Dental stitches / Gum tissue flaps. -

When are they needed?  |  How (and when) are sutures removed?   Which types dissolve away?  |  Complications - Lost stitches. What to do.  |  The dental flap procedure (as used with tooth extractions).

Some tooth extractions involve the creation of a gum tissue flap, so to gain better access to the tooth being removed or bone surrounding it. And then the placement of one or more sutures (stitches), whose purpose is to stabilize soft tissues loosened up during the procedure in place until a degree of healing has had a chance to occur.

This page explains issues related to dental flaps and sutures when they're included as a part of the tooth extraction process. We've divided its coverage into the following subtopics:

Most people who visit this page are interested in the subject of stitches, so we'll cover them first.


1) Types of stitches - suture materials.

There are two general categories of suturing material that dentists use. The big difference between the two is that one type "resorbs" (dissolves away on its own) and the other doesn't.

Illustration of a needle with attached suture material.

Suture needle and thread.

a) Stitches that dissolve.

Resorbable (absorbable) stitches offer the advantage that they don't need to be taken out later on. Your body breaks them down and disposes of the byproducts.

These types of stitches are sometimes called "catgut" or just "gut" sutures, related to the fact that some are actually made from intestines of animals (sheep usually).

Beyond natural materials, various synthetic compounds are used too (polyglycolic acid, glycolic and lactic acid copolymer, glycolide and epsilon-caprolactone copolymer, polydioxanone).

How long does it take them to dissolve?

The amount of time it takes for disintegration depends on the type of material. Catgut sutures are generally resorbed by day 8 post-placement. Chromic-treated gut lasts a little longer, on the order of 12 to 15 days. Stitches made from synthetic materials, like glycolic acid, may remain intact for up to a month.

What will you notice?

As the stitches deteriorate, it may seem as if they are getting loose or coming untied.

b) Stitches that don't dissolve.

In comparison, nonresorbable (nonabsorbable) sutures are made out of materials that the body can't degrade and dispose of. This includes: silk, polyester, polyvinylidene fluoride, polypropylene and nylon.

As a basis of comparison, whereas with absorbable stitches it's counted on that they fall out on their own, the duration-of-strength characteristics of nonabsorbable sutures is much longer. Silk still retains 20% of its original strength at 6 months, nylon only looses 20% of its strength each year, and polypropylene lasts essentially indefinitely.

When should they be taken out?

Since their strength characteristics far exceed the duration of their needed service, nonresorbable sutures must be removed.

This appointment is usually scheduled somewhere between 7 to 10 days after the stitches were originally placed. (Fragiskos FD. - linked above)

Of course, their removal will be based on the purpose they serve. As such, the scheduling of the appointment to remove them will simply be per your dentist's instructions.

Resorbable vs. Nonresorbable stitches - Which kind is better?

Clearly this is a decision for your dentist to decide. But in case you're wondering about some of the key advantages and disadvantages of each ...

Resorbable stitches.
  • The biggest advantage of using this kind of suturing material is convenience. Because these stitches just dissolve away on their own, you won't have to make a special trip back to your dentist's office to have them removed.

    That can be a nice time saver for all involved, and the primary reason this option is chosen.

Nonresorbable stitches.

A type of nonresorbable suture material that's frequently used with oral surgery is braided silk. As advantages, and as compared to resorbable materials:

  • Braided silk is easier for the dentist to handle and tie. Knots are less likely to come loose.
  • The cut ends of silk sutures tend to lie flat and are not pointed or stiff, making them less noticeable, and less irritating to the patient's cheeks and tongue.
  • Of course, their main disadvantage is simply that they require an added trip to your dentist's office to be removed.

2) Removing stitches.

Having your sutures taken out is usually an easy, quick and pain free process.

When should they be removed?

In most cases, on the same day that your oral surgery is performed, your dentist will schedule a return appointment for you.

The timing of this appointment can vary (and is up to the discretion of the dentist) but stitches are usually taken out somewhere between 7 and 10 days after they were originally placed.

(As explained above, some types of suturing materials are dissolved by your body and therefore do not need to be taken out. So you'll know, you'll need to ask which type was placed.)

How are sutures removed?

Despite some patient's apprehensions about this procedure, the process of removing stitches is actually quite easy. And there's no need for an anesthetic.

  • Your dentist will first cleanse the tissue in which your stitches have been placed.

    They might dab or wipe the area with a piece of gauze that's been moistened with hydrogen peroxide. Or they may have you swish with an antibacterial rinse.

  • They'll then use a small pair of scissors and clip the suture's thread.

    They'll snip it close to the surface of your gums so the length of contaminated suture thread that must be pulled through them is minimal.

  • They'll then grab one of the free ends (the end that has the knot on it) with a pair of "cotton pliers" (dental tweezers) and gently pull the thread on out of your gum tissue.
  • They'll repeat this process until all of your sutures have been removed.

What you'll feel.

  • At the start of the process, you might feel a firm tug on your stitch as your dentist lifts it up slightly with their tweezers so they can position their scissors to cut it.
  • When they pull the cut thread through your gums, it's unlikely that you'll feel anything.
  • Possibly after the thread has been removed, a portion of a drop of blood may form on your gum's surface.

3) What should you do if you have a stitch fall out early?

If any of your stitches come out earlier than anticipated or scheduled, you should let your dentist know so they can pass judgment on your situation.

Why?

Only your dentist knows why your sutures were placed, and as you'll read below, they can serve several functions. Some of these are only important for the first hours, or first day or so, following your procedure. Other functions are needed for several days beyond.

Only by making contact with your dentist can a determination about the importance and urgency of your situation be made.

General rules of thumb about early suture loss.

While the plan of action needed can only be decided by the patient's dentist, there are some general guidelines that are typically considered.

What we list below generally applies for cases involving tooth extractions. For other procedures, like implant placement, bone grafting, ridge recontouring (alveoloplasty), etc..., additional or different considerations may apply.

  • With many cases, the primary purpose of suture placement may have to do with the initial control of the wound's bleeding and aiding with blood clot formation. If so, suture loss unaccompanied by bleeding, possibly even on the same day as your procedure, may not be of much concern.
  • Stitches are sometimes placed to aid with tissue (gum flap) stabilization. This function is usually most important during the first several days following an extraction. Then, with each additional day of healing, the strength of the wound will gradually increase thus reducing the importance of the stabilization effect they provide.

    In situations where the loss of the patient's sutures has occurred just a few days before their removal was originally expected/scheduled anyway, loosing them early may not be much of an issue. Or routinely in anticipation of this possibility, your dentist may have placed your stitches in a fashion where the loss of one can be tolerated.

  • Your dentist will be interested in the level of bleeding that's associated with the loss of your stitches, with renewed or persistent bleeding being of concern.
Things to know about lost stitches.
  • Obviously, if you've had a stitch fall out early you'll need to be careful with your wound until you've consulted with your dentist. You won't want to do anything (eating, tongue or finger exploration, etc...) that might traumatize your wound, dislodge its healing tissues or trigger renewed bleeding.
  • If the loss of the stitch has not resulted in the disruption of your wound, the event could be looked on favorably since stitches tend to delay the speed of wound healing.
  • In cases where the loss has created a disruption, such as a dehiscence (separation of tissues along a suture line), you can expect that your healing process in its entirety will take somewhat longer, so to cope with and adapt for the disturbance.

4) How stitches effect wound healing (positively and negatively).

As a point of interest, here are some of the effects that placing sutures in a wound can have. Different than you'd expect, they're not all entirely positive.

Functions and effects of placing stitches -

a) An aid in wound healing.

A primary function of stitches is stabilizing movable soft tissues (like a tissue flap that's been created during a surgical extraction).

The loose gum tissue between two extracted teeth has been sutured together so to stabilize it.

Picture of tooth extraction sockets with a suture placed.

Note that no attempt has been made to pull the gum tissue across the empty sockets.

Related to this purpose they can:

  • Help to minimize the distance between wound parts. - Placing stitches helps to approximate (bring together) the edges of gum tissue where an incision or separation has been made. This is referred to as primary wound closure. Shortening this distance helps to decrease the amount of time that's needed for healing.

    (After the extraction of just one or a few teeth, opposing portions of gum tissue may be sutured together. But only to stabilize the tissue, not to draw it over the empty socket(s). See picture.)

  • Hold loose gum tissue in close contact with its underlying bone. - This helps to protect the bone, prevent foreign materials (saliva, bacteria, debris, etc...) from getting into the space in between, and promotes quicker tissue reattachment.
  • Strengthen the wound. - This is an important function that helps to minimize the wound's potential for disruption during its early stages of healing.

(Hupp JR. - linked above.)

b) An aid in wound hemostasis (bleeding control).

Placing stitches in an extraction site tends to create soft tissue compression. This pressure in turn can help to minimize the amount of postoperative bleeding that occurs, help to bring the wound's bleeding under control more quickly, and generally aid with blood clot formation.

In theory, crisscrossing sutures across a tooth's socket might serve as an aid in blood clot retention (an important factor for the healing process). However, in practice the benefit of doing so tends to only be minor. But suture placement may be used to help retain clotting aids that have been placed into the socket.

(Hupp JR. - linked above.)

c) Wound healing inhibition.

This is probably something you didn't know about stitches. They actually tend to interfere with the wound healing process.

  • Your body considers suture material to be a foreign object. And as such, the placement of stitches triggers an inflammation reaction in the surrounding tissues. This will tend to inhibit wound healing at least to some degree. (This level of this effect varies with the type of suture material used.)
  • The stranded nature of some types of suture material, like silk, tend to create a wicking effect that draws oral fluids and debris into adjacent tissues, thus interfering with their healing process either by way of creating inflammation or infection.

While none of these events overshadows the benefit that placing stitches provides, it does mean that they shouldn't just be placed as a matter of routine but instead only for good reason. And if these reasons don't exist, you're actually better off without them.

4) Dental flaps.

Some extraction procedures (such as removing impacted wisdom teeth) require the creation of a gum-tissue flap.

  • When the gum flap is reflected (peeled back), it gives the dentist improved access to and visualization of the tooth and bone tissue that surrounds it.
  • Once the tooth has been removed, the flap is returned to its original position and tacked in place with stitches.
  • A basic premise of utilizing a flap during surgery is that it will heal more quickly and uneventfully than a torn, traumatized area of gum tissue.

(This page outlines extraction situations where the creation of a dental flap might be needed.)

The gum tissue flap procedure.

Here's the process that a dentist uses to "lay" a flap when performing a surgical tooth extraction.

Picture of a dentist giving a dental injection.

1) They'll first need to use local anesthetic ("novocain") to numb up your gums in the region where the flap will be created.

  • With most cases, the routine injections that your dentist has given you to numb up your tooth for its extraction will numb up the flap area too. If so, no extra "shots" will be needed. [More information about dental injections.]

2) They'll then use a scalpel to score the outline of the flap, cutting all of the way through the gum tissue down to the bone. (This is termed creating a "full thickness mucoperiosteal flap," indicating that all of the soft tissue layers covering the bone will be peeled back.)

  • Since you're numb, you won't feel any pain. You will, however, feel the pressure of the scalpel as it makes the incisions.
Animation illustrating the creation of a gum tissue flap so a broken tooth can be extracted.

A dental flap provides access to both a tooth and its surrounding bone.

3) Once the flap's outline has been scored, your dentist will reflect it back (peel it away from the bone). Here's how they'll do it:

  • At an edge of the flap near where your gums and teeth meet, your dentist will insert a tissue "elevator" (a hand instrument that looks like a flat-bladed screwdriver, only its blade is rounded and smooth).
  • As the elevator is pushed both along and underneath the outline of the flap, the gum tissue will peel back.
  • Since you're numb you won't feel any pain. You will, however, feel the pressure of the elevator being worked against the bone.

4) At this point, the three sides of the flap are loose and free. The underlying bone surface is entirely exposed.

  • Your dentist can now perform whatever procedure is required as a part of the tooth extraction process (such as bone removal or tooth sectioning).
  • Afterward they will position the flap back into place and tack it there with stitches (see below).

Why are tissue flaps so large?

A tissue flap stitched back into place following an extraction.

An illustration of a gum tissue flap stitched back into place.

Notice how the flap's base is wider than its free margin (edge).

When compared to the width of the space from which your tooth has been removed, the tissue flap for your procedure might seem quite large. Here's why:

  • Since the whole idea of creating a tissue flap has to do with visibility and access, the flap must be large enough to fulfill these needs.
  • If the flap is too small, your dentist will tend to pull and stretch on it. Creating trauma like this will complicate its healing. Postoperative pain, swelling and bleeding will be more likely.
  • Your dentist needs a firm base over which to suture (stitch) the flap back into place. This means that its edges must extend over and rest upon undisturbed bone.
  • The flap must maintain an adequate blood supply. For this reason, the base (still attached) portion of a flap is designed so it's always at least the same width, and preferably broader, than its free (loose) edge.

(Koerner KR. - linked above.)

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5) Closing flaps. / Placing stitches.

Here's an outline of what your dentist will need to do when "closing" the flap they created for your extraction process.

1) To start, your dentist will thoroughly flush your wound with saline solution or water. They'll also evaluate the surface and edges of the exposed bone to make sure it has smooth and rounded contours.

  • The goal here is to remove debris (tooth chips, bone spicules) and smooth off sharp edges that might interfere with the healing process.
  • Sharp or rough edges can be smoothed down using a dental drill or else a hand instrument called a "bone file" (a rasp-like tool). During this process, you may feel the action/vibrations of the tools as they're used but there shouldn't be any pain involved.

2) The flap is usually positioned back into pretty much its original position. Stitches will be placed to hold it there.

  • The usual goal is one of approximating the edges of the wound. (Bringing the tissues on each side of the incision close together.) Doing so aids in how quickly this aspect of the wound will be able to heal.
  • The number of stitches used will vary with each individual case, simply depending on how many your dentist feels are necessary to create adequate tissue stabilization.
Animation illustrating placing stitches to stabilize a gum tissue flap.

Placing sutures to tack a tissue flap back into place.

3) Placing stitches is similar to sewing with a needle and thread.

  • Dentists usually use a prepackaged, pre-assembled curved needle with attached suture material (silk, nylon, "gut", etc...).
  • The suture needle is grasped with a pair of hemostat-like forceps (a needle driver) and inserted through the thickness of the flap. The curved nature of the needle makes it so it tends to poke back out of the tissue once it's gone through.
  • You will feel the tug of the needle and thread as each individual stitch is placed and tied off. But you will not experience pain.
  • Your dentist will avoid tying your stitches too tight. Doing so would tend to reduce the blood flow into your gums (blanching would be a sign of this), which would tend to delay or even complicate the healing process to follow.

4) Your extraction site has now been closed and your procedure completed.

  • Your dentist will provide you with post-operative directions detailing steps and precautions you must take.
  • Among these should be specific instructions as to if and when your stitches need to be removed.

(Koerner KR., Fragiskos FD. - both linked above.)

Types of suturing.

The stitching pattern that your dentist uses will vary depending on the size and needs of the wound being closed.

a) Interrupted sutures.

This is the simplest, and most frequently used, type of suture placement following oral surgery procedures.

The term "interrupted" simply means that each stitch is placed and tied off independently (one-at-a-time placement). The advantage being that if one comes loose or unties, the integrity of the wound's other sutures won't be affected.

b) Continuous sutures.

"Continuous" stitches are the situation where a single line of suture thread is woven multiple times through the flap being anchored, with the whole placement being secured by the same knot(s).

Putting in stitches this way can be a lot quicker. But if any portion of the suture comes loose or breaks, it effects the integrity of the entire unit.

(Fragiskos FD. - linked above.)

Return to page surgical extractions. ▶

 

Authorship: Written by Animated-Teeth Dental Staff

Last revision/review: 10/15/2018 - Major update, content added.

Content reference sources.


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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.

Difficulty opening mouth

It has already been 5 days after my surgery, and I still cannot open my mouth wide enough. My cheeks are still swollen and my lower jaw is still in pain. I tried checking the suture, using my phone’s light while facing the mirror. I don’t know if this is normal but, seems like the inner skin of my cheek was somewhat stitched to the gums of my extracted area. This is why I’m having a hard time opening my mouth wide enough. This scares me since I am a singer by profession.

Anna

You need to check in with your dentist who pulled your tooth.
The pain you are experiencing may be associated with the formation of a dry socket (a complication that is more likely occur after a lower wisdom tooth extraction, which we think is part of what you've had done).

By asking you questions about your pain, your dentist will be able to determination if that complication exists. During your conversation you can also tell them what you notice about your stitches.

We'd guess that everything is fine with them. We'd expect that the limited opening you notice has more to do with your swelling or possibly jaw-joint irritation associated with the procedure. But that is for your dentist to decide.

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.

Tooth extraction and stitches

Hi I had an upper tooth pulled number 6 as the root was growing into the sinus I had to have stitches as there was a hole. The swelling has gone down 2 of the stitches have fallen out despite them being dissolvable and I still have 3 left. My mouth feels sore still and also chin and neck feel bruised I had a course of antibiotics to prevent infection so don’t think I have an infection but wondered how long the bruisings is going to last ?

Diana

Here's a link to our page that discusses post-extraction bruising.

Molar extracted

Hi, I had a molar extracted 4 days ago. Swelling has finally gone done & I'm in much less pain, however is it normal to have stitches anchored to an adjacent tooth because it seems I have a stitch around that tooth. Also, I have white gums laterally where the tooth was pulled.

Lisa

Sling suturing is a technique. And as you describe, the suture thread is wrapped around the circumference of the tooth. And yes, sometimes this technique is used to close flaps associated with molar extractions.

The white gum tissue you notice might be tissue that was traumatized during the extraction process (as your tooth was rocked back and forth). If your body has decided that it can't be salvaged, it will reduce the blood flow to it. During the healing process this tissue will be replaced with new.


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