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British Journal of Oral and Maxillofacial Surgery 50 (2012) 256258

The effect of sutureless wound closure on postoperative pain and swelling after impacted mandibular third molar surgery
Hamid Mahmood Hashemi a, , Majid Beshkar b , Reihaneh Aghajani c
a

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tehran University of Medical Sciences, Tehran, Iran Department of Oral and Maxillofacial Surgery, Craniomaxillofacial Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran c Department of Prosthodontics, Azad University, Tehran, Iran
b

Accepted 28 April 2011 Available online 1 June 2011

Abstract Our aim was to assess the inuence of sutureless and multiple-suture closure of wounds on postoperative complications after extraction of bilateral, impacted, mandibular third molars in 30 patients in a split mouth study. After the teeth had been removed, on one side the ap was replaced but with no suture to hold it in place (study side), and on the other side the wound was closed primarily with three sutures (control side). Recorded complications included pain, swelling, bleeding, and formation of periodontal pockets. The results showed that patients had signicantly less postoperative pain and swelling when no sutures were used (p = 0.005). There were no signs of excessive bleeding or oozing postoperatively on either side. Six months postoperatively there was no signicant difference in the depth of the periodontal pocket around the second molar. 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Pain; Swelling; Surgical wound; Third molar

Introduction Extraction of impacted teeth is one of the most common operations in oral and maxillofacial surgery. Postoperative pain and swelling are common, and so surgeons have always sought to use techniques that lessen them. Damage to the capillary vessels and the release of inammatory cytokines as a result of the trauma lead to increased permeability of vessels, which results in accumulation of serosanguinous uid and exudate.1 With this in mind, it is plausible to hypothesise that the maintenance of a pathway to drain the inammatory exudates and uids after extraction may lead to less postoperative pain and swelling. Placing drains in the surgical wound at the end of the procedure, and closing the wound with the

minimum number of sutures to allow a drainage path to be maintained, are two ways of draining exudate. We used the latter method in this clinical split mouth study to test the above hypothesis.

Patients and methods We designed a randomised clinical trial using a split mouth design, by which the subjects served as their own controls. The study sample was derived from the patients referred for management of impacted third molars to the department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tehran University of Medical Sciences, Tehran, Iran, September 2008 to January 2010. The ethics committee of Tehran University of Medical Sciences approved the study design, and informed consent was obtained from all patients.

Corresponding author. Tel.: +98 21 2610 4392. E-mail addresses: hamid5212@yahoo.com (H.M. Hashemi), majid.beshkar@yahoo.com (M. Beshkar).

0266-4356/$ see front matter 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2011.04.075

H.M. Hashemi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 256258 Table 1 Patients studied (n = 30). Variable Sex Male Female Age (years) Mean Range Number (%) 8 (27) 22 (73) 22 1924 Table 2 Mean (range) swelling (mm) (n = 30 in each group). Day 1 3 7 Study group 1.7 (0.62.7) 10 (6.613.4) 5 (2.87.2)

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Control group 3.1 (0.46.8) 18 (14.721.8) 9.2 (6.611.7)

tistical Package for Social Sciences, version 8.0, for Windows (SPSS, Chicago, IL, USA).

The inclusion criterion was bilateral, bony, mandibular third molars that were fairly similar in terms of angulation, degree of impaction, and estimated difculty of removal. Exclusion criteria included: the presence of any medical problem that would contraindicate extraction; the presence of any pathological lesion in the area of the impacted teeth; and soft tissue impaction that did not require removal during extraction of the tooth. One of the two impacted mandibular third molars in each patient was randomly allocated to the study or the control group. One single surgeon from the faculty extracted all the teeth, with strict attention to infection control. The teeth were extracted under local anaesthesia with 2% lignocaine and 1:100,000 epinephrine. Full thickness mucoperiosteal triangular aps were used to gain access to the site of impaction. Bone was removed and teeth sectioned with burs under constant irrigation with sterile normal saline. After each tooth had been removed the site was irrigated with equal amounts of sterile normal saline on both sides. On the study side the ap was replaced in its original position but no suture was inserted to hold it in place. In the control group one 3/0 silk suture was inserted over the releasing incision, and two others were placed over the distal arms of the ap to achieve primary closure. Teeth on the two sides were extracted at the same session. A small gauze pad was placed over the wound on each side and the patient was instructed to bite on it for 40 min. All patients were given amoxicillin 500 mg 3 times daily for 5 days and acetaminophen 500 mg 4 times daily for 3 days postoperatively. They were instructed to use an ice pack over the skin of the extraction site for the rst 6 h. They were also instructed to rinse their mouth with 0.2% chlorhexidine for 5 days after extraction. Preoperatively, and 1, 3, and 7 days postoperatively, the distance from the corner of mouth to the most inferior part of the ear lobe was measured (mm) over the skin as an indicator of the amount of swelling at the surgical site. All measurements were made on both sides and compared with the preoperative values. For assessment of postoperative pain, patients were provided with a visual analogue scale (VAS) with 6 scores. A score of zero indicated no pain while a score of 5 indicated extremely severe pain. These data were also collected on the rst, third, and seventh postoperative days. The signicance of differences between the sides was assessed using Students paired t test with the help of the Sta-

Results Thirty patients who required removal of bilateral, boneimpacted mandibular third molars were included in the study (Table 1). There was signicantly less swelling and pain on the third (p = 0.005) and seventh (p = 0.005) postoperative days in the study group than in the control group (Tables 2 and 3). None of the patients developed postoperative infection or alveolar osteitis, or both, in either the control or the study side. None of the patients reported excessive bleeding or oozing postoperatively on either side. Six months after extraction there were no signicant differences from preoperative values (p = 0.005) between the depths of periodontal pockets around the second molars on either group. The depth of the periodontal pocket around the second mandibular molar was less than 3 mm on both sides in all patients.

Discussion In a recent split mouth study, Danda et al.2 compared the inuence on postoperative pain and swelling of primary and secondary closure of the extraction wound after removal of impacted mandibular third molars. In the primary closure group, 2 sutures were placed on the distal arm of the incision and one on the mesial arm of the incision. In the secondary closure group, a wedge of mucosa distal to the second molar was removed and then only 1 suture was placed on the distal arm of the incision and 1 suture on the mesial arm. The results showed that patients in the
Table 3 Pain scores in the two groups (n = 30 in each). Day Pain score 0 Day 1 Study Control Day 3 Study Control Day 7 Study Control 28 (93) 22 (73) 12 (40) 2 (7) 24 (80) 14 (47) 1 0 8 (27) 12 (40) 10 (33) 6 (20) 12 (40) 2 2 (7) 0 6 (20) 14 (47) 0 4 (13) 4 0 0 0 4 (13) 0 0

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secondary closure group had signicantly less pain and swelling postoperatively than those in the primary closure group. This study was similar to ours in terms of objectives, study design, and results. However, an advantage of our study was that we evaluated swelling objectively (mm) while Danda et al.2 evaluated it subjectively using a VAS. We also provided results from the 6-month follow up, which showed that secondary wound healing did not increase the depth of the pocket around the second molar. Waite and Cherala3 evaluated the outcomes of 1280 extractions of third molars when no sutures were used for wound closure (sutureless technique), and showed that the sutureless technique gave favourable results in terms of postoperative complications. Dubois et al.4 also conducted a split mouth study and showed that secondary closure resulted in reduced pain, swelling, and discomfort in the immediate postoperative period. In a similar study, Pasqualini et al.5 found that hermetically suturing the ap after removal of impacted mandibular third molars resulted in signicantly more pain and swelling postoperatively than when the surgical wound was allowed to heal secondarily. They did not use a split mouth design or an objective method to evaluate the amount of swelling between patients. Several other studies have also assessed the effect on postoperative complications of inserting a drain into the wound after removal of impacted third molars. Cerqueira et al.6 found that the use of a drain signicantly reduced the amount of postoperative swelling but did not signicantly reduce the amount of pain and trismus. In a randomised crossover study, Saglam7 found that inserting a drain reduced postoperative facial swelling. The degree of trismus was greater in the no drain group, but the difference was not signicant. The results of a study by Chukwuneke et al.8 indicated that the use of a rubber drain reduced postoperative discomfort in the form of swelling and trismus, but seemed to have no effect on pain. Rakprasitkul et al.9 compared the insertion of a small tube drain with primary wound closure (drain group) with simple primary wound closure (no drain group). They found no signicant difference in the severity of pain between the two groups, and there was signicantly less facial swelling in those in the drain group. The number of patients with wound breakdown, oedema, and bleeding was also less in the drain than in the no drain group. However, de Brabander et al.10 found that insertion of a drain and allowing the surgical wound to heal secondarily has no signicant

inuence on the amount of postoperative pain, swelling, or trismus. In conclusion, the results of our study indicate that, after extraction of impacted mandibular third molars, allowing the surgical wound to heal secondarily with no sutures is benecial in terms of reducing the amount of postoperative pain and swelling. Considering the results of other studies, we suggest that maintaining or creating a path through which inammatory exudates could be drained from the site may help to reduce postoperative complications after extraction of impacted teeth.

Conict of interest The authors have no conict of interest.

References
1. Eming SA, Krieg T, Davidson JM. Inammation in wound repair: molecular and cellular mechanisms. J Invest Dermatol 2007;127:51425. 2. Danda AK, Krishna Tatiparth M, Narayanan V, Siddareddi A. Inuence of primary and secondary closure of surgical wound after impacted mandibular third molar removal on postoperative pain and swelling-a comparative and split mouth study. J Oral Maxillofac Surg 2010;68:30912. 3. Waite PD, Cherala S. Surgical outcomes for suture-less surgery in 366 impacted third molar patients. J Oral Maxillofac Surg 2006;64:66973. 4. Dubois DD, Pizer ME, Chinnis RJ. Comparison of primary and secondary closure techniques after removal of impacted mandibular third molars. J Oral Maxillofac Surg 1982;40:6314. 5. Pasqualini D, Cocero N, Castella A, Mela L, Bracco P. Primary and secondary closure of the surgical wound after removal of impacted mandibular third molars: a comparative study. Int J Oral Maxillofac Surg 2005;34:527. 6. Cerqueira PR, Vasconcelos BC, Bessa-Nogueira RV. Comparative study of the effect of a tube drain in impacted lower third molar surgery. J Oral Maxillofac Surg 2004;62:5761. 7. Saglam AA. Effects of tube drain with primary closure technique on postoperative trismus and swelling after removal of fully impacted mandibular third molars. Quintessence Int 2003;34:1437. 8. Chukwuneke FN, Oji C, Saheeb DB. A comparative study of the effect of using a rubber drain on postoperative discomfort following lower third molar surgery. Int J Oral Maxillofac Surg 2008;37:3414. 9. Rakprasitkul S, Pairuchvej V. Mandibular third molar surgery with primary closure and tube drain. Int J Oral Maxillofac Surg 1997;26:18790. 10. de Brabander EC, Cattaneo G. The effect of surgical drain together with a secondary closure technique on postoperative trismus, swelling and pain after mandibular third molar surgery. Int J Oral Maxillofac Surg 1988;17:11921.