, and horizontal mattress sutures under surgical magnification.

Soft Tissue Grafting for Implant Reconstruction explores advanced applications—graft stabilization, tension release, and layered closure.

Mastering Implants in the Esthetic Zone: A Perio-Prosthodontic Approach focuses on applying EVM principles where esthetics and biology intersect.

Each CE-Based surgical implant training course reinforces real-world surgical integration—showing dental clinicians how small refinements in suturing technique improve graft stability, papilla preservation, and overall patient outcomes.

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BIOLOGICAL RATIONALE FOR IMPLANT SUCCESS

The predictable healing associated with the external vertical mattress suture is rooted in sound biologic principles:

• Primary Intention Healing: By everting the wound edges, epithelial cells migrate directly across the incision, reducing scar formation.

• Vascular Preservation: The vertical configuration preserves underlying vasculature, essential for graft and flap survival.

• Controlled Tension: The deep, distant bites remove stress from the incision margin, minimizing ischemia and dehiscence.

• Enhanced Stability: The vertical loop stabilizes soft tissue against micromotion, particularly valuable in areas adjacent to implants or regenerative materials.

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These biologic advantages make the EVM a cornerstone technique across oral surgery, periodontics, and implant reconstruction.

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CONCLUSION

The external vertical mattress suture remains one of the most valuable tools for the implant surgeon seeking precise, tension-free wound closure and predictable soft-tissue healing. Its strength lies in its simplicity: four deliberate bites that harmonize deep anchorage with superficial control.

When properly executed, it provides reliable eversion, balanced tension distribution, and stable margin approximation—three ingredients essential for long-term implant success.

Clinicians mastering this technique under the guidance of the Pikos Institute faculty gain not only technical confidence but also an appreciation for the subtle artistry of soft-tissue management. Whether performed in single implant, esthetic zone, or full-arch reconstruction cases, the external vertical mattress suture exemplifies the philosophy at the heart of modern implant dentistry: meticulous attention to detail leads to surgical excellence.

If you are interested in more soft-tissue pearls, protocols and procedures, join us for our upcoming Pikos Symposium 2026: Hard and Soft Tissue Grafting for Optimal Implant Reconstruction - Our globally renowned 3-day Pikos Symposium featuring 12 expert clinicians sharing cutting-edge surgical protocols, digital implant workflows, regenerative biomaterials, and hands-on training—all designed to elevate your clinical outcomes in dental implantology.