How to Suture: Periodontal Flaps or Soft Tissue Grafts


  • Wash your hands for at least 20 seconds with soap and water. Dry hands
  • The flap or graft should be irrigated copiously with normal saline (preferably) or tap water. Irrigating removes foreign material and dilutes bacterial concentration. This helps reduce infection rate.



  1. Povidone-iodine solution and hydrogen peroxide, and cleaning products with detergents are not recommended as their toxicity can impede healing.


  • Apply local anesthetic. Allow 30-60 seconds for the anesthesia to begin work.
  • Gather a sterile kit.
  • Place sterile kit on clean, dry flat work surface. Open outside cover away from body to avoid contamination.
    1. Sterile kit should contain the following: tissue forceps, scissors, needle holder, needle with thread, and gloves.
    2. Silk sutures are most commonly used in dentistry as they are easy to handle and tie.
    3. Size 4-0 is commonly used for periodontal flap surgeries. 5-0 is most commonly used for soft tissue grafts.


  • With the needle holder, take out the needle from its package and attach to needle holder. The needle holder should “click” to indicate the needle is secured in place


  • Hold the needle by its flat side using the needle holder
    1. If you are right-handed, hold the needle holder with the right ring finger and thumb. To assist with control and stability, place index and middle finger along the side of the needle holder. Hold the tissue forceps with the left hand. These tools will be held opposite if you are left-handed.
    2. Tissue forceps should be held like holding a pen.

  • Holding the needle holder with needle, begin suturing the flap or graft by piercing at a 90-degree angle from outside to inside. Twist your wrist half a circle clockwise so the trailing suture follows the curve of the needle.

 Source: Online Library


  • Release the needle holder’s “click” using your ring finger and thumb to push the device to the left. This will release the needle, allowing you to piece the wound


  • Puncture the opposite side of the flap or graft as you did in the step #7 except go inside to outside.


  • Pull the suture through, leaving 2-3 inches behind


  • Release the needle from the needle holder


  • Use your opposing hand to hold the suture and wrap two to three times clockwise around the

closed needle holder. Grab the tail of the suture with the needle holder to pull through and make a knot.

  1. Place knot to side of the flap or graft, never on top.
  2. Be mindful of pulling too tight. Only pull enough to seal the sides of the flap or graft.


  • Cut the tail off approximately 0.5 inch
  • Continue placing the remaining stitches symmetrically using the steps above until the flap or graft is closed.




Hupp, JR. (2015). Guide to Suturing with Sections on Diagnosing Oral Lesions and Post-Operative Medications. Journal of Oral and Maxillofacial Surgery 73(1), 3-17.