Dental stitches / Gum tissue flaps (as utilized with extractions and wisdom tooth surgery). –
Gum tissue flaps and suture placement.
Some tooth extractions require the creation of a gum tissue flap, so to gain better access to the tooth being removed, or the bone that surrounds it. And then the placement of one or more sutures (stitches), whose purpose is to stabilize soft tissues loosened up during the procedure until the needed degree of healing has had a chance to occur.
This page explains the use of dental flaps and sutures when they’re included as a part of the tooth extraction process, like wisdom tooth surgery. We’ve divided its coverage into the following subtopics:
- The dental flap procedure – Why are flaps needed? How are they created?
- Suturing – The stitches placement process.
- Types of suturing materials (resorbable vs. nonresorbable). – An explanation of the different kinds of stitches.
What kinds dissolve away? How long does that take? When do non-dissolving sutures need to be removed?
- How suture placement affects healing – Benefits and disadvantages.
- How stitches are taken out – The procedure. Timing – When should they be removed? (This topic now has its own page.)
- Lost or loosened sutures – What happens if a stitch comes loose or falls out early? What to do. (This topic now has its own page.)
Most people who visit this page are interested in the subject of stitches, so we’ll cover them first.
Suture needle and thread.
1) Types of stitches – suture materials.
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 (usually sheep or cattle).
Beyond natural materials, various synthetic compounds are used to make dissolving stitches too (polyglycolic acid, glycolic and lactic acid copolymer, glycolide and epsilon-caprolactone copolymer, polydioxanone).
How long does it take resorbable stitches to dissolve?
The amount of time it takes for disintegration depends on the type of suture material placed and what type of treatment it has received.
- Plain gut sutures have usually substantially deteriorated (have lost most of their original strength) by day 8 post-placement. (This type of suture is often yellowish-tan in color.)
- Chromic-treated gut lasts a little longer, on the order of 12 to 15 days, due to the fact that the chromium salt treatment makes it more resistant to body enzymes. (This type of suture usually has more of a brown coloration.)
- Stitches made from synthetic materials, like glycolic acid, may retain their strength for up to a month.
So if you weren’t told at the time of your surgery, in order to know exactly what to expect you’ll probably need to touch base with your dentist’s office.
What will you notice as your sutures dissolve away?
As the strength of your stitches deteriorates, it may seem as if they’re getting loose or coming untied. There’s usually a point where they have become so fragile that their exposed portions just break off and fall away.
Within your tissues, the completion of the absorption process by your body will take many weeks. Once again, the kind of suture material used and the treatment it has received are factors. Other issues include the type and conditions of the tissue in which the stitches have been placed, and even the general health status of the patient.
b) Stitches that don’t dissolve.
In comparison to stitches that dissolve away, 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.
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)
▲ Section references – Fragiskos
Resorbable vs. Nonresorbable stitches – Which kind is better?
- 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.
- 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) How stitches affect 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.
Note that no attempt has been made to pull the gum tissue across the empty sockets.
- 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.
▲ Section references – Hupp
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.
▲ Section references – Hupp
c) Wound healing inhibition.
- 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, tends 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.
3) 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.
- 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.
A dental flap provides access to both a tooth and its surrounding bone.
- 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.
Notice how the flap’s base is wider than its free margin (edge).
- 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.
▲ Section references – Koerner
4) 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.
Placing sutures to tack a tissue flap back into place.
- 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.
▲ Section references – Koerner, Fragiskos
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).
▲ Section references – Fragiskos
Return to page surgical extractions. ►
Page references sources:
Dunn DL. Wound closure manual. Chapter: The suture.
Fragiskos FD. Oral Surgery. (Chapter: Principles of Surgery.)
Hupp JR. Guide to suturing with sections on diagnosing oral lesions and post-operative medications.
Javed F, et al. Tissue Reactions to Various Suture Materials Used in Oral Surgical Interventions.
Koerner KR. Manual of Minor Oral Surgery for the General Dentist. (Chapter: Surgical Extractions.)
Wray D, et al. Textbook of General and Oral Surgery. (Chapter: Wound healing and suture materials.)
All reference sources for topic Tooth Extractions.
This section contains comments submitted in previous years. Many have been edited so to limit their scope to subjects discussed on this page.
Extent of stitches.
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.
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.
I got one of my lower molars extracted about 2 weeks ago and now the stitches in my mouth have begun to smell/taste bad. I can’t brush the area, so how do I clean them? I’m not getting the stitches out for two more weeks!
It’s possible that what you smell and taste is related to the accumulation of debris and bacteria underneath and around your stitches, or possibly even within their thread strands. If so (at this point, 2 weeks post op) gentle rinsing with a hydrogen peroxide solution should be a way to help to clean them up (dislodge debris, kill bacteria). (3% hydrogen peroxide diluted with an equal amount of water, or use the product Peroxyl.) Pass this suggestion by your dentist to get their OK.
I had an upper molar extracted 4 days ago, the dentist stitched the area using black nonresorbable stitches and asked me to return after 10 days to remove them. The swelling has reduced in my face but the gums are still swollen some.
The stitches (which have been irritating my cheek and tongue) seem to have loosened up to the point where the knotted part is now a long hanging stitch. Its irritating me even more now, and is so much more sore since coming loose.
Would it do any harm for me to remove the stitch myself? Also the area where the stitches are is now a white gum surface rather than pink – is this normal?
These are all pretty simple questions for your dentist to answer. You need to give them a call.
In general terms:
If an individual stitch that has been placed to stabilize tissues is extremely loose, then we’d agree that it is no longer serving its function, and at least in theory is actually retarding the healing process.
But if what seems loose is a part of continuous stitches (where cutting one undoes others), or what has been seen has been misinterpreted, then at just 4 days (according to our tissue healing graph) removal might be problematic.
The white gum tissue you notice might be tissue that has been traumatized during your procedure. During the healing process your body may find that some tissue can’t be or shouldn’t be salvaged. As such, it will reduce the blood flow to it.
All of the above is just general information. Only your dentist can tell you how these issues apply to your case.
Stitches in cheek.
Hey I had 3 wisdom teeth removed and the dentist stitched the wounds close. It’s looks as if he has stiched them to the cheek. Is this normal?
You’ll need to check back with your dentist for specifics about your case but generally, there is no clear demarcation between the skin of the cheek and the gums surrounding the area of a 3rd molar. And in order to be able to close the extraction wound, the stitches placed may need to impinge somewhat on what’s interpreted as being cheek tissue.
Due to Covid-19 Pandemic, dental offices are closed, preventing post surgical exam and suture removal. How long can sutures remain?
It’s not possible to provide an answer for your specific case. Surely someone must be answering emergency calls for your dentist and you can discuss matters with them.
In general terms:
Following oral surgery, non-absorbable stitches are usually left in place for 7 to 10 days, here’s why.
And generally, after they have served their purpose (often/typically as an aid in strengthening the healing wound), leaving them in place for longer tends to delay healing.
It’s common that toward the end of the stitches’ intended lifespan, they have started to loosen and sag (just part of the evidence that they no longer are needed). And especially if so, they are usually easily removed, as explained here.
Not removing them leads to the potential that some of the suture material will remain within the tissues as it fragments and deteriorates. And while not usually resulting in a significant complication, isn’t the ideal scenario. (More details here.)