Dental stitches. / Gum tissue flaps. -

When are sutures needed?   How (and when) are they removed?   Which type dissolve away?  |  The dental flap procedure (as used with tooth extractions).

Your dentist may find it necessary to place sutures (stitches) after your tooth has been removed. For example, if a gum tissue flap was raised during your procedure, stitches will be needed to tack it back into place.

This page explains issues related to dental flaps and sutures (when used with tooth extractions). We've broken its coverage into the following subtopics:

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

1) Types of stitches.

There are two general classifications of suturing material that dentists use. The big difference between them 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 removed. 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. Gut sutures remain fairly intact for 5 to 7 days, chromic-treated gut lasts on the order of 9 to 14 days. Those made from synthetic materials, like polyglycolic acid, may remain for a couple of weeks (2 to 4).

As 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.

When should they be taken out?

Nonresorbable stitches must be removed. This appointment is usually scheduled somewhere between 7 to 10 days after they were originally placed.

Picture of tooth extraction sockets with sutures placed.

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?

The process of removing stitches is quite easy. There's no need for anesthetic.

  • Your dentist may first wipe, or have you swish, the area of your stitches with an antibacterial rinse.
  • They'll then use a small pair of scissors and clip a suture. They'll do so close to the surface of your gums so the length of thread that must be pulled through them is minimal (next step).
  • 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 pull the thread on out of the 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 each stitch as your dentist positions it with their tweezers so they can cut it.

If they've grabbed the knotted end when they pull it through your gums, it's unlikely that you'll feel anything. If they end up dragging knotted end through the healing tissue you may.

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

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

Their function (like stabilization of the flap) is most important during the first several days after your extraction (the period before much healing has taken place). So, if yours stay in put until just a day or two before their removal was originally scheduled, it might not be much of an issue.


3) The effects of stitches on wound healing.

As a point of interest, here are some of the effects that placing sutures in a wound have. They're not all entirely positive.

a) Aiding wound healing.

A primary purpose of stitches is the stabilization of movable soft tissues (like a tissue flap that's been created during a surgical extraction). Related to this function, they also:

  • Hold the tissue in close contact with the underlying bone. - This helps to protect the bone, prevent foreign materials (saliva, bacteria, debris, etc...) from getting into the space between the tissue and bone, and promotes quicker reattachment of the tissue to its underlying bone during the healing process.
  • Help to minimize the distance between wound parts. - The cut edges of gum tissue are brought together, referred to as primary wound closure. Shortening this distance helps to decrease the amount of time needed for healing.

    (After the extraction of just one or a few teeth, the parts of the flap are brought together but likely not so they cover over the empty socket(s).)

  • Their presence helps to strengthen the wound. - An important function that helps to minimize the potential for its disruption during the early stages of healing.

Overall, placing stitches helps to create a more uneventful and predictable healing process and outcome.

b) They can help to minimize initial wound bleeding.

When stitches are placed in an extraction site, they create soft tissue compression. This pressure can help to minimize postoperative bleeding.

c) Sutures have an inhibitory effect on wound healing.

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, its presence triggers inflammation and a "foreign body" reaction. These processes will tend to inhibit the progress of the wound's healing, at least to some minor degree.
  • The stranded nature of some types of suture material, like silk, can create a wicking effect that tends to draw oral fluids and debris into the wound, thus interfering with its healing process.

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.

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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 will then be positioned back into pretty much its original position. Stitches will be placed to hold it there.

  • The number of stitches that are placed will vary with each individual case, simply depending how many your dentist feels are necessary to create adequate 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 tugging pressure as each individual stitch is threaded through your gums and then tied off. But you will not experience pain.

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.

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.

It's probably most common that a dentist will place "interrupted" stitches. That means each one is placed and tied off independently. And if it comes loose, the integrity of other stitches is not affected.

b) Continuous sutures.

In comparison, "continuous" stitches involve threading a single line of suture material multiple times through the tissue being anchored, with the whole placement secured by the same knotting.

Placement this way can be quicker. But if any portion of the suture comes loose or breaks, it effects the integrity of the whole unit.

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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...). Less than that, they'll likely want to see you and replace it. Either way, you need your dentist to tell you what should be done.

Piece from #3 left in

I had an extraction of number 3 and number 4 about 6 hours ago and now I can feel a small piece still in there what should I do? Small meaning it feels like a piece of 3 grains of rice stuck together

Barbara

During the first 24 hours your job as a patient is to leave your extraction site alone, so blood clot formation and retention are not disrupted.

As for treatment, you need evaluation by your dentist so they can determine what it is you feel.

If it is a loose shard of tooth or bone, they will remove it.

If the piece is immovable, with larger extraction sites (molars/multiple adjacent teeth, you mention both), objects in the area your tongue can feel may be exposed bone.

If so, your dentist may smooth it off, or at least explain to you what you feel.

As far as immovable remnants of your teeth. Those objects would be expected to be so deep in the socket that it would be unlikely that you could feel them.

Whatever your problem, contact your dentist's office and have them evaluate you.

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 is that your offending stitch has probably fullfilled 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, the purpose of placing stitches is 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.

pain at my surgical site

I made a bony impacted canine surgery where the doctor told me it was not an easy one and a lip repositioning one 7 days ago and the dentist told me that sutures should be taken off 2 weeks after the surgery .At the first 3 days the pain was not that much hard but at day four it started to become very painful and ubearable the pain radiates from my upper jaw at the surgical site to my teeth , i am afraid that my case is a dry socket case or that my tooth nerve is dead .. or even the sutures got inflammated , I NEED TO KNOW THE REASON AND WHAT IS THE TREATNMENT PLZ ? and a last question is it normal to have swelling at one side of my lip at day 7 ? thank you

lynn

The only question we can really address is the swelling. In most cases (at least following a tooth extraction) the swelling should start to subside around day 4.

As far as the cause of your pain, the timing and "radiating pain" symptom are reminiscent of a having dry socket, the swelling characteristic not so much, but of course we would have no way of actually knowing for sure.

Here's our pages that describe the signs and symptoms of having a dry socket and needing endodontic therapy.

Whatever the problem, the remedy lies with treatment from your dentist. All dentists expect patients to contact them as complications develop, so you should take advantage of that and let them provide the attention you require.

I had my wisdom teeth removed

I had my wisdom teeth removed two weeks ago and everything it fine with their healing but the tooth in front of a socket on the bottom has a flap of gum on the outer side. Will it go back to normal on its own or will the dentist have to do something? It’s not infected as far as I can tell.

Anonymous

You should call you dentist and describe your situation and let them make a decision.

In routine cases, over time (several weeks) the expectation would be that your body will just take care of the excess flap of tissue on its own. The tissue will slowly shrink down and ultimately smooth out.

In cases where the dentist feels that the excess is somewhat sizable, they may trim it for the patient, so to speed things along and to insure an ideal final tissue contour (one that doesn't trap debris or interfere with brushing and flossing).


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