We were interested in the study by Osunde et al. on 80 patients undergoing mandibular third molar (M3M) surgery and their considerations about the differences between the suture-less group and the control group.

We congratulate Osunde et al. on their well-designed clinical trial, but in the discussion they say the drawback of the suture-less technique is delayed wound healing compared with the primary closure technique. Many studies have noted the significant role of delayed healing time after M3M surgery regarding severe or moderate complications, and showed that delayed healing delays recovery for lifestyle, oral function, late symptoms, and pain. Osunde et al. provided swelling and visual analogue scale (VAS) measurements, but in the results section they do not report the incidence of any major complications as evidence of alveolar osteitis, and haemorrhage, or milder complications such as soft tissue infection, spontaneous pain, bone resorption, and wound dehiscence. We would like to know if any type of complication occurs more often in the suture-less technique, as the absence of primary closure of the wound and the exposure of bone at the surgical site could lead to fibrinolysis, as a result of bacterial invasion with subsequent loss of blood clotting, which could easily evolve in alveolar osteitis.

Recently, health-related quality of life (HRQOL) parameters have been introduced in M3M surgery to evaluate the influence of surgical removal of the third molars on the patients’ quality of life. This has led to a great improvement in understanding the effect of M3M surgery on the lifestyle of patients.

We would like to suggest a focus for future study. Is there less effect on the patients’ quality of life in the suture-less group compared to the multiple-suture group? This could be determined simply by assessing the patients’ HRQOL scores and measuring the influence of surgery and the suture-less technique on their lifestyle.

Waite and Cherala reported better post-surgical outcomes on a greater number of patients with the suture-less technique, but underlined the need for small flaps, and advocated the use of this technique for M3M that could be easily removed with a reduced surgical field. Osunde et al. consider that the suture-less technique can be used in third molar surgery, including those performed via standard incisions, without expressing the need to use small flaps. Flap design influences the direct vision of bone and tooth, and is essential for M3M surgery especially in situations where the third molar is in close communication with the second molar or alveolar inferior nerve, or where cystic neoformation involves the tooth.

The results from Osunde et al. support the use of a suture-less technique only in the cases they reported, but they do not justify the routine use of suture-less techniques for extraction of any third molar.

We think that the study by Osunde et al. adds to our knowledge about the possibility of using suture-less techniques in some conditions, but we would like to note that occasionally third molars can be extracted easily with a small flap. The use of a small flap to remove any impacted M3M could make the intervention more difficult for the surgeon and the risk of complications in third molar surgery increases in proportion to the surgical difficulty.