A Randomized Comparison of the Effect of Partial and Total Wound Closure Techniques on Postoperative Morbidity After Mandibular Third Molar Surgery

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.

Radiological findings associated with postoperative wound infection after extraction of impacted mandibular third molar: A retrospective study

INTRODUCTION

Studies directly relating radiological findings to the risk of postoperative wound infection (PWI) in impacted mandibular third molars (M3) are limited and poorly understood. This study aimed to clarify the radiological risk of PWI.

MATERIALS AND METHODS

Twenty-six patients who developed PWI after M3 extraction were retrospectively analyzed using orthopantomography (OPG) and computed tomography (CT) before M3 extraction to determine the association between M3 impaction status and PWI. These were compared with an equal number of non-infected groups. Moreover, the possibility of assessing the same risk in OPG as in CT imaging was examined.

RESULTS

Multivariate analysis identified class III and position B of the Pell and Gregory classification system as independent risk factors for PWI. On CT, an axial overlap distance (AOD) >3.5 mm was significantly associated with PWI. Furthermore, the sagittal overlap distance (SOD) and AOD of the OPG were significantly greater in group III-B. A strong positive correlation was observed between SOD and AOD.

CONCLUSION

These results indicate that class III, position B, and an AOD >3.5 mm may be novel risk factors for M3 PWI. The strong correlation between SOD and AOD suggests that the risk assessment for PWI can be performed by evaluating OPG alone.

The effect of primary closure versus secondary closure techniques on postoperative wound pain in patients undergoing mandibular surgery: A meta-analysis

This research is intended to explore the influence of second and first degree closure methods on the degree of wound pain and swelling of the face following the removal of the mandible. For the purpose of this study, three data sets, including PubMed and Embase, were selected. A separate statistical analysis was conducted on the choice of the trial, the collection of data and the risk of bias. Differences between trials were analysed with a chi-square approach, with data analyses dependent on I2. A sensitivity analysis was conducted, and a possible publication bias was evaluated. Ultimately, nine qualifying trials were chosen out of an original pool of 1922 related trials following an in-depth evaluation under the eligibility and exclusion criteria, as well as a follow-up screening. The results indicated that there was no statistically significant change in the degree of post-operation pain after 1 day operation between one or secondary closures of treatment (MD, -0.46; 95% CI, -0.93, 0.01, p = 0.06); the results showed that there were no statistically significant differences in post-operation wound pain after 3 days in two group (MD, -0.15; 95% CI, -0.68, 0.37, p = 0.56); the results showed that there were no statistically different effects on the post-operation wound pain after the 7th day in two groups (MD, -0.14; 95% CI, -0.31, 0.03, p = 0.1). The results showed that there were no statistically different effects on the post-operation wound pain after the 1 day in two groups (MD, -0.26; 95% CI, -0.38, -0.13, p < 0.0001); on the 3rd day after surgery, the face was significantly smaller swelling in the secondary closure of closure compared with the first-stage closure group (MD, -0.70; 95% CI, -1.40, -0.00, p = 0.05). While there is no obvious effect on post-operation wound pain in patients with mandibular surgery, there is significant difference in post-operation face swelling. The findings do not support a preference for any of these methods.

Evaluation of complications and quality of life of patient after surgical extraction of mandibular impacted third molar teeth

BACKGROUND

The aim of our study is to evaluate the postoperative complications after the extraction of impacted third molar teeth and to investigate the effects of these complications on the quality of life of patients.

METHODS

Demographic, clinical, and radiological evaluations were conducted, covering factors like age, gender, and tooth position. Clinical measurements, pain and edema assessments, and quality of life evaluations through OHIP-14 scores were performed. Preoperative and postoperative mouth opening, trismus, alveolitis and dehiscence were evaluated.

RESULTS

A total of 100 patients were included in our study. No significant gender-based differences were found in measurements, pain, or swelling. There was no statistically significant difference between the preoperative and postoperative results of difference A-C, difference B-E, difference A-D, and difference mouth opening. Procedure duration correlated positively with age, alveolar osteitis, trismus, and swelling. Postoperative quality of life, assessed by OHIP-14, demonstrated a negative correlation with age and trismus. It was observed that the gender and the tooth positions of the patients had no effect on the severity of postoperative pain and edema.

CONCLUSIONS

As the age of the patients increases and the duration of the procedure increases, the rate of postoperative complications increases and it is concluded that the quality of life decreases significantly.

Predicting Pain Intensity after Mandibular Third Molar Surgery using Cold Pressor Testing: A Quasi-Experimental Study

BACKGROUND

Patients complain differently about their experiences of post-operative pain. However, clinicians are often guided by their own viewpoints despite the highly subjective nature of pain resulting in suboptimal post-operative pain management. This impacts negatively on the quality of life of patients in the immediate post-operative period. Investigating patients' pain behavior in the pre-operative period may therefore help to predict the intensity of post-operative pain, thereby assisting in identifying patients who are at risk of greater pain after third molar surgery, and allocating extra resources for pain control.

AIM

This study aims to predict the intensity of pain after third molar surgery by correlating post-operative pain perception with the sensory-discriminative dimension and affective response to a cold pressor stimulus.

MATERIALS AND METHODS

This study is a quasi-experimental study that was conducted in the oral surgery clinic of (name of hospital in the title page). The procedure was undertaken in an isolated clinic cubicle with well-controlled room temperature and minimal distraction. Study participants were recruited by convenience sampling. Forty-three consenting participants, 20 years and above, who met eligibility criteria were subjected to pre-operative cold pressor testing. Subsequently, third molar surgery was done and post-operative pain intensity was recorded at specific intervals. Data analyses were completed using IBM SPSS version 25. The Kolmogorov-Smirnov (KS) test was used to test for normality of continuous variables. Ordinal regression was used to test for contributory value of pre-operative measurement while Spearman's rank correlation test was used to test their degree of relationships with post-operative pain P < 0.05.

RESULT

The median pain threshold was 20 s (Interquartile Range, IQR 12.75-32.25) and the median pain tolerance was 33 s (IQR = 23.00-54.00) from the cold pressor test. The peak median pain score in this study was reached at 3-h after the last stitch. There was a statistically significant predictive effect of both variables on post-operative pain at 3-h.

CONCLUSION

Sensory-discriminative dimension and affective response to cold pressor test are significant predictors of peak post-operative pain after impacted mandibular third molar surgery.

Evaluation of the effectiveness of tube drain on postoperative discomfort in mandibular third molar surgery: prospective randomized split-mouth study

INTRODUCTION

The present randomized split-mouth study aimed to investigate the clinical effectiveness of postoperative discomfort of the use of a surgical drain after lower third molar extraction.

MATERIALS AND METHODS

It was conducted a prospective randomized split-mouth study involving 30 patients with bilateral symmetric lower third molar. Each patient underwent two operations for the extraction of impacted teeth: test site (tube drain) and control site (conventional total closure of surgical flap), resulting in 30 cases in the test group, and 30 cases in the control group.Pain, swelling, and mouth opening were evaluated immediately before the surgeries, after 1, 3 and 7 days postoperatively in both groups. Data were analyzed with non-parametric test (Kruskal-Wallis test and the post hoc Dun test, and Wilcoxon matched-pairs signed rank test).

RESULTS

Facial swelling (p < .001) was significantly less in test group compared with the control group on all examined days. Trismus is significantly reduced only on the third day (p < .001); Pain measurements did not differ statistically significantly between the two groups on all post-operative days (p > .05).

CONCLUSION

The use of the tube drain reduced facial swelling and trismus, but had no influence on the subjective perception of postoperative pain.

Comparison of two suture techniques on the inflammatory signs after third molars extraction-A randomized clinical trial

PURPOSE

Wound closure technique is an operative factor that influences early post-operative complications after third molar surgery. This study investigates and compared the effectiveness of two closure techniques, primary closure and healing by second intention of the oblique incision on postsurgical discomfort after mandibular third molar surgery.

MATERIALS AND METHODS

This is a prospective, randomized, double-blind, split mouth controlled trial. Surgical sites were divided into two groups Control group received simple sutures in both alveolar crest incision and oblique incision and intervention group received simple sutures in alveolar crest incision, while the oblique incision healed by second intention. All the patients were instructed to measure pain according to visual analogue scale (VAS) in postoperative period, swelling, mouth opening was assessed at 72h and 7 days after surgery. The wound healing was assessed on day 7.

RESULTS

Thirty-five patients, who had bilateral impacted third molars of similar surgical difficulty, were recruited. Thirty-one successfully completed the study. Patients in the second intention group had significantly less pain at 24h (p < 0.27). and 48h (< 0.001), had significantly less swelling (< 0.001) and trismus (< 0.001) and patients submitted to primary closure had a better evaluation of the Landry index (p < 0.001).

CONCLUSION

Healing by second intention of the oblique relaxing incision by partial surgical wound closure, in our study, were superior to the primary closure in reduction of post-operative pain, swelling and trismus.

TRIAL REGISTRATION

This trial is registered at Brazilian Registry of Clinical Trials-ReBEC -UTN: RBR-5fxbqsf (https://ensaiosclinicos.gov.br/rg/RBR-5fxbqsf).

Effect of manuka honey socket dressing on postoperative sequelae and complications following third molar extraction: A randomized controlled study

To evaluate the effect of manuka honey on the healing of mandibular third molar extraction sockets. This was a prospective randomized study at a tertiary health institution in Lagos, Nigeria. All extractions were transalveolar, using the distobuccal bone guttering technique. Participants were randomized into two study groups. Group A underwent intrasocket application of manuka honey, after which sockets were completely closed using the mucosal flap, while participants in group B underwent mucosal flap closure of the socket without application of manuka honey. The primary outcome was healing of the extraction socket at 7 days postoperatively. The secondary outcomes measured were postoperative sequelae, namely pain, swelling, and trismus on postoperative days 1, 3, and 7, and socket healing complications - specifically inflamed socket, infected socket, and alveolar osteitis. In total, 112 participants completed the study, with 56 participants per group. There were no significant differences in demographic variables between both groups. On the 7th day postoperatively, 26.8% of participants in group B had an unhealed extraction site, compared with 10.3% of participants in group A (p = 0.029). A significant difference was observed between pre- and postoperative pain scores in both study groups (p = 0.001). A comparison of postoperative mean facial swelling between the two groups showed no statistically significant differences on all the review days (p = 0.66). The difference in postoperative socket healing complication rate between both groups was statistically significant (χ² = 4.747, p = 0.029). Within the limitations of the study it seems that the application of manuka honey appears to aid earlier healing of the third molar extraction socket, with a significantly lower frequency of complications. Therefore, the application of manuka honey is recommended whenever appropriate.

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.

Local interventions for the management of alveolar osteitis (dry socket)

BACKGROUND

Alveolar osteitis (dry socket) is a complication of dental extractions more often involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively with or without halitosis, a socket that may be partially or totally devoid of a blood clot, and increased postoperative visits. This is an update of the Cochrane Review first published in 2012.  OBJECTIVES: To assess the effects of local interventions used for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction.

SEARCH METHODS

An Information Specialist searched four bibliographic databases up to 28 September 2021 and used additional search methods to identify published, unpublished, and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket postextraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques because these interventions are evaluated in separate Cochrane Reviews.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We followed Cochrane statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data, it was not possible to calculate RR so we calculated the exact odds ratio (OR) instead. We used GRADE to assess the certainty of the body of evidence.

MAIN RESULTS

We included 49 trials with 6771 participants; 39 trials (with 6219 participants) investigated prevention of dry socket and 10 studies (with 552 participants) looked at the treatment of dry socket. 16 studies were at high risk of bias, 30 studies at unclear risk of bias, and 3 studies at low risk of bias. Chlorhexidine in the prevention of dry socket When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and 24 hours after extraction(s) substantially reduced the risk of developing dry socket with an OR of 0.38 (95% CI 0.25 to 0.58; P < 0.00001; 6 trials, 1547 participants; moderate-certainty evidence). The prevalence of dry socket varies from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated (NNT) with chlorhexidine rinse to prevent one patient having dry socket was 162 (95% CI 155 to 240), 33 (95% CI 27 to 49), and 7 (95% CI 5 to 10) for control prevalence of dry socket 0.01, 0.05, and 0.30 respectively.  Compared to placebo, placing chlorhexidine gel intrasocket after extractions reduced the odds of developing a dry socket by 58% with an OR of 0.44 (95% CI 0.27 to 0.71; P = 0.0008; 7 trials, 753 participants; moderate-certainty evidence). The NNT with chlorhexidine gel (0.2%) to prevent one patient developing dry socket was 180 (95% CI 137 to 347), 37 (95% CI 28 to 72), and 7 (95% CI 5 to 15) for control prevalence of dry socket of 0.01, 0.05, and 0.30 respectively. Compared to chlorhexidine rinse (0.12%), placing chlorhexidine gel (0.2%) intrasocket after extractions was not superior in reducing the risk of dry socket (RR 0.74, 95% CI 0.46 to 1.20; P = 0.22; 2 trials, 383 participants; low-certainty evidence).  The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% chlorhexidine mouthrinses (alteration in taste, staining of teeth, stomatitis) though most studies were not designed explicitly to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket. Platelet rich plasma in the prevention of dry socket  Compared to placebo, placing platelet rich plasma after extractions was not superior in reducing the risk of having a dry socket (RR 0.51, 95% CI 0.19 to 1.33; P = 0.17; 2 studies, 127 participants; very low-certainty evidence).  A further 21 intrasocket interventions to prevent dry socket were each evaluated in single studies, and there is insufficient evidence to determine their effects. Zinc oxide eugenol versus Alvogyl in the treatment of dry socket Two studies, with 80 participants, showed that Alvogyl (old formulation) is more effective than zinc oxide eugenol at reducing pain at day 7 (mean difference (MD) -1.40, 95% CI -1.75 to -1.04; P < 0.00001; 2 studies, 80 participants; very low-certainty evidence) A further nine interventions for the treatment of dry socket were evaluated in single studies, providing insufficient evidence to determine their effects.

AUTHORS' CONCLUSIONS

Tooth extractions are generally undertaken by dentists for a variety of reasons, however, all but five studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is moderate-certainty evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, probably results in a reduction in dry socket. There was insufficient evidence to determine the effects of the other 21 preventative interventions each evaluated in single studies. There was limited evidence of very low certainty that Alvogyl (old formulation) may reduce pain at day 7 in patients with dry socket when compared to zinc oxide eugenol.

Clinical Evaluation of Intraoral Suture Patterns Using Poliglecaprone 25 in Greyhound Dogs

To evaluate healing and complications of extraction sites closed with a simple interrupted pattern (SI) and a simple continuous (SC) suture pattern in a prospective randomized clinical trial. Greyhounds were selected from a rescue with a standardized environment and naturally occurring disease. Surgical extractions were performed (35 sites) and all mucogingival flaps were closed with 4-0 poliglecaprone 25 using either SI or SC randomly assigned by surgical site. Oral healing/dehiscence, suture inflammation, suture loss, accumulation of debris, presence/nature of discharge, necrotic tissue and adjacent contact ulceration were evaluated. Fisher's exact test was used to compare categorical data and two-tail T tests used to compare continuous data. Results showed SC was faster to apply. No new dehiscence events were detected after Recheck 1. There was no significant difference for dehiscence scores between SI and SC. A trend was seen towards more major dehiscence in the SI group. This study concluded SC is an alternative to SI for closure of occlusal surfaces in the mouth. Mandibular canine tooth extraction sites were more likely to have a high dehiscence score than all other sites combined regardless of surgical technique.

Aetiology, Prevention and Management of Alveolar Osteitis-A Scoping Review

BACKGROUND

Alveolar osteitis (AO) is a poorly understood, common, painful complication following exodontia. It is sometimes managed by inappropriate prescription of antibiotics which contributes to the global threat of antimicrobial resistance. Use of intra-alveolar chlorhexidine also presents a serious risk of anaphylaxis to the patient.

OBJECTIVE

This scoping review aims to investigate the aetiology, prevention and management of AO and highlight the extent of inappropriate prescribing and intra-alveolar chlorhexidine use.

DESIGN

A scoping review was undertaken using the PRISMA guidelines. Medline, Ovid and Pubmed were searched between 2010 and 2020, from which 63 studies were selected for review that related to the aetiology, prevention or management of AO. Data were analysed for frequency of studies reporting information on risk factors for aetiology, prevention strategies and management including inappropriate management using antibiotic prescribing and intra-alveolar chlorhexidine.

RESULTS

Impaired immune response, surgical technique and age were identified as significant factors in the development of AO, while there is conflicting evidence regarding the effects of smoking and gender. With regard to prevention, the use of prophylactic antibiotics is not supported within the literature. Saline irrigation and eugenol pastes used preventively have been shown to be cheap and effective alternatives to chlorhexidine with no adverse effects. Hyaluronic acid and low-level laser therapies showed a significant reduction in pain and soft-tissue inflammation in the management of AO compared to Alveogyl.

CONCLUSIONS

Further understanding of the pathophysiology of AO is needed, in addition to large high-quality RCTs or long-term observational studies into the aetiology, prevention, and management of AO to produce up-to-date evidence-based clinical guidelines. Clinicians should also be mindful of their contribution to growing antimicrobial resistance and avoid inappropriate prescribing of antibiotics. Saline should replace chlorhexidine as the intra-alveolar irrigant of choice.

Third molar surgery: Past, present, and the future

Third molar surgery is the most common ambulatory procedure done by oral and maxillofacial surgeons. Surgical approaches for the removal of third molars have been published since the 20th century. This article reviews the history and development of extraction techniques through a literature review. The literature was selected through a search of an electronic database. Key words for the Medline search were "mandibular/maxillary third molar," "impacted mandibular/maxillary third molar," "mandibular/maxillary third molar flap design," and "mandibular/maxillary third molar incision." The search was restricted to English-language articles. Additionally, a manual search in the major oral surgery journals and books was performed. The aim of this article is to examine the evolution of third molar surgery, recognize pioneering techniques, and compare these techniques to current approaches. Common approaches employed today are discussed and treatment philosophies with thoughts for future therapies are provided.

Comparison of the Effect of Sling and Single Interrupted Sutures on Periodontal Parameters after Surgical Extraction of Impacted Mandibular Third Molars

Objectives:

This study aimed to compare the sling and single interrupted sutures regarding dehiscence, probing pocket depth (PPD), and clinical attachment loss (CAL) of adjacent second molars after surgical extraction of impacted or semi-impacted mandibular third molars.

Materials and Methods:

This randomized clinical trial, with a split-mouth design, involved 25 patients with similar bilateral impaction of their mandibular third molars. The same surgeon performed surgical procedures, including a triangular flap and osteotomy. After surgical extraction of third molars, the distal surface of the flap was sutured with sling sutures on one side and single interrupted sutures on the other side. The allocation of suture type to the side of the jaw was random, and the patient was blinded to it. Patients were examined for dehiscence after 7 and 14 days. The PPD and CAL were recorded at the baseline and after 17 weeks. Data were analyzed using the Wilcoxon signed-rank test and generalized estimating equation (GEE) regression model.

Results:

The sling suture was significantly superior regarding the improvement of PPD (P=0.041) and CAL (P=0.016). The dehiscence was significantly smaller in the single interrupted suture group 7 days postoperatively (P=0.059). This difference was not significant 14 says postoperatively (P=0.852).

Conclusion:

The results of this study show that the sling suture was superior to the single interrupted suture regarding PPD and CAL. However, the technique of suturing does not seem to have a significant long-term effect on wound dehiscence.

Postoperative effects of intra-alveolar application of 0.2% chlorhexidine or 1% hyaluronic acid bioadhesive gels after mandibular third molar extraction: a double-blind randomized controlled clinical trial

OBJECTIVE

The aim of this study was to analyze the postoperative effects of intra-alveolar applications of 0.2% chlorhexidine (CHL) or 1% hyaluronic (HA) acid bioadhesive gels following the extraction of mandibular impacted third molars (MITMs).

MATERIALS AND METHODS

In this double-blind randomized controlled clinical trial, 90 patients with one asymptomatic MITM were randomized into three group (n = 30 per group): group 1 (0.2% CHL), group 2 (1% HA), and group 3 (control). Visual analogue scales (VAS) were used to assess postoperative pain 24, 48, and 72 h and 7 days after surgery. Postsurgical complications were recorded: trismus, alveolitis osteitis, infection, or hematoma.

RESULTS

In order from least to greatest, postoperative pain at all evaluation times was 0.2% CHL < 1% HA < control. At 24 h, statistically significant differences were found between both study groups and the control groups (0.2% CHL/control: P = 0.001; 1% HA/control: P = 0.010). At 48 and 72 h, significant differences were only found between 0.2% CHL and the control group (P = 0.229 and P = 0.046, respectively). At 7 days, no significant differences were found between any groups. Comparing the incidence of postoperative trismus, alveolitis osteitis, infection, or hematoma, although complications were more frequent in the control group, no statistical differences between groups were found (P > 0.050).

CONCLUSIONS

Both 0.2% CHL and 1% HA bioadhesive gels applied intra-alveolarly minimize the postoperative complications after MITM extraction. Further research is necessary to confirm the present results.

CLINICAL RELEVANCE

This study might help to reduce the postsurgical complications in patients after MITM extraction.

Surgical techniques for the removal of mandibular wisdom teeth

BACKGROUND

Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short-term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity.

OBJECTIVES

To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth.

DATA COLLECTION AND ANALYSIS

Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel-group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross-over or split-mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split-mouth studies in our analyses, and combined parallel-group and split-mouth studies using the generic inverse-variance method. We used the fixed-effect model for three studies or fewer, and random-effects model for more than three studies.

MAIN RESULTS

We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low-certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low-certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low-certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low-certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand-piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low-certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low-certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low-certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low-certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low-certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported.

AUTHORS' CONCLUSIONS

In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future.

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.

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.

How effective is collagen resorbable membrane placement after partially impacted mandibular third molar surgery on postoperative morbidity? A prospective randomized comparative study

Background

Collagen membranes have some benefits include promoting wound healing through isolation, clot stabilization, wound stability, and hemostasis, enhancing primary wound coverage through its chemotactic ability to attract fibroblasts, and augmenting flap thickness by providing a collagenous scaffold. The purpose of this study was to compare primary and secondary healing and collagen membrane-based primary healing after surgical removal of partial impacted mandibular third molars, evaluating the incidence of postoperative complications and analyzing the swelling, mouth opening, and pain.

Methods

This was a prospective, randomized controlled study. Patients were randomly assigned to three groups: the SC (Secondary closure) group, the PC (Primary closure) group, and the MBPC (membrane based primary closure) group. Data were collected on pain, mouth opening, swelling, and complications experienced by the patients.

Results

There was no statistically significant difference between the groups for the pain (p > 0.05), relatively. The swelling recorded on postoperative days 2 and 7 was lower in the SC group than in the PC (p = 0.046 and 0.00) and in MBPC (p = 0.005 and 0.002) groups, respectively. Mouth opening showed a statistically significant difference between the three groups at day 2 (p = 0.00). Wound dehiscence was shown in 6 patients in the PC (20%) group and 2 patients in the MBPC (6.7%) group. Dry socket was observed 3 patients in the SC group (10%), 2 patients in the PC group (6.7%), and no dry socket in the MBPC group. No cases of infection or postoperative bleeding were encountered.

Conclusions

The secondary closure provides a marked advantage over the primary closure in terms of swelling and mouth opening. However, the absence of alveolitis in the primary closure using the collagen membrane and minimal wound dehiscence, suggests that membrane use may support primary healing in terms of wound healing.

A novel method in the removal of impacted mandibular third molar: buccal drainage

Food impaction after impacted mandibular third molar extraction is a serious problem that should not be ignored. Incomplete suturing of the distal incision in the conventional method is the main cause of food impaction and delayed wound healing. The present study introduces a novel suture and drainage technology that requires hermetic suturing of the distal incision and rubber drainage for buccal drainage. 76 patients with horizontally/mesially impacted third molars (bilateral) were enrolled in this prospective study. An impacted tooth on one side of each patient was extracted by occlusal drainage using the conventional method, whereas the other side tooth was extracted by buccal drainage using the novel method. The differences in wound healing, facial swelling, bleeding and dry socket between the two sides of each patient were compared postoperatively, and the trends for patient selection of the surgical method were also compared. The results indicated that buccal drainage had obvious advantages in wound healing and reduced the risk of postoperative bleeding, and most patients preferred this technique; there were no significant differences in postoperative facial swelling or pain. Thus, buccal drainage can solve the problem of long-term food impaction induced by traditional incision postoperatively and is worthy of clinical promotion.

Delayed onset infections after lower third molar germectomy could be related to the space distal to the second molar

The onset of delayed infection after lower third molar germectomy is influenced by the amount of distal space. This retrospective study aimed to determine whether the incidence of delayed onset infection is related to the space distal to the second molar. The ratio between the distal space and the crown width, measured according to the Ganss protocol on panoramic radiographs, was obtained for 218 surgical germectomies performed for orthodontic reasons in 134 patients. A delayed onset infection occurred following 20 germectomies at between 2 and 8 weeks after surgery; purulent exudates from the alveolus and swelling were present. In 16 of the 20 cases of infection, a Ganss ratio of <0.5 showed the almost complete absence of space distal to the second molar. This study found that the distal space was significantly and inversely correlated with delayed onset infection (P=0.004). From a clinical point of view, it is important for the surgeon to be aware that a higher Ganss ratio may indicate that a delayed onset infection is less likely to occur and that a lower Ganss ratio could indicate a greater likelihood of this type of infection, so that the patient can be properly informed.

Surgical Site Infections Following Bimaxillary Orthognathic, Osseous Genioplasty, and Intranasal Surgery: A Retrospective Cohort Study

PURPOSE

Frequency estimates of surgical site infection (SSI) after orthognathic surgery vary considerably. The purpose of this study was to determine the incidence and site of SSIs and associated risk factors after bimaxillary orthognathic, osseous genioplasty, and intranasal surgery.

MATERIALS AND METHODS

The authors executed a retrospective cohort study of patients with a bimaxillary developmental dentofacial deformity (DFD) and symptomatic chronic obstructive nasal breathing. All patients underwent at a minimum Le Fort I osteotomy, bilateral sagittal ramus osteotomies (SROs), septoplasty, inferior turbinate reduction, and osseous genioplasty. The primary outcome variable studied was the incidence and site of SSI. Predictor variables were type and extent of prophylactic antibiotic used, demographic (age and gender), and anatomic (pattern of DFD, surgical site, and presence of third molar).

RESULTS

Two hundred sixty-two patients met the inclusion criteria. Their average age at surgery was 25 years (range, 13 to 63 yr) and there were 134 female patients (51%). The major presenting patterns of DFD included long face (30%) and maxillary deficiency (25%). Forty percent of patients undergoing an SRO and 47% of those undergoing a Le Fort I osteotomy underwent simultaneous removal of a third molar. Ninety percent of patients received cefazolin or cephalexin antibiotics. Overall, 5 of 1,048 (0.5%) osteotomy sites sustained an infection, including 1 chin and 4 ramus SSIs. There were no delays in bone healing. Fixation hardware removal was not required in any patient who developed an infection. Two of the 25 patients (8%) given clindamycin prophylaxis developed an SSI, whereas 3 of 237 patients (1%) receiving cefazolin did. Three of the 4 patients who developed an SRO SSI underwent simultaneous removal of an erupted or partially erupted mandibular third molar (P < .05).

CONCLUSIONS

In this study, the incidence of SSI was limited to 1% of patients who were given cefazolin or cephalexin extended for 5 days. The removal of an erupted or partially erupted mandibular third molar in conjunction with an SRO was associated with risk of SSI, but the incidence remains low.

Postoperative socket irrigation with drinking tap water reduces the risk of inflammatory complications following surgical removal of third molars: a multicenter randomized trial

Objectives

The primary aim of the present study was to evaluate the effectiveness of postoperative irrigation of the socket with drinking tap water on inflammatory complications following lower third molar removal.

Material and methods

A multicenter randomized controlled trial was carried out from June 2013 to June 2014. In one arm of the study, patients were instructed to irrigate the tooth socket and surgical site with a Monoject® Curved 412 Tip Syringe (Tyco/healthcare-Kendall, Mansfield, MA, USA) with tap water. In a second arm of the study, the standard postoperative instructions did not include irrigation instructions. The incidences of alveolar osteitis and wound infection were recorded for each group and analyzed by the Fisher’s exact test.

Results

A total of 280 patients with 333 mandibular third molars were analyzed. According to the intention-to-treat (ITT) analysis, inflammatory complications occurred in 18 cases in the Monoject® group (11.4 %) compared to 34 cases (19.1 %) in the control group (p = 0.04). These complications were associated with significant worse outcomes regarding quality of life, pain, and trismus and caused significantly more missed days of work or study. Female gender, age >26, bone removal, deep impacted third molars, less experienced surgeons, and a high amount of debris at the surgical site were also identified as risk factors for developing inflammatory complications following lower third molar removal.

Conclusion

Irrigation of the surgical site with drinking tap water using a curved syringe following removal of third molars is effective in reducing the risk of inflammatory complications.

Clinical relevance

Water is a very accessible, cost-effective irrigant without side effects and the results from this study have proven that it can be used to reduce the risk of inflammatory complications and associated morbidity following lower third molar removal.

Effect of the suture technique on postoperative pain, swelling and trismus after removal of lower third molars: A randomized clinical trial

BACKGROUND

To evaluate the intensity of pain, swelling and trismus after the removal of impacted lower third molars comparing two different suture techniques of the triangular flap: the complete suture of the distal incision and relieving incision and the partial suture with only one suture knot for closure of the corner of the flap and the closure of the distal incision, without suturing the relieving incision.

MATERIAL AND METHODS

A prospective, randomized, cross-over clinical trial was conducted in 40 patients aged from 18 to 45 years who underwent surgical extraction of impacted lower third molars at the Department of Oral Surgery in the Odontological Hospital of the University of Barcelona during the year 2011. Patients were randomly divided in 2 groups. Two different techniques (hermetical closure and partial closure of the wound) were performed separated by a one month washout period in each patient. Postoperative pain, swelling and trismus were evaluated prior to the surgical procedure and also at 2 and 7 days postoperatively.

RESULTS

No statistically significant differences were observed for pain (p<0.06), trismus (p<0.71) and swelling (p<0.05) between the test and the control group. However, the values of the three parameters related to the test group were lower than those for the control group.

CONCLUSIONS

Partial closure of the flap without suturing the relieving incision after surgical extraction of lower third molars reduces operating time and it does not produce any postoperative complications compared with complete closure of the wound.

[Comparison between closure and absence of closure after removal of fully impacted mandibular third molar: a prospective randomized study]

We prospectively and randomly assessed the absence of surgical wound closure on the patient's postoperative outcome when removing impacted mandibular third molars.

MATERIAL AND METHOD

Patients were randomized in 2 groups: the "open group" (O) and the "closed group" (C). We considered the postoperative perimandibular edema, postoperative pain, and limitation of mouth opening at preoperative time, Day2, and Day7. The same physician performed all preoperative (D0) and postoperative measures (D2, D7).

RESULTS

Fifty-four patients (27 female and 27 male patients) were included in the study. Ninety-nine cases of impacted mandibular third molars were studied. The statistical analysis revealed a significantly more important postoperative edema in Group C at D2 (P<0.0001) and at D7 (P<0.0001). Postoperative mandibular pain was significantly greater in Group C at D2 (P<0.05) but not at D7 (P>0.05). The decrease of mouth opening was significantly more important in Group C at D2 and at D7 (P<0.05).

DISCUSSION

Our prospective randomized study data suggests a significant improvement of postoperative outcome when the mucoperiosteal flap was not sutured after removal of impacted third molars.

Surgical techniques for the removal of mandibular wisdom teeth

BACKGROUND

The surgical removal of mandibular wisdom teeth is one of the most common operations undertaken in oral and maxillofacial surgery. The most common indication for surgery is infection about a partially erupted tooth that is impacted against bone or soft tissues. Other indications include unrestorable caries, pulpal and periapical pathology, fracture of the tooth and cyst development, amongst others. Most commonly the benefits of surgical removal of a wisdom tooth include alleviation of the symptoms and signs of pericoronitis and its potential consequences. However, surgery is frequently associated with postoperative pain, swelling and trismus. Less commonly complications include infection, including dry socket, trigeminal nerve injuries and rarely fracture of the mandible.

OBJECTIVES

To compare the relative benefits and risks of different techniques for undertaking various aspects or stages of the surgical extraction of mandibular wisdom teeth.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 21 March 2014), CENTRAL (The Cochrane Library 2014, Issue 1), MEDLINE (OVID) (1946 to 21 March 2014) and EMBASE (OVID) (1980 to 21 March 2014). We searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for ongoing trials. There were no restrictions regarding language or date of publication in the electronic searches.

SELECTION CRITERIA

RCTs comparing surgical techniques for removal of mandibular wisdom teeth.

DATA COLLECTION AND ANALYSIS

Two review authors conducted assessment of relevance, risk of bias and data extraction. Study authors were contacted for additional information. RRs were used for dichotomous data and MDs for continuous data, unless the event rate was very low and Peto ORs were used. The pairing of the split-mouth studies was taken into account in the analysis for both dichotomous and continuous outcomes, and parallel group and split-mouth studies were combined using the generic inverse variance method. Random-effects models were used provided there were more than three studies (fixed-effect models otherwise).

MAIN RESULTS

A total of 35 trials (2569 patients) were included. The interventions under consideration fell into seven broad categories, with many comparisons including only a small number of trials. Twenty-one of the trials were assessed at high risk of bias, the remaining 14 as unclear. The results are described in the summary of findings tables.Triangular flaps were associated with a 71% reduction in alveolar osteitis at one week (RR 0.29, 95% CI 0.11 to 0.78; three trials, moderate quality) and reduction in pain at 24 hours (MD -0.21, 95% CI -0.32 to -0.10; two trials, moderate quality) compared with envelope flaps. There was no evidence of a difference in overall infection rates, in maximum mouth opening or in permanent sensation. However, there was some evidence that residual swelling after one week was slightly increased in the triangular flap groups compared to envelope flap types (MD 0.66 mm, 95% CI 0.26 to 1.07; two trials, low quality). We found no data on temporary sensation, or adverse events.There was low quality evidence from two studies, looking at the use of a retractor during third molar surgery, to indicate more cases of temporary altered sensation (up to one month) when a retractor was used (Peto OR 5.19, 95% CI 1.38 to 19.49; two trials, low quality). One study reported that this did not persist for more than six months in either group. We found no data for use of a retractor on other primary outcomes or adverse effects (including fracture of the mandible).Due to the small number of studies, the different comparisons evaluated, the variable outcomes reported and the paucity of useful data for all primary outcomes we were not able to draw any conclusions concerning bone removal in third molar surgery.There was insufficient evidence from single studies of very low quality on irrigation method (manual versus mechanical) or irrigation volume (low or high) to determine whether there were differences or not for the outcomes of alveolar osteitis or postoperative infection. We found no data for any of the other primary outcomes.There was insufficient evidence (low to very low quality) that any wound closure technique (primary versus secondary) was superior to another for the outcomes of alveolar osteitis, postoperative infection or maximum mouth opening achieved after seven days, or reactionary bleeding. There was evidence that secondary wound closure was associated with reduced pain at 24 hours (MD 0.79, 95% CI 0.35 to 1.24; four trials, moderate quality) and slightly reduced swelling after one week (MD 0.33, 95% CI 0.09 to 0.57; seven trials, moderate quality).We found no data on other primary outcomes.There was some evidence that the use of a surgical drain was associated with less postoperative swelling (MD -0.90, 95% CI -1.62 to -0.19; five trials, moderate quality) and greater maximum mouth opening one week after surgery (MD 3.72 mm, 95% CI 2.84 to 4.59; two trials, moderate quality). There was insufficient evidence from a single study (low quality) to determine whether the presence of a drain made any difference to pain at 24 hours postoperation. There were no data for the other primary outcomes.Although two RCTs compared coronectomy with complete extraction, flaws in the design and the unit of analysis of these studies meant that there were no reliable data available for inclusion.

AUTHORS' CONCLUSIONS

The thirty-five included trials looked at a range of different surgical techniques. The comparisons related to seven broad aspects of the surgical procedures for impacted mandibular third molars: type of surgical flap raised, use of retractors, techniques for bone removal, wound irrigation, wound closure, wound drainage, and complete/incomplete tooth removal. The quality of the body of evidence for each of these comparisons was very low to moderate due to the small number of trials and patients, and the majority of the trials being at high risk of bias (65%) with the remainder at unclear risk of bias.The evidence for making changes to surgical practice is therefore limited. However, it is useful to describe the state of the research evidence supporting practice so that surgeons can make an informed choice in adopting new techniques, or continuing with established techniques.

Local interventions for the management of alveolar osteitis (dry socket)

BACKGROUND

Alveolar osteitis (dry socket) is a complication of dental extractions and occurs more commonly in extractions involving mandibular molar teeth. It is associated with severe pain developing 2 to 3 days postoperatively, a socket that may be partially or totally devoid of blood clot and in some patients there may be a complaint of halitosis. It can result in an increase in postoperative visits.

OBJECTIVES

To assess the effects of local interventions for the prevention and treatment of alveolar osteitis (dry socket) following tooth extraction.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 29 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10), MEDLINE via OVID (1946 to 29 October 2012) and EMBASE via OVID (1980 to 29 October 2012). There were no restrictions regarding language or date of publication. We also searched the reference lists of articles and contacted experts and organisations to identify any further studies.

SELECTION CRITERIA

We included randomised controlled trials of adults over 18 years of age who were having permanent teeth extracted or who had developed dry socket post-extraction. We included studies with any type of local intervention used for the prevention or treatment of dry socket, compared to a different local intervention, placebo or no treatment. We excluded studies reporting on systemic use of antibiotics or the use of surgical techniques for the management of dry socket because these interventions are evaluated in separate Cochrane reviews.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook risk of bias assessment and data extraction in duplicate for included studies using pre-designed proformas. Any reports of adverse events were recorded and summarised into a table when these were available. We contacted trial authors for further details where these were unclear. We followed The Cochrane Collaboration statistical guidelines and reported dichotomous outcomes as risk ratios (RR) and calculated 95% confidence intervals (CI) using random-effects models. For some of the split-mouth studies with sparse data it was not possible to calculate RR so we calculated the exact odds ratio instead. We used the GRADE tool to assess the quality of the body of evidence.

MAIN RESULTS

Twenty-one trials with 2570 participants met the inclusion criteria; 18 trials with 2376 participants for the prevention of dry socket and three studies with 194 participants for the treatment of dry socket. The risk of bias assessment identified six studies at high risk of bias, 14 studies at unclear risk of bias and one studies at low risk of bias. When compared to placebo, rinsing with chlorhexidine mouthrinses (0.12% and 0.2% concentrations) both before and after extraction(s) prevented approximately 42% of dry socket(s) with a RR of 0.58 (95% CI 0.43 to 0.78; P < 0.001) (four trials, 750 participants, moderate quality of evidence). The prevalence of dry socket varied from 1% to 5% in routine dental extractions to upwards of 30% in surgically extracted third molars. The number of patients needed to be treated with (0.12% and 0.2%) chlorhexidine rinse to prevent one patient having dry socket (NNT) was 232 (95% CI 176 to 417), 47 (95% CI 35 to 84) and 8 (95% CI 6 to 14) for control prevalences of dry socket of 1%, 5% and 30% respectively.Compared to placebo, placing chlorhexidine gel (0.2%) after extractions prevented approximately 58% of dry socket(s) with a RR of 0.42 (95% CI 0.21 to 0.87; P = 0.02) (two trials, in 133 participants, moderate quality of evidence). The number of patients needed to be treated with chlorhexidine gel to prevent one patient having dry socket (NNT) was 173 (95% CI 127 to 770), 35 (95% CI 25 to 154) and 6 (95% CI 5 to 26) for control prevalences of dry socket of 1%, 5% and 30% respectively.A further 10 intrasocket interventions to prevent dry socket were each evaluated in single studies, and therefore there is insufficient evidence to determine their effects. Five interventions for the treatment of dry socket were evaluated in a total of three studies providing insufficient evidence to determine their effects.

AUTHORS' CONCLUSIONS

Most tooth extractions are undertaken by dentists for a variety of reasons, however, all but three studies included in the present review included participants undergoing extraction of third molars, most of which were undertaken by oral surgeons. There is some evidence that rinsing with chlorhexidine (0.12% and 0.2%) or placing chlorhexidine gel (0.2%) in the sockets of extracted teeth, provides a benefit in preventing dry socket. There was insufficient evidence to determine the effects of the other 10 preventative interventions each evaluated in single studies. There was insufficient evidence to determine the effects of any of the interventions to treat dry socket. The present review found some evidence for the association of minor adverse reactions with use of 0.12%, 0.2% and 2% chlorhexidine mouthrinses, though most studies were not designed to detect the presence of hypersensitivity reactions to mouthwash as part of the study protocol. No adverse events were reported in relation to the use of 0.2% chlorhexidine gel placed directly into a socket (though previous allergy to chlorhexidine was an exclusion criterion in these trials). In view of recent reports in the UK of two cases of serious adverse events associated with irrigation of dry socket with chlorhexidine mouthrinse, it is recommended that all members of the dental team prescribing chlorhexidine products are aware of the potential for both minor and serious adverse side effects.