The Effect of Sutureless Surgery on Postoperative Pain and Swelling Following Mandibular Third Molar Surgery

Introduction

Extraction of impacted teeth is one of the most common operations in oral and maxillofacial surgery. Adjacent teeth and hard and soft tissue barriers are the most common reasons of impaction. As a principle, an impacted tooth must be extracted unless it causes undesirable side effects (1).

The most common impacted teeth are maxillary and mandibular third molars, maxillary canines and mandibular premolars. Since third molars erupt after other teeth, probable lack of space and impaction is more possible than others. The best extraction time is in 17-20 (1).

The side-effects of surgical extraction can be divided into immediate injuries and post-operative complications. Soft tissue trauma, trauma to the adjacent structure and extraction complications are some of the immediate injuries. Post operation complications include bleeding, dehiscence, infection and dry socket (1).

Since most patients avoid surgery because of complications like pain and edema, surgeons have always sought to use techniques to decrease these complications. Inflammation is one of the natural mechanisms of the human body to harm or cell death, which shows up with redness, heat, pain and swelling. A huge amount of inflammatory cytokines like histamine, bradykinin, serotonin and other chemical cytokines are released after a trauma. These chemical cytokines especially histamine, increase blood stream and permeability of vessels in the hurt area, which results in accumulation of exudates and pain and swelling (1).

There are some methods to facilitate the exudates drainage such as drain placement or partial suturing or sutureless technique.

Materials and Methods

This study was an randomized clinical trial in which 19 referred patients to Mashhad dental faculty who had bilaterally impacted third molar with similar estimated removal difficulty entered the study. Exclusion criteria included presence of pathologic lesion in the area, soft tissue impaction and presence of any medical or psychological problem. The ethics committee approved the study design and ensured that consent was obtained from the patients.

A checklist was improvised with two parts; one for demographic information and medical history and the other for surgical information. In the demographic part age, sex and systemic diseases were recorded. In the surgical information pre-operation factors, the distance between tragus to oral commissure, was recorded. A 100mm scaled ruler was used as visual analogue scale (VAS) in which (0) denoted “no pain” and 100 meant “severe pain”. The investigator registered these data in the first, third and seventh days after operation. The same prescribed analgesic was used in equivalent sequences. Tragus to oral commissure distance was recorded using a flexible ruler in order to evaluate inflammation in the first, third and seventh day of surgery. First, patients received oral hygiene instruction and scaling and root planning. Then, all the patients underwent the surgery in same protocol: prep and drape was done. Lingual and inferior alveolar and long buccal nerves were anesthetized using 2%Lidocaine and 1:100000 epinephrine (Ultracaine; Dental forte;,Frankfurt/Main,Germany). After elevation of triangular mucoperiosteal flap, the bone was removed by round bur No.8 and fissure bur No.730 under constant irrigation with sterile normal saline. After extraction, curettage and cleansing was done using a 60ml sterile normal saline rinse. Control site sutured using 3.0 silk (fig. 1) but in study site the flap deflected to its own place for secondary wound healing (fig. 2). Sterile gauze pad, saturated with normal saline, was placed over the wound and patients received written and oral post-operative instructions and a prescription for medication. Cold compress was used immediately every 15 minutes to 5 hours. Ibuprophen (400mg tablets) four times daily and Amoxicillin (500mg capsules) three times daily were prescribed for five days to all patients. There was a one-month interval between the two operations (study and control site).

All patients were recalled to the dental department to evaluate the healing procedure, pain and swelling on the first, third and seventh days of surgery. All patients were advised to confer with dental department in case of severe and progressive pain in the first week after surgery. The data were analyzed statistically with paired t-test and performed using statistical package for social science (SPSS 8.0).

Figure 1. Suture in control side

Figure 2. Triangular incision in study side

Results

19 healthy patients( 8male ,11female)  with bilateral impacted teeth participated in this randomized clinical trial, by which the subjects served as their own control and their Pain and swelling was evaluated on the first, third and seventh days of operation. The mean age was 26.6±4.4 (range: 18 to 32).

There was no statistically significant difference in pain and swelling in both groups (p=0.16) on the first day but it was significantly lower in study group in the third and seventh days after surgery (p<0.001, p=0.001) (table1). The pain increased from the first to the third day and decreased from the third to the seventh day (figure 3) but its decrease was much greater in the study group (p<0.001). Swelling in control group increased between the first to the third day and decreased from the third to the seventh day but it was statistically significant (p=0.002)(figure 4). Swelling in the study group increased between the first to the third day but it decreased from the third to the seventh day and it was statistically significant (p<0.001). Pain from day 1 to 7 was not statistically different in both genders but swelling was much more in the male group (p<0.001).

Table1.  Pain and swelling comparison between two groups