Dental stitches. / Gum tissue flaps. -
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:
- The dental flap procedure - Why are flaps needed? How are they created?
- Placing stitches - The process.
- Types of suturing materials - Kinds. Which types need to be removed and which ones dissolve away on their own?
- How does placing sutures affect healing?
- Taking out stitches - The procedure. When should they be removed?
1) Types of stitches.
There are generally two kinds of suturing material that dentists use. The difference between them is that one type "resorbs" (dissolves away), the other doesn't.
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 them.
These types of stitches are sometimes called "catgut" or just "gut" sutures. Historically they were made from sheep intestines. Nowadays, various synthetic materials are used too.
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. Some synthetic materials may remain for a couple of weeks.
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 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.
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.
- Your dentist will use a small pair of scissors and clip the suture thread.
- 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 out of the gum tissue.
- There's no need for anesthetic.
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 tissue (like a tissue flap that's been created during a surgical extraction).
They also help to minimize the distance between wound parts. (Cut edges of gum tissue are brought together.) And their presence helps to strengthen the wound.
Overall, they help to create a more uneventful and predictable healing process and outcome.
b) They can help to minimize 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 inhibit wound healing.
Your body considers suture material to be a foreign object. And as a result, its presence triggers inflammation and a "foreign body" reaction. This tends to interfere with the progress of the wound's healing process (at least to some minor degree).
That means, stitches 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 (pealed 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.
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 pealed 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 tooth and bone.
3) Once the flap's outline has been scored, your dentist will reflect it back (peal 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 peal 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 dental flap provides access to both tooth and bone.
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 still-attached base portion of a flap is always broader than its free edge.
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.
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 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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