Stitches after dental implants: when do they dissolve, when are they removed, and what happens if they come apart?

In conventional implant surgery the gum is lifted like a flap, together with the membrane covering the bone beneath it; the dentist places the implant with the bone in view, then puts the gum back and stitches it. The implant leaflet from Cambridge University Hospitals explains this plainly: the gum is cut and pushed back, the bone is exposed, and after the implant has been placed the gum is put back in position with stitches. The job of a stitch is to hold the wound edges together in the first days; once the edges have knitted together by themselves, the stitch's task is over.

Not every implant involves stitches. With the flapless (stitch-free) method, carried out through a small hole without lifting the gum, stitches are usually not needed; we have explained on a separate page under which conditions this is possible. When an implant is placed on the same day as an extraction, when bone is added or in full-arch treatment, on the other hand, there are almost always stitches. In full-mouth treatment the stitches stay under the fixed teeth, on top of the gum; so cleaning and checking need more care.

Stitches fall into two main groups. Dissolvable stitches break down over time through the body's own processes and do not need to be removed. Non-dissolvable stitches, on the other hand, are made of materials such as silk, nylon or polytetrafluoroethylene (PTFE) and are removed by the dentist. Guy's and St Thomas' Hospital in London writes that stitches usually dissolve, and that if non-dissolvable stitches were used they are removed at a check-up appointment. The easiest way to find out which type was used is to ask: when you are discharged, make a note of whether the stitches will dissolve and of the date of your check-up.

How long a dissolvable stitch lasts varies with the material and the area. The King's College Hospital leaflet writes that dissolvable stitches dissolve in up to two weeks, sometimes longer, the oral surgery department of the Lothian region that they may fall out within a few days or stay for up to two weeks, and the Oxford community dental service that they usually dissolve in 7 to 10 days. Cambridge's implant leaflet also states that implant stitches are usually dissolvable but that it can take a few weeks for them to disappear. In other words, still seeing the end of a stitch in your mouth after two weeks is not a sign of a problem on its own.

The material of the stitch affects cleaning too. Multifilament silk thread can hold bacteria between its strands. In a systematic review that examined 649 stitch samples taken from 360 patients in impacted wisdom tooth surgery, the most commonly used material was silk, and it mostly carried the highest bacterial load; bacterial adherence was lower on monofilament synthetic and antibacterial-coated stitches. In a small randomised study carried out in Granada, too, silk showed more bacteria and a more pronounced tissue reaction than monofilament nylon and PTFE stitches. These findings come from wisdom teeth; exactly the same result has not been measured for implants, but they show why the area around the stitches needs to be kept clean.

A stitch falling out early and the wound opening are not the same thing. Guy's and St Thomas' writes that stitches can come loose or fall out soon after surgery and that this does not normally cause a problem. What matters is the state not of the stitch but of the wound edges beneath it: if the edges have stuck together and there is no bleeding, one stitch fewer is of no importance. The Oxford leaflet tells you to consult your dentist if you see that the gum has parted or has started to bleed.

The wound line opening is a well-known problem, especially in surgery where bone is added. In bone grafting (guided bone regeneration), the volume of the membrane and the graft puts the wound edges under tension. The systematic review and meta-analysis on this subject calculated the weighted rate of soft tissue complications, including exposure of the membrane, wound opening and acute infection, at 16.8 per cent; these problems were reported from the first week up to the sixth month. The authors stress that the rate is similar for resorbable and non-resorbable membranes and that the real determining factor is soft tissue management. In simple implant surgery without added bone, the wound is smaller and the tension is lower.

The soft white or yellowish layer you may see over the wound in the first weeks is most often healing tissue: repair tissue rich in blood vessels that takes the place of the clot, and the layer of fibrin on top of it. This layer is odourless and painless and does not go away with rinsing. Pus is different: it is a thick discharge with a bad taste or smell that comes out on pressing or by itself, and it mostly comes together with increasing pain, swelling or a fever. The King's College leaflet writes that there can be slight oozing and a bad taste in the first few days and that on its own this does not mean a problem; a bad taste that does not pass or that increases despite care, however, should be mentioned to your dentist.

The pictures in the first list are situations that are common in a stitched wound and mostly get better by themselves. If an item from the second list applies to you, show it to your dentist.

The order below is based on the shared recommendations of hospital leaflets in the UK. If the instructions of the dentist treating you are different, theirs apply.

1. 1

   The first day: no rinsing, no touching

   On the day of surgery, do not rinse your mouth and do not spit; Guy's and St Thomas' writes that this can dislodge the clot and delay healing. Do not probe the stitches with your tongue or your finger; the Oxford leaflet states that touching the wound with a finger or the tongue can cause bleeding.

2. 2

   Salt water from the next day

   Mix a teaspoon of salt into a glass of warm water and move it gently around your mouth, especially after meals. Guy's and St Thomas' recommends 4 times a day for 4 to 5 days; Oxford up to 4 times a day and for 7 days. The aim is to prevent food catching on the stitches.

3. 3

   Do not give up brushing

   Brush your other teeth and your fixed teeth as normal, and be gentle with a soft brush around the stitched area. The NHS recommends cleaning the other teeth carefully while avoiding the area of the operation. If your dentist has given you a chlorhexidine mouthwash, use it for the length of time stated.

4. 4

   Protect the stitches when you eat

   The NHS recommends avoiding hard, crunchy foods and foods such as nuts and seeds that can get stuck in the wound. Oxford writes that small foods such as grains of rice and sweetcorn can get stuck in the wound. Eat soft, lukewarm food in the first days.

5. 5

   Take a break from smoking and alcohol

   The NHS writes that smoking increases the risk of infection, and that alcohol and very hot drinks can increase bleeding. The Lothian leaflet states that you should stay away from smoking and alcohol for the first 24 hours and that these delay healing. The longer the break, the better for the wound line.

6. 6

   Look in the mirror every day, do not touch

   In the mirror, look at whether the wound edges are touching each other, whether a stitch has gone missing, and whether the white layer is smelly or painful. Looking is allowed, probing is not. If you see a change, take a photograph of it and show it to your dentist.

7. 7

   The check-up appointment

   Non-dissolvable stitches are removed at the check-up appointment; Guy's and St Thomas' writes that the hospital or a local dentist can do this. Removing stitches is generally a procedure that takes a few minutes and does not require numbing. If dissolvable stitches were used, the check-up looks at whether the wound line has closed.

The type of stitch, and whether one is needed, varies with the scope of the surgery. The options below are not rivals to one another; the dentist chooses according to the situation.

The following are decisions that are made with good intentions but put strain on the wound line.

The sequence below is a general framework; with bone grafting and full-arch surgery the times may be longer. What sets it apart is that the pain and swelling are decreasing.

1. The first day

   Traces of blood in the saliva are ordinary. The stitches are tight, and the area is numb or tender. Do not rinse, do not spit, do not touch the stitches.

2. The second to the fourth day

   Salt water rinses begin. A white or yellowish layer may start to appear on the wound edges. Some stitches may come loose or fall out; the Lothian leaflet writes that this can happen within a few days.

3. The end of the first week

   According to the Oxford leaflet, dissolvable stitches usually dissolve in 7 to 10 days. If non-dissolvable stitches were used, the check-up appointment is planned for this period.

4. The second week

   The Guy's and St Thomas' and King's College leaflets write that dissolvable stitches can last up to two weeks. The wound line should have closed, and the colour of the gum should have started to return to normal.

5. The following weeks

   Cambridge's implant leaflet states that it can take a few weeks for implant stitches to disappear. The gum settles into its final shape over time; Cambridge recommends keeping the surgical area as clean as possible for the first few weeks.

Stitches are usually part of the surgery and not a separate treatment. But whether additional steps related to the stitches will be needed is determined by these items:

The type of stitch

With dissolvable stitches there is no removal appointment; with non-dissolvable stitches the check-up and stitch removal are a planned step.

Whether bone was added

In surgery where bone is added, the likelihood of the wound line opening is higher and an additional check-up may be needed.

The travel schedule

If you are coming from out of town, whether the stitches are dissolvable and where the check-up will take place should be discussed at the outset.

The work to be done if the wound line opens

It ranges from cleaning and monitoring alone to a reassessment of the exposed membrane or graft.