Primary and secondary closure of the surgical wound after removal of impacted mandibular third molars

Analysing inflammatory responses after mandibular third molar extraction: a comparison of suture-less and multiple suture techniques

PURPOSE

This study aims to compare the outcomes of suture-less and multiple suture closure methods on postoperative pain, swelling, and trismus, and associated complications.

MATERIALS AND METHODS

This prospective, randomized clinical trial was conducted at the Department of Oral & Maxillofacial Surgery, Goa Dental College & Hospital. Inclusion criteria encompassed subjects aged between 17 and 55 years, classified as American Society of Anaesthesiologists (ASA) I, with asymptomatic impacted third molars falling within the moderately difficult impaction range (Pederson's difficulty index: 5-7). Study excluded individuals classified as ASA II, III, or IV, those with known or suspected allergies to the anaesthetic solution, immunocompromised patients, and individuals taking medications that could affect healing. Pregnant or lactating females and those with a history of bleeding disorders were also excluded. Wound closure methods were compared: Group A underwent primary closure with silk sutures, while Group B had suture-less closure. Subjects were allocated to the specific groups using a simple randomization method. This involved using a lottery-based random sequence to assign each participant to either Group A or Group B. Pain intensity, facial swelling, and trismus were key outcomes. Secondary outcomes included lingual nerve sensation and postoperative complications. Demographics factors, surgical details, radiographic and perioperative data, and physiological parameters were considered. Non-parametric tests and parametric test (repeated measure ANOVA) were employed. Statistical significance was set at P < 0.05.

RESULTS

Among 101 participants, both closure techniques exhibited similar outcomes in pain, swelling, and lingual nerve function. However, suture-less closure resulted in significantly less trismus and fewer cases of delayed wound healing.

CONCLUSIONS

Suture-less method after surgical removal of third molar may reduce trismus compared to multiple sutures. While pain, swelling, and lingual nerve function management were comparable.

Patient-reported outcomes following guided bone regeneration: Correlation with clinical parameters

OBJECTIVES

Postoperative oral health-related quality of life is procedure-dependent and may vary during early healing. There is scarce evidence on patient-reported outcome measures (PROMs) after extraction and guided bone regeneration (GBR) or on the clinical parameters influencing PROMs. This prospective observational study aimed to evaluate PROMs during the first 2 weeks following extraction and GBR and correlate them with clinical parameters.

METHODS

Patients undergoing extraction and GBR (bone graft and resorbable membrane) at a single tooth-bound site were recruited. PROMs (pain, swelling, difficulty of mouth opening, and OHIP-14) were recorded immediately preoperatively, and at 2, 7, and 14 days postoperatively. Flap advancement, gingival and mucosal thickness, duration of surgery, and wound opening were the clinical parameters assessed.

RESULTS

Twenty-seven patients were included. All PROMs peaked on postoperative day 2, decreased subsequently and were significantly correlated with each other. Although 41-56% of patients reported moderate to severe pain, swelling, or mouth opening difficulty on day 2, most patients experienced mild or no symptoms throughout the postoperative period. Pain, swelling and difficulty of mouth opening were determinants of OHIP-14 and were correlated with all OHIP-14 domains during different time points. Wound opening peaked on day 7. Flap advancement, soft tissue thickness, wound opening, duration of surgery and preoperative PROMs affected postoperative PROMs.

CONCLUSIONS

Within the limitations of the present study, postoperative symptoms after guided bone regeneration are worst on day 2 and oral health-related quality of life is significantly impacted by pain, swelling, difficulty of mouth opening, surgery duration and flap advancement.

CLINICAL SIGNIFICANCE

This is the first study to report PROMs following extraction and GBR with particulate bone graft and resorbable membrane in preparation for implant placement. It will help guide both practitioners and patients on what should be the anticipated experiences following such a routinely performed surgery.

Efficacy of secondary vs primary closure techniques for the prevention of postoperative complications after impacted mandibular third molar extractions: A systematic review update and meta-analysis

BACKGROUND

The aim of this systematic review was to determine whether secondary closure (SC) or primary closure (PC) is better at preventing postoperative complications after impacted mandibular third-molar extraction.

TYPES OF STUDIES REVIEWED

The authors sought randomized controlled trials comparing the effects of PC and SC on pain, swelling, trismus, infection, and bleeding after impacted mandibular third-molar extraction. Screening, data extraction, and risk of bias assessments were conducted independently and in duplicate. The reviewers pooled results across studies using a random-effects meta-analysis and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

This review identified 785 unique citations and included 40 trials. Compared with PC, SC was found to have trivial benefits for pain at day 7 and trismus within 1 week (moderate certainty). The incidence of infection and bleeding did not differ importantly between techniques (moderate certainty). However, SC is probably associated with less swelling on day 1 (standardized mean difference, -0.98; 95% CI, -1.22 to -0.73; moderate certainty) and day 3 (standardized mean difference, -0.87; 95% CI, -1.16 to -0.59; moderate certainty). There was very low certainty evidence for pain on days 1 and 3 and low certainty evidence for swelling on day 7.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Clinicians choosing between closure techniques should be aware that SC probably imparts an important benefit only for swelling at days 1 and 3. There seems to be a trivial difference between the techniques in other outcomes.

A Retrospective Evaluation of Secondary Wound Healing for Extraction of the Maxillary First Molar in Dogs

Oral surgery and exodontia can present challenges in veterinary patients, with a particular area of challenge being extraction and closure of the maxillary first molar (M1) in dogs. This retrospective assessment evaluated patients that had the maxillary first molar extracted with placement of a cruciate suture across the alveolus to achieve partial closure and secure the blood clot. Patients that had teeth extracted adjacent to M1 (maxillary fourth premolar [PM4] or second molar [M2]) were excluded from the study. Three groups of patients were assessed: Group A - at the time of extraction of M1, both the maxillary PM4 and M2 were still present in the oral cavity. Group B - at the time of M1extraction only PM4 or M2 was present, but not both. The tissue was completely intact at the location of the missing tooth. Group C - at the time of M1 extraction neither PM4 or M2 were present, but tissue in these locations was intact. In a three-and-a half-year time period (2015-2018), 179 dogs with 213 solitary M1 extractions were performed. Of these 213 extraction sites, 127 sites (60%) had follow up examination within a two-week postoperative period. Of these 127 sites, 126 (99.2%) appeared appropriately healed without complication. The results of this retrospective evaluation demonstrate that primary closure of a maxillary first molar extraction site may not be required for appropriate soft tissue wound healing in canine patients.

Effect of Intraoral Drainage after Impacted Mandibular Third Molar Extraction on Non-Infectious Postoperative Complications

Surgical removal of mandibular third molars is associated with non-infectious postoperative complications, including pain, swelling, trismus. Intraoral drains are noteworthy because of their ease of application, availability, and effectiveness. This study aimed to evaluate the use of latex and calcium–sodium alginate mouth flat drains on the severity of postoperative complications such as pain, trismus, and edema after surgical removal of mandibular third molars. Ninety patients who underwent surgical removal of wisdom teeth were studied. The patients were divided into three groups. Group A—with a latex flat drain, group B—with a sodium–calcium alginate (Kaltostat) flat drain, and group C—with a wound closed with knotted sutures. Patients were assessed for pain on a VAS scale every day from surgery to postoperative day 7. Before the procedure and on postoperative days 1, 2, and 7, the pain level, edema, and trismus were measured, respectively. Intraoral drainage with a flat drain after mandibular third molar removal does not significantly reduce pain, as measured by the VAS scale, or postoperative swelling, as measured by lines between craniometric points. Intraoral drainage with a latex drain after mandibular third molar removal does not significantly reduce trismus, while intraoral drainage with a calcium–sodium alginate drainage bag significantly increases trismus.

The effect of triangular and reversed triangular flap designs to post third molar odontectomy complications (a pilot study)

Background

Odontectomy is one of the most common surgical procedures in oral and maxillofacial surgery. Flap design influences the post operative complications. Triangular flap is the most widely used flap design but it has many shortages such as dehiscence, alveolar osteitis, reactionary bleeding, and periodontal disruption distal of second molar. The aim of this study is to introduce an alternative flap design in the surgical removal of impacted mandibular third molars – reversed triangular flap – and to compare this flap design with the triangular flap in case of dehiscence, reactionary bleeding, and clinical attachment loss.

Material and Methods

This prospective, split-mouth study involved 15 patients with bilateral partially impacted mandibular third molars with similar impaction classification. One impacted tooth was removed using a triangular flap and the other using a reversed triangular flap. Post operative complications such as dehiscence, reactionary bleeding, and clinical attachment loss were recorded 1, 3, 7, 14, and 30 days post odontectomy.

Results

Chi square test result shows that there were fewer incidences of dehiscence seven days post surgery using the reversed triangular flap (p=0.032). Mann Whitney-U test result shows that the reversed triangular flap exhibited less bleeding score on day 1 (p=0.002) and day 2 (p=0.035) post surgery. There were no statistically significant differences according to Mann Whitney-U test between the flap designs for the clinical attachment loss on distal of second molar on day 14 (p=0.512) and day 30 (p=0.902) post surgery.

Conclusions

The reversed triangular flap design is preferable to triangular flap for impacted third molar surgery, escpecially in terms of wound dehisence and reactionary bleeding.

Key words:Flap design, third molar impaction, odontectomy, post odontectomy complications.

Comparison of two different suture knot techniques on postoperative morbidity after impacted mandibular third molar surgery

INTRODUCTION

In third molar surgery, one of the most important factors is how the wound was closed. Tight suturing of the wound commonly gives more discomfort to the many patients in terms of postoperative pain, swelling and trismus. The purpose of this study is to investigate the effects of two different knot techniques in suturing after extraction of impacted mandibular third molars (IMTM) on quality of life and postoperative complications such as pain, swelling and trismus.

MATERIAL AND METHODS

This study was conducted with a randomized and split-mouth design and included 50 patients over the age of 18 in the ASA I group who had bilateral horizontal impacted mandibular third molars. In all patients, the wounds were closed by simple sutures by applying two different knot techniques as locked (GroupL, n=50) and unlocked (Group UL, n=50) knots. In the postoperative period, pain, swelling, trismus, chewing activity and quality of life were examined.

RESULTS

In the group where the unlocked knotting technique was used, significantly better results were obtained in comparison to the group where the locked knotting technique was used for all values (P<0.05).

CONCLUSION

In preventing postoperative complications that are observed after impacted mandibular third molar surgery and affect the quality of life of patients negatively, suturing of the wound by the method of unlocked knotting is a useful technique that may be preferred.

Comparison of primary and secondary closure with a buccal mucosal-advancement flap on postoperative course after mandibular impacted third molar surgery

PURPOSE

The purpose of this study was to compare primary and secondary wound closure with a buccal mucosal-advancement flap technique on the postoperative course after mandibular impacted third molar surgery.

METHODS

The study was conducted on 150 patients who required surgical removal of impacted mandibular third molars under local anesthesia. The study subjects were divided into three groups of 50 patients each, based on the type of closure over the third molar socket. Patients in group I underwent primary closure of the socket with hermetic suturing of the flap, including the vertical release. In group II, a secondary closure was performed, leaving the socket communicating with the oral cavity. In group III, a buccal mucosal-advancement flap technique was employed to achieve primary closure of the flap over the socket while leaving the anterior vertical release, generously patent. All the patients were assessed for pain using the visual analogue scale (VAS), swelling, and mouth opening at postoperative intervals of 2, 4, and 7 days. The wound healing was assessed on day 7.

RESULTS

Patients in the buccal mucosal-advancement flap group had significantly less pain and swelling and increased mouth opening compared with primary and secondary closure. Wound dehiscence was seen in 18 patients and alveolar osteitis in 4 patients in primary closure. Delayed wound healing with food accumulation was seen in 6 patients in secondary closure. No complications of flap dehiscence or breakdown were observed in the buccal mucosal-advancement flap group.

CONCLUSION

This study concludes that the buccal mucosal-advancement flap technique was a superior closure technique with less pain, swelling, trismus, and satisfactory wound healing compared with both primary and secondary closure after mandibular third molar surgery.

Efficacy of secondary closure technique after extraction of third molars: a meta-analysis

The purpose of this study was to assess the influence of two suture methods on the postoperative complications of extraction of mandibular third molars (M3M). We searched the MEDLINE (PubMed), Cochrane Library, and Web of Science databases until 18 May 2018 for randomised controlled trials (RCT) that evaluated the influence of any suture techniques on postoperative complications after the removal of impacted M3M. Pain, facial swelling, and trismus were measured for both the early stage (2-3 days) and late stage (5-7 days) after extraction. We identified 655 records, of which five were assessed for eligibility. All trials included had a moderate risk of bias. The analysis showed that the patients whose wounds had been closed primarily had significantly more pain than those whose wounds were closed secondarily (a wedge of mucosa) during the early stage (standardised mean difference (SMD), -0.49; 95% CI -0.71 to -0.27; P<0.0001) and the late stage (SMD -0.36; 95% CI -0.54 to -0.19; P<0.0001) after the removal of impacted M3M. Patients whose wounds were closed secondarily had less swelling (mm) at the postoperative early stage (SMD -1.12; 95% CI -1.57 to -0.66; P<0.00001) and late stage (SMD -0.51; 95% CI -0.68 to -0.33; P<0.00001). There was more trismus in the primary closure group than in the secondary group during both stages. Our findings suggest that secondary closure causes less pain, facial swelling, and trismus in both early and late stages of surgical removal of impacted M3M, and therefore it improves the quality of life by reducing postoperative discomfort.

A Comparison between Primary and Secondary Flap Coverage in Ridge Preservation Procedures: A Pilot Randomized Controlled Clinical Trial

Aims

To assess the bone dimensional changes after extraction and alveolar ridge preservation (ARP) using primary coverage (closed flap technique, CFT) or healing by secondary intention (open flap technique, OFT).

Materials and Methods

Ten patients (split mouth design) were planned for extraction and ARP. All sites received ARP with freeze-dried bone allograft (FDBA) and nonresorbable membrane after extraction. Clinical standardized measurements were used to assess the dimensional alterations of the alveolar ridge.

Results

All patients completed the study, and a total of 20 sites were randomized to CFT or OFT group. Center height (mean difference of 8.1 mm, SD =1.9 CFT, and 7.5 mm, SD= 1.8 OFT) and buccal height (mean difference of 0.8 mm, SD =1.0 CFT, and 0.3 mm, SD= 1.1 OFT) were significantly different within the same group. However, there was no statistically significant difference between groups. In the OFT group, the keratinized tissue width was higher and the pain VAS scores at 24 hours were lower compared with the CFT (p = 0.004 and p = 0.006, respectively).

Conclusions

Leaving the flap open did not have any effects on the dimensional changes of bone height or width. However, there was a wider band of keratinized tissue and less pain with the CFT compared with the OFT. The study protocol was registered at ClinicalTrials.gov, Identifier NCT03136913.

Effect of One-Suture and Sutureless Techniques on Postoperative Healing After Third Molar Surgery

PURPOSE

The wound closure technique for lower third molar surgery (LTMS) is an operative factor that influences wound healing and the occurrence of early postoperative complications. The present study investigated 2 closure techniques (partial closure using 1 suture and the suture-less technique) after use of a modified buccal envelope flap for LTMS.

MATERIALS AND METHODS

We performed a prospective, randomized, double-blind, split-mouth, controlled trial. Partial closure using 1 suture was compared with closure using the sutureless technique. The surgical sites were divided into 2 groups, group A (1 suture) and group B (sutureless). Each patient received both treatments at the same surgery. During the first postoperative week, all patients were asked to daily assess pain, facial swelling, and bleeding using self-assessment scales. All patients attended the follow-up appointment at 1 week to objectively assess facial swelling and wound healing and at 1 month to assess wound healing. An analysis of data was performed using the statistical package SPSS Statistics, version 24 (IBM Corp, Armonk, NY). A P value ≤ .05 was accepted as statistically significant.

RESULTS

A total of 37 patients with bilateral impacted third molars of similar surgical difficulty were recruited. Of the 37 patients, 34 successfully completed the study. The results showed a statistically significant difference between the 2 techniques in postoperative pain at days 5 (P = .046) and 6 (P = .034); socket healing at 1 week (P = .002) and 1 month (P = .014), and soft tissue healing at 1 week (P = .016).

CONCLUSION

We found the 1-suture technique for LTMS to be superior to the sutureless technique in the reduction of postoperative pain and improving wound healing during the early postoperative period. We found no difference between the 2 techniques in the reduction of postoperative swelling.

Efficacy of Murva (Sansevieria roxburghiana Schult. and Schult.f.) as a suture material in closure of incisions in third molar surgeries: A prospective study

Introduction:

Adequate closure of the surgical wound is one of the most important aspects of surgery; improper suturing techniques or improper suturing materials sometimes compromise the success of surgery. Many synthetic materials have replaced the natural materials, which were once used for suturing in the ancient era, and Murva is one of them. There are references of Murva (Sansevieria roxburghiana Schult. and Schult.f.) at various contexts of “Sushruta Samhita” where it has been used as a suture material. It is a xerophytic herbaceous plant occurring abundantly in the eastern coastal region of India. The aim of this study is to evaluate the efficacy of Murva fibers as a suturing material in closure of intraoral incision in third molar surgeries.

Materials and Methods:

Fifty incisions (Wards incision) placed for the surgical removal of mandibular third molar were sutured with Murva, and follow-up was carried out postoperatively on 1^st, 2^nd, 3^rd, and 7^th day. Patients were evaluated for pain, swelling, bleeding, infection, wound dehiscence, local tissue irritation, and bacterial colonization.

Results:

On various follow-ups, progressively significant and predictable healing was observed without any uneventful evidence.

Conclusion:

The use of Murva as a suture material proved to be effective in closure of intraoral incisions.

Wound Dehiscence after Wisdom Tooth Removal in Mandibular Mesioangular Class IB Impactions: Triangular Transposition Flap versus Envelope Flap

Background and aims. Wound dehiscence after lower third molar surgery extends the postoperative treatment period and may cause long-standing pain. The aim of this study was to compare wound dehiscence after removal of wisdom teeth in the most prevalent mandibular impaction (mesioangular class IB) by two different soft tissue flap designs.

Materials and methods. Partially-erupted mandibular third molars with mesioangular class IB impaction (Pell and Gregory classification) were selected. Split mouth technique was used to compare the two flap designs (envelope vs. triangular transposition flap—TTF). The patients were recalled one week and a month later and rechecked for dehiscence, infection, and dry socket formation.

Results. There were no cases of infection in either group. However, three cases of dry socket in the envelope group and four in the TTF group were recorded. In the envelope group, dehiscence occurred in 43% of cases during the first week, with 67% of cases being a large dehiscence (diameters of more than 5 mm). Extra appointments (those requested by the patient exclusively related to the problem of the hole distal to the second molar) were scheduled in 10% of cases in the envelope group. In the TTF group, dehiscence occurred during the first week for the same impaction in 19% of cases with large dehiscence cases occurring in 65% of cases and extra appointment rate at 4.1%.

Conclusion. According to theresults in the evaluated operation, TTF may prevent postoperative wound dehiscence more probably than the envelope flap.