Dental stitches / Gum tissue flaps - as used with tooth extractions. -

When are stitches needed? Purposes & placement disadvantages.  |  Types of suturing materials. Which types dissolve away?  | When should stictches be removed?  |  The dental flap and suture placement procedure.

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, and therefore needs to be removed at some later date (see below).

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) 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.

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.

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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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.
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. ▶

 

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

 
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Comments

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.

Cleaning stitches

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!

RS

It's possible that what you smell and taste is related to the accumulation of debris and bacteria underneath and around your stitches. 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.

clot

I had a molar pulled a week ago. Dissolving stitches were used. The socket feels like it is full with I'm guessing is the blood clot. I have been careful not to dislodge it. Is the clot absorbed or will it come out or does it just dissolve? What about what feels like a skin flap that moves slightly with my tongue? Will it die off? Thanks

Marsha

Over time, the clot is infiltrated and replaced by other types of cells that are an important part of the healing process and important in the formation of new tissues.

Smallish flaps of gum tissue should disappear (by a process termed apoptosis that eliminates unneeded tissues) in the weeks following your procedure. This is part of the the surgical area's "remodeling" process. Large flaps may persist and may need to be removed surgically by your dentist.


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