Abstract
The aim of this prospective randomized study was to evaluate the effect of not using sutures on postoperative pain, swelling and trismus after lower third molar surgery. 80 patients with impacted lower third molars were referred for surgical extraction (42 males; 38 females; aged 18–38 years). The patients were randomly divided into two equal groups (sutures n = 40; suture-less n = 40). In the experimental group, the flaps were replaced without suturing. The control group was selected using the same criteria and treated under the same surgical protocol as the experimental group, except that the flaps were apposed using multiple sutures. Pain, swelling and trismus were evaluated at 24 h, 48 h and 1 week postoperatively in both groups. The operation time was found to be significantly longer in the multiple sutures group ( p < 0.05). There was significantly less pain, swelling and trismus at 24 h and 48 h, respectively, in the suture-less group ( p < 0.05). There was no significant difference between the two treatment groups in terms of pain, swelling and trismus, at 1 week postoperatively ( p > 0.05). There is less postoperative pain, swelling and trismus with the suture-less technique in third molar surgery.
Surgical extraction of third molars is considered a routine aspect of oral surgery. Patients complain of the pain, swelling and limitation in mouth opening associated with the inflammatory response following third molar surgical extractions, as the factors affecting their daily life. Methods to alleviate these complications have been the focus of several experimental studies. These include different closure techniques with or without incorporation of drains, use of drugs such as analgesics, corticosteroids and antibiotics. Other reported modalities include physical therapeutic methods such as cryotherapy and soft laser application.
The number of modalities mentioned above shows that there is no ideal agent that can minimize postoperative pain, swelling and trismus without unwanted side effects. Techniques that allow for evacuation of inflammatory exudates appear to have received more attention in the past as these have been thought to result in less pain, swelling and trismus with comparatively few undesirable effects.
These modalities include excision of mucosa immediately distal to the second molar to create a window, which serves as an outlet for inflammatory exudates. Other methods include a combination of mucosa excision and drains, incorporation of drains which may be in the form of a gauze or rubber and ‘suture-less’ techniques in which no form of suturing is used. While suture-less third molar surgery is fast gaining global attention, the technique has not been fully embraced by dentists and oral surgeons in Nigeria. The present study compares the effect of multiple sutures and suture-less techniques on pain, swelling and trismus in third molar surgery at an urban Nigerian teaching hospital.
Materials and methods
The study was a randomized, single-blind, clinical trial undertaken to determine the effect of suture-less and multiple suture techniques on postoperative variables such as pain, swelling and trismus. 80 participants, males and females, between the ages of 18 and 38 years with indications for extraction of a single impacted mandibular third molar under local anaesthesia were included in the study. The study protocol was reviewed and approved by the Ethics Committee of the Aminu Kano Teaching Hospital. All of the participants were informed of the possible risks and benefits of the procedure and signed a detailed informed consent form. The subjects were consecutively randomized into two treatment groups, suture-less ( n = 40) and multiple sutures ( n = 40). Inclusion criteria were patients with mesioangular, distoangular, horizontal and vertical impactions with a difficulty index of 3–8, according to Pederson’s criteria.
Other inclusion criteria were the absence of symptoms such as pain, facial swelling or limited mouth opening from any cause within 10 days preceding surgery. All subjects were non-smokers, none were taking medications that could interfere with healing after surgery and none had any form of systemic diseases at the time of surgery. Participants who did not meet the criteria were excluded. Patients with indications for surgical extraction of more than one impacted tooth as well as pregnant and lactating females were also excluded.
Surgical protocol
The surgical procedure was performed by the same surgeon and assistant under the same environment. Local anaesthesia was obtained using 2% lignocaine hydrochloride with 1:80,000 adrenaline. A full-thickness incision was made to prepare a 3-sided mucoperiosteal flap, with the mesial relieving incision as far forward as the distal third of the buccal surface of the second molar. The flap was reflected and osteotomy was performed using the buccal guttering technique. Bone was removed using a round bur on a straight surgical hand piece under constant irrigation with physiological saline. The tooth was removed with a Couplan elevator. Toileting of the sockets was carried out, haemostasis achieved and the flaps were replaced. In the multiple sutures group, 3/0 silk was used for suturing, placing the suture at the interdental papilla immediately distal to the second molar, the buccal relieving incision and at the distal relieving incision ( Fig. 1 ). No form of suturing was used in the suture-less group to serve as controls ( Fig. 2 ). The duration of surgery starting from time of incisions to placement of last sutures (where sutures were used) was recorded in minutes. Patients were given the same oral antibiotics and analgesics (amoxyl 500 mg 8 hourly and metronidazole 400 mg 12 hourly for 5 days; diclofenac sodium 50 mg 12 hourly for 3 days) and they were also given written postoperative instructions.
Evaluation procedure
The patients were evaluated in a blinded manner by the same independent observer preoperatively and postoperatively and on the first, second and seventh days after surgery. Pain was evaluated using a 10 cm visual analogue scale (VAS). Trismus was evaluated by measuring the distance between the mesial-incisal corners of the upper and lower right central incisors at maximum mouth opening in cm, preoperatively, and on the first, second and seventh postoperative days, using Vernier callipers.
The difference between each postoperative and the preoperative measurement indicated the trismus for that day. The facial swelling in cm was determined by measuring the distance from the corner of the mouth to the attachment of the earlobe following the bulge of the cheek, and the distance from the outer canthus of the eye to the angle of the mandible ( Fig. 3 ). The arithmetic mean of the 2 measurements was considered as the baseline. The difference between each postoperative measurement and the baseline indicated the facial swelling for that day.
Statistical analysis
The data were analysed using Statistical Package for Social Sciences (SPSS) version 13. The χ 2 test was used to compare the proportion of descriptive variables between the two groups, while Student’s t test was used to compare the means of continuous variables between both groups at a 95% confidence interval. A p -value of less than 0.05 was considered significant.
Results
There was equitable distribution of the participants in terms of demographic, operative and baseline characteristics between the suture-less and multiple sutures techniques ( Table 1 ). The operation time was found to be 3 min longer in the multiple sutures group ( Table 2 ). Table 3 shows comparative statistics for the parameters of pain, swelling and trismus between the two treatment modalities.
| Description | Suture-less | Multiple sutures | Test | p -Value |
|---|---|---|---|---|
| Gender | ||||
| Male | 23 (57.5) | 19 (47.5) | x 2 = .802 | 0.50 |
| Female | 17 (42.5) | 21 (52.5) | ||
| Impaction | ||||
| Mesioangular | 18 (45.0) | 19 (47.5) | x 2 = 0.67 | 0.99 |
| Distoangular | 7 (17.5) | 7 (17.5) | ||
| Horizontal | 2 (5.0) | 2 (5.0) | ||
| Vertical | 13 (32.5) | 12 (30.0) | ||
| Indications | ||||
| Pericoronitis | 27 (67.5) | 17 (42.5) | x 2 = 3.681 | 0.45 |
| Apical periodontitis | 10 (25.0) | 14 (35.0) | ||
| Dental caries | 2 (5.0) | 3 (7.5) | ||
| Pulpitis | 2 (5.0) | 5 (12.5) | ||
| Dentoalveolar | 2 (5.0) | 1 (2.5) | ||
| Abscess | ||||
| Age (years) | ||||
| Mean ( SD) | 27.9 (5.47) | 26.3 (4.47) | t = 1.477 | 0.14 |
| Difficulty index | ||||
| Mean (SD) | 5.4 (1.85) | 5.0 (1.63) | t = 1.025 | 0.31 |
| Mouth opening (cm ) | ||||
| Mean (SD) | 4.6 (0.40) | 4.5 (0.38) | t = 1.382 | 0.17 |
| Facial width (cm) | ||||
| Mean (SD) | 10.1 (0.47) | 9.9 (0.36) | t = 1.701 | 0.09 |
| Treatment method | Surgery time (min) Mean (SD) |
df | t | p -Value | Mean difference |
|---|---|---|---|---|---|
| Suture-less | 30.0 (6.60) | 78 | −2.53 | 0.013 | −3.1 |
| Multiple suture | 33.1 (3.81) |
| Days | Suture-less M (SD) |
Multiple sutures M (SD) |
df | t | p -Value |
|---|---|---|---|---|---|
| Pain | |||||
| 1 | 3.7 (0.56) | 4.8 (0.46) | 78 | −9.42 | 0.001 * |
| 2 | 2.3 (0.50) | 3.0 (0.31) | −7.54 | 0.001 * | |
| 7 | 0.2 (0.05) | 0.2 (0.09) | −1.03 | 0.305 | |
| Swelling | |||||
| 1 | 0.9 (0.12) | 1.1 (0.13) | 78 | −6.16 | 0.001 * |
| 2 | 1.1 (0.09) | 1.2 (0.11) | −6.34 | 0.001 * | |
| 7 | 0.1 (0.03) | 0.1 (0.03) | −0.69 | 0.492 | |
| Trismus | |||||
| 1 | 1.0 (0.11) | 1.2 (0.10) | 78 | −7.44 | 0.001 * |
| 2 | 0.9 (0.11) | 1.0 (0.07) | −7.66 | 0.001 * | |
| 7 | 0.2 (0.08) | 0.2 (0.09) | −1.83 | 0.072 | |
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