Lost stitches after a tooth extraction. -

What happens if you have a stitch come out?  |  What should you do?  |  Is replacement necessary?  |  Factors your dentist will consider when evaluating your situation and deciding what treatment is needed.  |  What to do about loose stitches.

Lost stitches after oral surgery.

Despite your dentist's skill in placing them, and your best efforts in taking precautions, sometimes things just happen and sutures (stitches) that were placed following an oral surgery procedure, like a tooth extraction, end up loosening or coming out before anticipated or scheduled.

What needs to be done in response to your predicament, if anything, typically boils down to judgments based on just a couple of issues. They are:

  • The reason why your stitches were placed.
  • The time frame during which they fell out/loosened up.
  • The type of suturing and number of stitches originally placed.
  • What has occurred as a consequence of the stitches' failure.

In our discussion below, we give examples of how each of the above issues might be considered and weighed by a dentist when deciding what steps are now indicated for their patient.

It's your dentist who must decide what treatment is required.

After reading this page, you should be fairly knowledgeable about the topic of lost and loose stitches, and have a basic understanding of why replacement may or may not be necessary.

But in regard to the governing factors listed above, it should be obvious to you that there are always going to be some issues that you, the patient, simply won't be in the position to fully know the answer.

Because of this, it's important for you to report what has transpired to your dentist so they can make a determination about your situation.

  • As your doctor, it's their opinion that's the definitive one in making decisions about your post-extraction care.
  • It's also their obligation to respond to your postoperative needs, so don't hesitate.

Note.

This page has been composed with routine surgical extraction cases in mind (removing impacted wisdom teeth, broken teeth, root tips, etc...).

For other procedures, like bone grafting, ridge recontouring (alveoloplasty) and some aspects of dental implant placement, many of the issues involved should be very similar. But only your dentist can decide if additional or different considerations apply.

Differences would be especially likely in cases where the sutured tissue flap is a "free" graft (taken from one site and placed in another), or those where a "barrier membrane" has been positioned. (These are terms your dentist would almost certainly have used in describing your procedure to you.)

Precautions you should take.

Obviously, if you've had a stitch fall out early or come loose you'll need to be careful with your surgical site until you've consulted with your dentist. You won't want to do anything that has the potential to traumatize your wound, dislodge its healing tissues or trigger renewed bleeding.

Depending on your circumstances, precautions with tongue or finger exploration of your surgical site, making extreme mouth movements or even eating might all be indicated.


Examples and general rules of thumb about premature suture loss.

1) Loss of stitches placed to create soft tissue stabilization.

Placing stitches as a way of providing surgical flap (gum tissue) stabilization is the application that patients seem to be most familiar with.

The need for this function is most important during the first days following an extraction. Then, with each additional day of healing that passes, the strength/reattachment of the manipulated tissues to the bone underneath gradually increases, thus lessening this requirement.

A graph showing the rate at which loose tissue flaps reattach during healing.

The rate at which tissue flaps reattach to underlying bone.

The biology of the matter.

How this transition takes place was evaluated by a study by Werfully (2002). It documented the speed and degree to which gum tissue reattaches to the bone underneath during the healing process in dogs. (The assumption being that this process would be similar in humans.)

We've reproduced one of the graphs from the study here. The curve of the graph shows the increase in tensile strength of the wound over time.

Notice on the graph -

As an interesting point, notice that at 7 to 10 days post-op, which is the usual time frame when stitches are removed, the strength of the tissue flap is still only about half as strong as it will ultimately become.

Apparently, however, this is enough strength that short of an excessive challenge to the healing tissues they'll typically remain satisfactorily in place.

A paper by Pippi (2017) confirms this point in stating that at 7 to 14 days post-op, flaps are still susceptible to mechanical trauma. And that only after 4 to 5 weeks of healing has the tissue completely reattached to bone and teeth so that no differences with adjacent tissues exist.

What happens when your stitches fall out early or loosen?

In cases where tissue stabilization is a primary concern, as the graph above shows, the point in time at which the suture(s) failed can be an important factor.

  • If the event occurred just a few days before their removal was originally expected/scheduled anyway, losing them early may not be much of an issue.

    (Notice on the graph how the strength of the tissue's attachment on days 4, 5 and 6 rapidly approaches the evidently satisfactory level reached on day 7.)

  • But if they were compromised early on, like before day 3, disruption of the flap is much more of a possibility because its healing simply hasn't progressed very far. And in this event, your dentist may decide that stitches lost early on need to be replaced.

Considerations and concerns.

When one or more stitches are lost or have loosen up, a number of considerations will come into play.

a) Can the extraction site be favored?

The degree to which the now unstitched/unsupported tissues are subject to disruptive forces is a concern.

  • It may be possible that by practicing great care for the few days needed until the healing process has created a satisfactory level of strength, the patient can nurse their situation along and their fragile wound will remain undisrupted.
  • This won't be possible in all cases however. Conditions may be such that adjacent tissues (lips, cheeks and the muscles in them) create enough pull on the wound that even with just routine and minor movements it will still be subjected to forces greater than it can tolerate. Flap stability can also be compromised due to increases in normal wound swelling.

 Reference: 

Kurtzman G, et al. Suturing for surgical success.

b) How crucial was the stitch that was lost?

Picture of a single post-extraction interrupted suture.

A single (interrupted) suture.

The suturing technique and placement layout the dentist has used will be a major consideration.

  • The stitches that have been placed may be interrupted (individual) or continuous (a series of stitches tied off with a single knot).

    If interrupted, losing one or a few of many might be tolerated. If continuous, a single knot coming untied will ultimately affect the entire row.

  • With the potential for loss in mind, a dentist might have incorporated some degree of redundancy into their suturing plan as a precaution. Only they will know.
Animation illustrating placing stitches to stabilize a gum tissue flap.

The number of stitches and method of suturing will be a consideration.

c) Signs of tissue movement or detachment.

If stitches have come out early or loosened up, especially before day 3 post-op (see graph above), there will be greater potential for the flap to shift, or a portion of it to become detached. As a result:

  • There's some potential that you may discover an edge of tissue that's come loose.

    Gum-to-tooth interfaces gain reattachment strength at a slower rate than gum-to-underlying-bone interfaces. (Werfully - linked above.) So a stitch lost in this region might prove to be more problematic.

  • Often what is noticed is the formation of a dehiscence. This is the situation where two edges of your wound that were stitched together have now come apart. As a consequence, since there is now a space between the two edges, the completion of new tissue formation will take longer.

    The treatment needed will be based on the extent of the dehiscence and its subsequent healing progress. If it is limited in width, no treatment will be required. Large gaps may need to be resutured. If the dehiscence's healing seems stalled, the wound may need to be surgically refreshened. (Annibali)

Renewed bleeding.

It's possible that tissue displacement events will trigger renewed bleeding. In fact, soft tissue not firmly bound to underlying bone is often the cause of persistent postoperative bleeding from a surgical site (with the needed remedy being suture placement). (Koerner)

Significant displacement events are most likely to occur when stitches are lost during the first few days postoperatively. Bleeding escaping from underneath the flap presents itself as flow from the edges of the incision and gingival margin (the edge of the flap that lies along the teeth). (Pippi)

In cases where this complication occurs, your dentist should be notified. As first aid, application of pressure to the wound via moisten gauze is the typical solution. But the pressure must be applied in an orientation that doesn't further disrupt the positioning of the flap. Since your dentist is familiar with the configuration of your wound, let them provide you with instructions.

Tissue tears.

In some cases, stitches can rip through the tissue in which they've been placed. This type of failure can be associated with excessive suturing tension, tissue flaps that are especially thin, the use of thick suture thread, placing sutures too close to the incision line or flaps placed under tension by adjacent tissues and muscle movements or developing swelling. (Pippi - linked above.)

With the stitches now disrupted, the same concerns discussed above apply. Additionally, the tissue lacerations will constitute a secondary, although minor, wound. Associated tenderness, and small amount of bleeding at the time of the event, would be expected.

More details about loose stitches.

While possibly not immediately apparent to most patients, loose sutures provide no benefit to wound healing and actually create some risk. The treatment that's indicated is removing them. (Pippi - linked above.)

Here's why.

In terms of function, a loose stitch provides no stabilizing effect at all, which means that all of the possible problems and concerns discussed above apply to this situation.

As an added concern, the possibility exists that the loop of suture thread might be snagged (like by your toothbrush) and this tension result in tissue laceration as it tears free. So unlike a lost one, a loose stitch has the potential to cause further physical damage and that's why it should be removed.

FYI -
  • Its common for sutures to start to show signs of looseness as the level of swelling in the tissues in which they've been placed starts to subside.
  • In regard to a need for replacing loose sutures, all of the factors and concerns discussed above will apply and will need to be weighed by your dentist when making their decision.
  • If not providing a service, the physical presence of a suture is actually counterproductive to tissue healing.
  • In the case of loose single (interrupted) sutures, removal is quite easy and painless and might be considered as a DYI solution if you have adequate access and visibility.

2) Loss of stitches placed to control postoperative bleeding.

While a patient may not realize it, their stitches may have been primarily placed to aid hemostasis (the control of bleeding from their surgical site). Here are some examples:

  • A common application is one where following a tooth's extraction a clotting aid (typically in the form of an absorbable piece of sponge, gauze or foam) is placed in its socket. Stitches are then used to stabilize and hold the aid in place.

    (As hints that this technique has been used with your situation: The clotting aid that's been placed is typically quite visible. The method of suturing used typically criss-crosses over the socket, often a number of times.)

  • Another application involves the use of stitches to create soft tissue immobilization and compression. Both of which can help to arrest postoperative bleeding.

In cases involving these techniques, the now lost sutures may have already served their purpose, even after just a short period of time. As opposed to stitches placed for tissue stabilization that are not usually removed for at least a week, the purpose of those placed in this context is typically fulfilled within just 2 to 3 days.

 

Last revision/review: 11/04/2018 - Page created.

 
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Comments

Stiches came out.

I had a stich that was loose. Now it is gone. What do I do?

Kat

You haven't given us much information to go by. And we will state that in all cases you should contact your dentist and seek their advice, and attention if they feel it's needed.

In general terms, the main issue involved is simply how long the now missing stitch had been in place.

In most cases, sutures that need to be removed (i.e. those that don't dissolve away on their own) are taken out 7 to 10 days after they were originally placed. So that gives you an idea of what the preferred length of time having a stitch in place is (no matter what kind).

So, if your lost stitch had been in place for 6 days or longer, the event is probably a total non-issue. Although you would still want to favor the area so not to disrupt or dislodge the fragile healing tissues.

From what you describe, we can see how this might be the case with your situation. It's common that as the healing process extends into the first several days that some sutures tend to get noticeably loose (swelling goes down, the healing tissues start to recontour).

If your lost stitch had been in place less than 6 days, you'll need your dentist to pass judgment on your situation. A common breakpoint dentists use is 3 days.

If one is lost after that point, possibly enough healing has taken place to retain the gum tissue in place. Especially if it isn't provoked (by finger, tongue, extreme mouth movements, eating, etc...). Loosing a stitch with no accompanied (new/renewed) bleeding likely represents a situation of less concern but it will take an evaluation by your dentist to determine this.

Pain

It’s been about 5 days after my wisdom tooth surgery extraction and one of top stitches has come out and the bottom two are dissolving. However, my top right stitch feels as if it’s protruding and it’s very painful. It feels very sharp and thick. What should I do?

Ca

Stitches that don't dissolve are typically removed 7 to 10 days after placement. Some types of stitches that do dissove do so at the 5 to 7 day point. (This seems to be what you report.)
The point we are trying to make here is that your offending stitch has probably fulfilled most of the service it was intended to.

Contact your dentist's office. They'll probably appoint you so then can just clip or remove the stitch.

I had my wisdom teeth removed

I had my wisdom teeth removed six days ago, and I had the dissolving stitches. I guess I rinsed my mouth too vigorously last night because I remember spitting out and seeing a stitch I down the sink. Tonight, I felt a lot of pain on my upper left corner wisdom tooth, and I used a mirror and saw that the skin flap was hanging down, and the bone fragments and what was left of the hole, as it had mostly healed, were exposed. Should I be worried? I'm really worried about accidentally biting off the skin flap, because its hanging so low. Should I schedule an emergency meeting with my surgeon?
Thanks

E P

You should call your surgeon's office and have them make the decision about a need to be seen by them.

As this page describes, a purpose of placing stitches can be tissue stabilization during the early phases of the healing process (7 to 10 days). And at a point 5 to 7 days out, it's not uncommon for some types of stitches that resorb on their own to have already significantly deteriorated. So, the stitches have probably provided all of the service that they're capable of or intended to have.

You don't mention that any bleeding occurred, implying that the tissue had healed in this loose or drooping form, as opposed to being ripped from the wound. If its exposed surfaces are healed over, stitching it back into place as is will serve no purposed, the tissue won't reattach.

Sometimes loose tissue is trimmed. In other cases it's just left and your body will get rid of the excess on its own over time. If the tissue wasn't attached to the bone you can now see, we're not so sure anything there has really changed. But of course, these are all issues for your surgeon to evaluate.

Describing things via phone will probably be enough for your surgeon's office to know if you need to be seen or not.

tooth extraction

Hi I had2 teeth pulled 48 hours ago and it was stitched up with dissolvable stiches and one has come out there is no bleeding but I'm kinda worried about what to do about it I don't wanna go back to dentist as it's expensive

cb

As this page mentions, two main purposes of stitches is tissue stabilization (keep them from moving apart) during the initial stages of wound healing, especially during those first days following your procedure. And also aiding in controlling bleeding.

Only your dentist knows why your stitches were placed, so it will take consulting with them to know what needs to be done. If they were to help with controlling bleeding, then possibly what has occurred is of no consequence. In the case of tissue stabilization, at just 2 to 3 days out, they no doubt would want to know. Also, there are other factors that may influence what's needed, such as was this the only stitch, or one of several in that location?

When you do you can ask about what costs you might occur. While we don't know your circumstances, it seems a bit harsh to hold you (the patient) responsible for what has occurred.

STICHES CAME OUT IN LOWER FRONT NOW GAP

The dentist pulled out a molar along with a tooth that had broken off at the root. She removed the root and added stitches on top and a small ways down the front of the lower gum. No stiches for the molar which seems ok. The stitches moved about 4 days later and a small root left opening to the sides and down the front. The swelling went down and the split down the front of the gum is getting noticeably longer with food getting in. I went in and the doctor didn't even come in. She had the assistant tell me to let it heal up to a month. It seems like the sides are healed, but not together and the just put me off again over the phone.

KM

The lack of first hand information about your situation makes it difficult to know precisely how to reply but as a basic explanation ...

In general, a major purpose in placing stitches often has to do with stabilizing the soft tissues during those first days following surgery. Then, as the healing process progresses, the wound strengthens and the sutures become less and less important. As this page states, stitches are often taken out as early as 7 days following their placement.

Another function stitches may provide is approximation of tissues, meaning they hold the two cut edges of a wound together (like where a scalpel has been used to incise gum tissue before raising a flap). Doing so speeds up healing (because there is less of a gap between the two parts).

With your case, you mention that it seems "like the sides are healed," suggesting that at this point your dentist has decided that simply replacing the stitches won't reverse/correct what has occurred (there are no fresh edges to approximate any more, no fresh wound to lay gum tissue over). In a way, your wound is healing as if it didn't have the benefit of stitches/tissue stabilization.

With that case, you'd expect that healing would take somewhat longer. Only time will tell how well your healing process can compensate for the less than ideal situation that's transpired. At a point after substantial healing has occurred (we're assuming the 30 days your doctor mentioned), and if anatomically the shape/contours of the healed tissues aren't ideal (such as they still trap debris), then a corrective surgical procedure might be indicated. Your dentist would have to decide.

Check with your dentist first, but gently rolling water through your wound (gentle swishing) to carry off the accumulated debris you've noticed should benefit the healing process.

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