A surgeon’s dilemma: Evidence based selection of suturing technique to minimize post-operative complications following lower third molar surgical extraction
Selecting Suitable Suturing Technique
Lower third molar extraction is usually associated with multiple stigmae that deters the patients in most cases to postpone or not seek appropriate surgical care. It is also one of the most feared procedure amongst dentists and dental students. However, evidence has been reported suggesting that the choice of suturing technique can have a profound effect on post-operation complications and thereby can improve the overall outlook and comfort of the patient. In the past, multiple techniques like Mattress, Continuous etc have been compared with tissue glues, staples however, a comparative clinical study amongst the simplest and most commonly used suturing techniques have not been reported.
Material and Methods
Sixty patients with impacted mandibular third molars fulfilled the inclusion criteria and were randomly divided into three groups of 20 each. All patients underwent third molar extraction and sutures were placed using different techniques – Simple Interrupted (Group A), Continuous (Group B) and Figure of eight (Group C). Patients were evaluated pre-operatively as well post-operatively (at different time points) for five parameters - Pain, Swelling, Trismus, Periodontal health of second molar and Wound infection. Kruskal-Wallis (non-parametric ANOVA) with post-hoc and effect size was used for statistical analysis with P < 0.05 as statistically significant.
Statistically significant differences were obtained in terms of pain and trismus between Groups A and C post-operatively (P < 0.05). There were also significant differences in pain between Groups B and C post-surgery (P < 0.05). No significant differences were found between groups for swelling, periodontal health of second molar and wound infection.
Figure of eight suturing presents with better patient outlook and is associated with lower pain, swelling and trismus. Continuous and simple interrupted suturing can be preferred as second-in-line techniques. Final choice of technique shall be made based on wound anatomy, patient history and surgeon’s expertise.
2. Gay-Escoda C, Gómez-Santos L, Sánchez-Torres A, Herráez-Vilas JM. Effect of the suture technique on postoperative pain, swelling and trismus after removal of lower third molars: A randomized clinical trial. Med Oral Patol Oral Cir Bucal. 2015 May 1;20(3):e372-7. doi: 10.4317/medoral.20307. PMID: 25662551; PMCID: PMC4464926.
3. Syed KB, AlQahtani FH, Mohammad AH, Abdullah IM, Qahtani HS and Hameed MS. Assessment of pain, swelling and trismus following impacted third molar surgery using injection dexamethasone submucosally: A prospective, randomized, crossover clinical study. J Int Oral Health 2017;9:116-21. doi: 10.4103/jioh.jioh_65_17.
4. Archer WH. Oral Surgery: A Step-By-Step Atlas of Operative Techniques, 4th ed. Philadelphia: W.B. Saunders Company; 1966. p. 507-10.
5. Peterson LJ. Principles of Management of Impacted Teeth. In: Peterson LJ, Ellis E III, Hupp JR, Tuker MR, editors. Contemporary Oral and Maxillofacial Surgery, 3rd ed. St. Louis: Mosby; 1998. p. 184-248.
6. Agarwal KN, Gupta R, Faridi MM, Kalra N. Permanent dentition in Delhi boys of age 5-14 years. Indian Pediatr. 2004 Oct;41(10):1031-5.
7. Syed KB, Zaheer KB, Ibrahim M, Bagi MA, Assiri MA. Prevalence of Impacted Molar Teeth among Saudi Population in Asir Region, Saudi Arabia - A Retrospective Study of 3 Years. J Int Oral Health. 2013 Feb;5(1):43-7. Epub 2013 Feb 26. PMID: 24155577; PMCID: PMC3768082.
8. Elsey MJ, Rock WP. Influence of orthodontic treatment on development of third molars. Br J Oral Maxillofac Surg. 2000 Aug;38(4):350-3.
9. Pahkala R, Pahkala A, Laine T. Eruption pattern of permanent teeth in a rural community in northeastern Finland. Acta Odontol Scand. 1991 Dec;49(6):341-9.
10. Frost DE, Hersh EV, Levin LM. Management of impacted teeth. In: R Fonseca, editor. Oral and Maxillofacial Surgery. Vol. I. Philadelphia: Saunders; 2000. p. 245-80.
11. Dodson TB, Susarla SM. Impacted wisdom teeth. BMJ Clin Evid. 2010 Apr 8;2010:1302. PMID: 21729337; PMCID: PMC2907590.
12. Juodzbalys G, Daugela P. Mandibular third molar impaction: review of literature and a proposal of a classification. J Oral Maxillofac Res. 2013 Jul 1;4(2):e1. doi: 10.5037/jomr.2013.4201. PMID: 24422029; PMCID: PMC3886113.
13. Burkhardt R, Lang NP. Influence of suturing on wound healing. Periodontol 2000. 2015 Jun;68(1):270-81. doi: 10.1111/prd.12078. PMID: 25867989.
14. Adell R, Eriksson B, Nylén O, Ridell A. Delayed healing of fractures of the mandibular body. Int J Oral Maxillofac Surg. 1987 Feb;16(1):15-24. doi: 10.1016/s0901-5027(87)80026-7. PMID: 3104491.
15. Politis C, Schoenaers J, Jacobs R, Agbaje JO. Wound Healing Problems in the Mouth. Front Physiol. 2016 Nov 2;7:507. doi: 10.3389/fphys.2016.00507. PMID: 27853435; PMCID: PMC5089986.
16. Roy S., Das A., Sen C. K. (2013). Disorder of localized inflammation in wound healing: a systems perspective, in Complex Systems and Computational Biology Approaches to Acute Inflammation, eds Vodovotz Y., An G.(New York, NY: Springer; ), 173–183.
17. Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010 Mar;89(3):219-29. doi: 10.1177/0022034509359125. Epub 2010 Feb 5. PMID: 20139336; PMCID: PMC2903966.
18. Emin E, Ferda T, Okan A. Determination of the anti-inflammatory effect of methyl prednisolone on the sequelae of third molar surgery. J Oral Maxillofac Surg. 1999;57:1201–1206. doi: 10.1016/S0278-2391(99)90486-X.
19. Howe GL: Minor Oral Surgery. Bristol, England, John Wright & Sons Ltd, 1971.
20. Archer WH: Oral and Maxillofacial Surgery, 5th ed. Philadelphia, WB Saunders Co, 1975.
21. Guralnick WC (Ed): Textbook of Oral Surgery. Boston, Little Brown & Co, 1968.
22. Kruger GO (Ed): Textbook of Oral Surgery. St Louis, CV Mosby Co, 1974.
23. Thoma KH: Oral Surgery, 5th ed. St Louis, CV Mosby Co, 1969, Vol 1.
24. Killey HC, Kay LW: The Impacted Wisdom Tooth, 2nd ed. London, Churchill Livingstone Co, 1975.
25. Maria A, Malik M, Virang P. Comparison of primary and secondary closure of the surgical wound after removal of impacted mandibular third molars. J Maxillofac Oral Surg. 2012 Sep;11(3):276-83. doi: 10.1007/s12663-011-0287-9. Epub 2011 Sep 23. PMID: 23997477; PMCID: PMC3428443.
26. 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;34:52–57. doi: 10.1016/j.ijom.2004.01.023.
27. 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;40:631–634. doi: 10.1016/0278-2391(82)90111-2.
28. Cohen I. K., Diegelmann R. F., Lindblad W. J. (eds.). Wound Healing: Biochemical and Clinical Aspects. 1992.Philadelphia: WB. Saunders Company; Harcourt Brace Jovanovich, Inc.
29. Sørensen L. T. (2012). Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann. Surg. 255, 1069–1079. Doi:10.1097/SLA.0b013e31824f632d.
30. Glim J. E., van Egmond M., Niessen F. B., Everts V., Beelen R. H. (2013). Detrimental dermal wound healing: what can we learn from the oral mucosa? Wound Repair Regen. 21, 648–660. 10.1111/wrr.12072.
31. Hashemi HM, Beshkar M, Aghajani R. The effect of sutureless wound closure on postoperative pain and swelling after impacted mandibular third molar surgery. Br J Oral Maxillofac Surg. 2012;50:256–8.
32. Osunde OD, Adebola RA, Saheeb BD. A comparative study of the effect of suture-less and multiple suture techniques on inflammatory complications following third molar surgery. Int J Oral Maxillofac Surg. 2012;1:1275–9.
33. Dolanmaz D, Esen A, Isik K, Candirli C. Effect of 2 flap designs on postoperative pain and swelling after impacted third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116:244–6.
34. Sandhu A, Sandhu S, Kaur T. Comparison of two different flap designs in the surgical removal of bilateral impacted mandibular third molars. Int J Oral Maxillofac Surg. 2010;39:1091–6.
35. Ege B., and Najafov E. Comparison of two different suture knot techniques on postoperative morbidity after impacted mandibular third molar surgery. J Stomatol Oral Maxillofac Surg. 2020; 121(3):206-212.
36. Joshi AD, Saluja H, Mahindra U, Halli R. A comparative study: efficacy of tissue glue and sutures after impacted mandibular third molar removal. J Maxillofac Oral Surg. 2011 Dec;10(4):310-5. doi: 10.1007/s12663-011-0241-x. Epub 2011 May 17. PMID: 23204746; PMCID: PMC3267907.
37. Ghoreishian M, Gheisari R, Fayazi M. Tissue adhesive and suturing for closure of the surgical wound after removal of impacted mandibular third molars: a comparative study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Jul;108(1):e14-6. doi: 10.1016/j.tripleo.2009.03.001. Epub 2009 May 22. PMID: 19464207.
38. American Society of Anesthesiologists website. Available at: https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system. Accessed 16 Aug 2020.
39. Ren Y-F, Malmstrom HS. Effectiveness of antibiotic prophylaxis in third molar surgery: a meta-analysis of randomized controlled clinical trials. J Oral Maxillofac Surg. 2007 Oct; 65(10):1909–21.
40. Coe R. It’s the effect size, stupid: What effect size is and why it is important. 2002. Available at: https://www.leeds.ac.uk/educol/documents/00002182.htm. Accessed 16 Aug 2020.
41. Page P. Beyond Statistical significance: clinical interpretation of rehabilitation research literature. Int J Sports Phys Ther. 2014; 9(5):723-36. PMID: 25328834.
42. Batterham AM, and Hopkins WG. Making meaningful inferences about magnitudes. Int J Sports Phys Ther. 2006; 1(1):50-57.
43. Sainani KL. Putting P values in perspective. PM & R: the journal of injury, function and rehabilitation. 2009; 1(9):873-877.
44. Larjava H. Oral Wound Healing: Cell Biology and Clinical Management. West Sussex: John Wiley & Sons, Inc. 2012.
45. Burkhardt, R., & Lang, N. P. Influence of suturing on wound healing. Periodontology 2000. 2015; 68(1), 270–281. doi:10.1111/prd.12078.
46. Discepoli N., Vignoletti F., Laino L., de Sanctis M., Muñoz F., Sanz M. Early healing of the alveolar process after tooth extraction: an experimental study in the beagle dog. J. Clin. Periodontol. 2013; 40, 638–644. 10.1111/jcpe.12074.
47. Takei, H.H. Surgical techniques for reconstructive periodontics. Dental Clinics of North America. 1991; 35, 531–539.
48. Mormann W, Ciancio SG. Blood supply of human gingiva following periodontal surgery. A fluorescein angiographic study. J Periodontol 1977; 48:681-692.
49. Reiser GM, Bruno JF, Mahan PE, Larkin LH. The subepithelial connective tissue graft palatal donor site: Anatomic considerations for surgeons. Int J Periodontics Restorative Dent 1996;16: 130-137.
50. Griffin, T. J., Hur, Y., & Bu, J. Basic Suture Techniques for Oral Mucosa. Clinical Advances in Periodontics. 2011;1(3), 221–232. doi:10.1902/cap.2011.110053.
51. Koshak H.H. Dental Suturing Materials and Techniques. Glob J Otolaryngol. 2017; 12(2):27-37. doi: 10.19080/GJO.2017.12.555833.
52. Hupp J.R (ed). Guide to suturing with sections on diagnosing oral lesions and post-operative medications. J Oral Maxillofacial Surg. Aug 2015; 73(S1). Available at: https://www.aaoms.org/docs/education_research/ dental_students /joms_guide_to_suturing.pdf
53. Nazar. M.N, Puthiriraj.V. Analgesics Following Mandibular Third Molar Surgery. IJPCR, 2014; 6(1):13-19.
54. Haraji A, Rakhshan V. Chlorhexidine gel and less difficult surgeries might reduce post-operative pain, controlling for dry socket, infection and analgesic consumption: a split-mouth controlled randomised clinical trial. J Oral Rehabil. 2015;42:209–219.
55. Wardle J. Dental pessimism: negative cognitions in fearful dental patients. Behav Res Ther. 1984;22:553–556.
56. Susarla SM, Blaeser BF, Magalnick D. Third molar surgery and associated complications. Oral Maxillofac Surg Clin North Am. 2003;15:177–186.
57. Messer EJ and Keller JJ. The use of intraoral dexamethasone after extraction of mandibular third molars. Oral Surg Oral Med Oral Pathol. 1975; 40:594-598.
58. Sortino F and Cicciu M. Strategies used to inhibit postoperative swelling following removal of impacted third molar. Dent Res J (Isfahan). 2011; 8(4):162-171. Doi: 10/4103/1735-3327.86031.
59. Holland CS and Hinole MO. The influence of closure or dressing of third molar sockets on post-operative swelling and pain. Br J Oral Maxillofac Surg. 1984; 22:65-71.
60. De Brabander EC and Cattaneo G. The effect of surgical drain together with a secondary closure technique on post-operative trismus, swelling and pain after mandibular 3rd molar surgery. Int J Oral Maxillofac Surg. 1988; 17:119-121.
61. Waite PD and Cherala S. Surgical outcomes for suture-less surgery in 366 impacted third molar patients. J Oral Maxillofac Surg. 2006;64:669-673.
62. Ten Bosch JJ and van Gool AV. The interrelation of postoperative complaints after removal of the mandibular third molar. Int J Oral Surg. 1977; 6:22-28.
63. Balakrishnan G, Narender R, Kavin T, Venkataraman S and Gokulanathan S. Incidence of trismus in trans-alveolar extraction of lower third molar. J Pharm Bioallied Sci. 2017; 9(Suppl 1):S222-S227. Doi: 10.4103/jpbs.JPBS_161_17. PMID:29284968.
64. Pederson A. Interrelation of complaints after removal of impacted mandibular third molars. Int J Oral Surg. 1985; 14:241-244.
65. Greenfield BE and Morre JR. Electromyographic Study of postoperative trismus. J Oral Surg. 1969; 27:92-98.
66. Montero J and Mazzaglia G. Effect of removing an impacted mandibular third molar on the periodontal status of the mandibular second molar. J Oral Maxillofac Surg. 2011; 69:2691-2697.
67. Stella PEM, Falci SGM, de Mederios LEO, Douglas de Oliveira DW, Goncalves PF, Felcha OD and Santos CRRD. Impact of mandibular third molar extraction in the second molar periodontal status: A prospective study. J Indian Soc Periodontol. 2017;21(4):285-290. Doi: 10.4103/jisp.jisp_79_17. PMID:29456302.
68. Blakey GH, Jacks MT, Offenbacher S, Nance PE, Phillips C, Haug RH et al. Progression of periodontal disease in the second/third molar region in subjects with asymptomatic third molars. J Oral Maxillofac Surg. 2006;64:189-193.
69. White RP Jr, Offenbacher S, Blakey GH, Haug RH, Jacks MT, Nance PE et al. Chronic Oral Inflammation and progression of periodontal pathology in the third molar region. J Oral Maxillofac Surg. 2006; 64:880-885.
70. Rakhshan V. Common risk factors for postoperative pain following the extraction of wisdom teeth. J Korean Assoc Oral Maxillofac Surg. 2015 Apr;41(2):59-65. doi: 10.5125/jkaoms.2015.41.2.59. Epub 2015 Apr 23. PMID: 25922816; PMCID: PMC4411729.