Postoperative recovery after mandibular third molar surgery. By Dr. Akhila Damodar { dr.akhila.n@gmail.com } This study sought to evaluate postoperative recovery after mandibular third molar surgery, with and without the use of sutures.

1. Postoperative recovery after mandibular
third molar surgery: a criteria for selection
of type of surgical site closure
Neeliahgari Durga Akhila Damodar, BDS, MDS n
Hanumanthaiah Nandakumar, MDS
Narashimha Murthy Srinath, MDS, FDSRCS, FIBOMS
This study sought to evaluate postoperative recovery after mandibular third
molar surgery, with and without the use of sutures.The study utilized 50
healthy subjects (19 females and 31 males, 18-40 years of age) with bilateral
impacted third molars.Two impacted teeth were removed from each patient
(60 min maximum operating time). For each patient, the surgical site on one
side of the mouth was closed for primary healing by using nonresorbable
sutures, while the surgical site on the other side of the mouth was left open
for secondary healing. Postoperative recovery was assessed by determining
pain (using a visual analog scale) and swelling (by measuring anatomical
landmarks pre- and postoperatively on Days 2, 5, and 7) Any incidence of
socket infection and hemorrhage were considered to be complications.
Both statistical analysis and clinical observation showed that the
surgical sites with nonresorbable sutures showed greater swell-
ing and a higher intensity of pain than the surgical sites without
sutures; however, there were no statistical or clinical differences in
pain and swelling postsurgery at Day 7. The results suggest second-
ary closure (that is, without sutures) after third molar surgery will
produce less postoperative discomfort than primary closure (with
nonresorbable sutures).
Received: December 6, 2011
Accepted:April 2, 2012
T
hird molars are present in 90% of the
population; among those, 33% have
at least one impacted third molar.1
Although extraction is a relatively common
procedure, an unknown percentage of
unerupted third molars may remain asymp-
tomatic throughout life.1
Conversely, some
third molars lead to complications such as
cellulitis or cystic lesions and subsequent
removal. The pathologic potential for
cyst development may be used to war-
rant removal of even asymptomatic third
molars.2
Impacted third molars frequently are
associated with recent acute inflammatory
episodes.3
It is possible that the chemi-
cal mediators of inflammatory response
render tissues more sensitive to nociceptive
stimuli. In areas already sensitized by
prostaglandins, subsequent inflammatory
mediators cause intense pain.3
Surgical removal of impacted third
molars usually leads to pain, swelling,
and dysfunction during the postoperative
period. The factors that contribute to this
situation begin with the inflammatory
process initiated by surgical trauma.4
A
socket closed with nonresorbable sutures
may break down and heal by secondary
closure.5
This study compares postopera-
tive recovery with and without sutures
by monitoring the extent of swelling and
the intensity of pain experienced at the
primary and secondary closure sites.
Material and methods
Medical audits have established the need
for systematic and precise evaluation of
the quality, quantity, and effectiveness of
all patient treatment. Phillips et al used
health-related quality of life (HRQOL)
outcomes to evaluate risk factors associated
with prolonged recovery and delayed heal-
ing after the removal of wisdom teeth.6
This study drew from 50 patients who
were treated by the same oral surgeon and
surgical assistant under identical clinical
conditions (Table 1). None of the patients
had any clinical infection at the operative
sites or elsewhere in the oral and pharyn-
geal cavities. The patients were neither
given preoperative antibiotics, nor did they
take any medications that might have influ-
enced the operative or postoperative course.
Analgesia was achieved by using an
inferior alveolar and buccal nerve block,
together with infiltration of the retro-
molar trigone mucosa (using two 1.8 ml
cartridges of 2% lignocaine containing
1:80,000 adrenaline) for one side of the
mouth. The same analgesia was obtained
for the other side of the mouth by using a
bilateral nerve block.7
The mucoperiosteal
flap was raised following a V-shaped
incision that extended distally from the
mesial corner of the second molar to the
retromolar trigone region (Fig. 1).8
This
V-shaped incision was proposed by Waite
& Cherala in their study as one that
promises better postoperative recovery
with minimal patient discomfort.8
Bone
Table 1. Distribution of patients based on age and gender.
Gender
Age
<20 yrs
% (n)
20-25 yrs
% (n)
26-30 yrs
% (n)
30-35 yrs
% (n)
36-40 yrs
% (n) Total
Male 6.5 (2) 25.8 (8) 35.5 (11) 22.6 (7) 9.7 (3) 100 (31)
Female 5.3 (1) 57.9 (11) 15.8 (3) 15.8 (3) 5.3 (1) 100 (19)
Total 6.0 (3) 38.0 (19) 28.0 (14) 20.0 (10) 8.0 (4) 100 (50)
Exodontia
www.agd.org General Dentistry May/June 2013 e9

2. was removed with round burs and straight
fissure burs in a high-speed handpiece.9
The wound was irrigated with chlorhexi-
dine.10
One surgical site was closed for
primary healing, while the other site was
left open for secondary healing (Fig. 2).
Prior to surgery, the following clinical
and radiographic variables were recorded:
patient age; degree of eruption; tooth
position [that is, relation of the tooth to
the ramus mandible (Pell and Gregory
Class I, Class II) and position of the tooth
in relation to the long axis of the second
molar (vertical, horizontal, mesioangu-
lar)]; and facial measurements [horizontal
(distance from corner of mouth to attach-
ment of the ear lobule following bulge
of the cheek) and vertical (distance from
the outer canthus of the ear to angle of
the mandible)] (Fig. 3). Class III dis-
toangular impacted teeth were excluded
from this study.
Evaluation criteria
For Group 1 samples, the surgical wound
on 1 side was closed primarily with non-
resorbable sutures; Group 2 samples on
the other side of the mouth were allowed
to heal secondarily without sutures. The
patients were kept under observation for
24 hours postsurgery, with follow-up
examinations 2, 3, and 7 days postsurgery.
Table 2. Visual analog scale.
Grade
0 No pain The patient feels well.
1 Slight pain If the patient is distracted, he/she does not feel the pain.
2 Mild pain The patient feels pain while concentrating on some activity.
3 Severe pain The patient is very disturbed but can continue normal activity.
4 Very severe pain The patient is forced to abandon normal activity.
5 Extremely severe pain The patient must abandon every type of activity and
feels the need to lie down.
Table 3. Pain analysis in Groups 1 and 2.
Time Group Mean pain SD Minimum Maximum t value P value
Preoperative 1 0 0 0 0
2 0 0 0 0
6 hours
postoperative
1 4.88 0.328 4 5 2.966 0.088
2 4.98 0.247 4 6
Day 1 1 4.28 0.536 3 5 12.544 0.001
2 3.96 0.348 3 5
Day 2 1 3.6 0.571 2 4 89.132 0
2 2.48 0.614 2 4
Day 3 1 2.94 0.767 1 4 2.526 0.115
2 2.3 2.742 1 21
Day 4 1 2.38 0.805 0 4 2.847 0.095
2 1.64 2.995 0 22
Day 5 1 1.82 0.774 0 3 70.038 0
2 0.7 0.544 0 2
Day 6 1 1.42 0.702 0 3 107.692 0
2 0.22 0.418 0 1
Day 7 1 1.2 0.7 0 3 104.018 0
2 0.1 0.303 0 1
Unit of pain as defined per VAS (Table 2). Minimum = lowest value of pain recorded in group.
Maximum = highest value of pain recorded in group.
Exodontia Postoperative recovery after mandibular third molar surgery: a criteria for selection of type of surgical site closure
e10 May/June 2013 General Dentistry www.agd.org
Fig. 3.An illustration of anatomical landmarks to
assess swelling. Image courtesy of Dr. Daniel M. Laskin.
Fig. 2.An intraoperative view of a patient showing
both surgical sites.
Fig. 1.An illustration of a V-shaped incision. Image
courtesy of Dr. Peter D.Waite.

3. A descriptive visual analog scale (VAS) was
used and each patient was given a feedback
form to grade their discomfort. (Table 2).
Swelling was evaluated by the oral surgeon
after measuring anatomical facial land-
marks (Fig. 3). The feedback sheets were
then reviewed, along with clinical exami-
nation of the surgical sites. The feedback
sheets were given to the patient for timed
recording of comfort status in relation to
pain, the same recordings were used for
statistical analysis. The swelling was evalu-
ated by the surgeon to ensure appropriate
date calculation.
Statistical method
Descriptive analysis (with mean and stan-
dard deviations) were computed to find the
significance of VAS and extent of swellings
between the 2 groups. One-way analysis
of variance (ANOVA) and Chi-square
(c2) tests were utilized. Statistical software
(SPSS) was used in analysis of the data
to determine the significance of VAS and
extent of swellings between the 2 groups.
The significant figures were determined to
be suggestive significance (0.05 < P < 0.10),
moderate significance (0.01 < P ≤ 0.05),
and strongly significant (P ≤ 0.01).
Statistical analysis
A suitable ANOVA model for repeated
measures was used to compare the varia-
tion of VAS values in the 2 groups at each
follow-up visit. Mean facial swelling
values were obtained at each follow-up
visit. The preoperative and subsequent
postoperative values on Days 2, 5, and 7
were compared.
Results
There were significant differences in the
severity of pain between the 2 groups, at
all recorded times using a VAS (Table 3).
The decrease in pain over time was also
significantly different in the 2 groups.
Intensity of pain was greater in the Group
1 site (primary healing) postoperatively
at 6 hours, Day 1, Day 2, and Day 3
(Table 4). Based on the statistical data,
the P values suggest that there was signifi-
cantly better pain relief on the surgical site
that healed by secondary healing (Group
2) than primary healing (Group 1). That
is, better pain relief was recorded in Group
2 from Day 1 (Chart 1).
Variation in swelling over time differed
in the 2 groups (Chart 2), especially on
Days 3 and 5. Swelling was more severe
in Group 1, with a peak of swelling being
recorded on Day 3. In Group 2, the sever-
ity of swelling had a much smaller peak
than Group 1, even on Day 3 (Table 5).
There was a statistically significant dif-
ference in swelling (Table 5) between the
2 groups at all times recorded (Table 6).
There were some postsurgical complications
in Group 2, including 4 patients who com-
plained of food lodgment over the second-
ary closure and 1 case of hemorrhage over
the secondary closure. There was no inci-
dence of alveolar osteitis in either group.
Discussion
The literature offers conflicting opinions
concerning primary healing, with some
authors reporting that primary healing
frequently causes greater pain and swell-
ing compared to secondary healing.11,12
Any categorical study on pain requires
reliable and sensitive methods for record-
ing pain intensity. For the present study,
a self-explanatory descriptive VAS was
used to record postoperative pain. This
scale has been widely used in the mea-
surement of subjective responses.11-13
Postoperative pain has been discussed
in several comprehensive studies of
complications following the extraction of
impacted mandibular third molars.14
Previous studies also have used VAS to
record pain intensity.11,15
A 1983 study by
Stephens et al compared 2 types of access
flaps used when removing impacted
mandibular third molars.16
In that
study, ANOVA indicated no significant
difference between the 2 flap techniques,
indicating that the technique is deter-
mined by operator preference.16
Because chlorhexidine is active against
yeast—as well as aerobic, anaerobic,
gram-negative, and gram-positive
organisms—rinsing and irrigation with
chlorhexidine (both preoperatively and
during surgery) is likely to reduce con-
tamination of the surgical site.10
The length of extraction is a poor
indicator of the level of surgical trauma
produced.3
The amount of time that it
Table 4. Significance of VAS pain
scores between Groups 1 and 2 at
different time intervals.
Score time P value Significance
6 hours
postoperative
0.088 Strongly
significant
Day 1 0.001 Strongly
significant
Day 2 0 Strongly
significant
Day 3 0.115 Suggestive
significance
Day 4 0.095 Suggestive
significance
Chart 1. Comparison of mean pain scores between
Group 1 and Group 2 at different time intervals.
6
5
4
3
2
1
0
Pre-op 6 hours Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
post-op
Painscore(VAS)
Group 1
Group 2
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4. takes an experienced clinician to remove
an impacted third molar has no dis-
cernible bearing on postoperative pain,
regardless of the invasiveness or the length
of surgical procedure. Swelling, pain, and
trismus are frequent sequlae following the
trauma of oral surgery.15
Cold dressings,
antibiotics (such as tetracycline), steroids
(particularly methylprednisolone), medi-
cated dressing, and NSAIDs have been
utilized in response to these sequelae.16-19
As pharmacological activity has some side
effects, the present study sought to reduce
postoperative swelling by using alternate
methods of wound closure.
Based on the literature, the sample
size of the present study made it pos-
sible to detect statistical differences
in patient responses to the closure
techniques.8,12,15,17,20-23
Furthermore, the
research design allowed each subject to
serve as his or her own control, which
limited the variance that would have
resulted from different cases and control
patients. Accordingly, this aspect made it
possible to detect true differences in the
treatment effects. The degree of edema
and severity of pain are the primary
indicators of a patient’s comfort. The
findings of the present study suggested
that the secondary closure sites were
more comfortable during the first 5
postoperative days, as no difference was
observed in terms of patient discomfort
between the 2 surgical sites at Days 6
and 7. During the immediate postopera-
tive period, there was a greater degree of
edema and hematoma formation at the
primary closure sites when compared
to the secondary closure sites. Szmyd
recommended open techniques and
reported reductions in edema and pain.22
As guided by a pilot study before the
commencement of this study, the muco-
periosteal flap used was ineffective in
surgical removal of Pell & Gregory Class
III, position c (distoangular impacted)
teeth. Therefore, it was decided that since
the V-shaped flap used in the present
study would be ineffective for Class III
distoangular impacted teeth, these teeth
were not used in this study.
In 2012, a study evaluated periodontal
status distal to the second molar and
proved that a secondary closure after
third molar surgery does not lead to any
periodontal pockets.23
A 2006 study by
Waite & Cherala used a V-shaped inci-
sion and found no periodontal defects
during postoperative healing.8
In the
flap technique used in their study, the
attached gingiva was not pulled up
tightly behind the second molar, and this
flap design did not create postoperative
complications, such as the loss of clot
leading to hemorrhage, exposure of the
bone, sensitivity, and/or food lodgment
when allowed to secondarily heal without
suturing the mucosal flaps. It seems that
a tight closure over a large bony socket
or defect does not facilitate drainage
and wound cleansing in cases of food
lodgments. The present study compared
primary and secondary healing after sur-
gical removal of impacted third molars,
evaluating the incidence of postoperative
complications, and the extent of swelling
and severity of pain following a V-shaped
incision.8
The flap design used in the
present study was smaller than that rec-
ommended by Waite & Cherala and did
not require suturing, essentially leaving
an open area (one that did not require a
distal wedge) over the socket for second-
ary healing.8
The V-shaped incision also
facilitated draining of the tissue fluids,
thus reducing postoperative swelling.
Table 6. Significance of differences
in swelling between Groups 1 and 2
at different time intervals.
Score time P value Significance
Day 3 0.004
Strongly
significant
Day 5 0.002
Strongly
significant
Day 7 0.426
Suggestive
significance
Table 5. Assessment of swelling.
Time Group
Mean Swelling
(cm) SD
Minimum
(cm)
Maximum
(cm) t value P value
Preoperative 1 10.875 0.72325 9.45 12.0 0.114 0.736
2 10.924 0.72529 9.8 12.0
Day 3 1 11.899 0.60756 10.75 12.95 8.634 0.004
2 11.504 0.73101 10.25 12.7
Day 5 1 11.492 0.61123 10.3 12.75 10.104 0.002
2 11.088 0.65881 10.05 12.45
Day 7 1 11.043 0.74485 9.95 12.45 0.639 0.426
2 10.925 0.73159 9.45 12.0
Two components were used to calculate swelling values: the vertical component and the horizontal component, per
anatomical landmarks (Fig. 3). The mean value of both were calculated for Groups 1 and 2.
Chart 2. Comparison of
mean swelling scores (in cm)
between Group 1 and Group 2
at different time intervals.
12
11.8
11.6
11.4
11.2
11
10.8
10.6
10.4
10.2
Pre-op Day 3 Day 5 Day 7
Swelling(cm)
Group 1
Group 2
Exodontia Postoperative recovery after mandibular third molar surgery: a criteria for selection of type of surgical site closure
e12 May/June 2013 General Dentistry www.agd.org

5. Conclusion
Based on the results of the present study,
it can be concluded that when removing
impacted third molars, open (secondary)
healing of surgical wounds produce less
postoperative swelling and pain than closed
(primary) healing by hermetically suturing
the socket (in cases of equal intraopera-
tive difficulty). The present study avoided
patient bias, as each patient served as both
the case and control groups. Secondary
closure appears to minimize immedi-
ate postoperative edema and pain, thus
enhancing patient comfort. In addition,
it is easier for a patient to manage the
postoperative care and hygiene of a second-
ary closure site compared to a primary
closure site. A long-term study is needed
to evaluate periodontal status distal to
the second molar.
Author information
Dr. Damodar is a senior lecturer, Depart-
ment of Oral and Maxillofacial Surgery,
VIDS and Research Centre, Bangalore,
India, where Dr. Nandakumar is a profes-
sor and head of the Department of Oral
and Maxillofacial Surgery, and Dr. Srinath
is a professor.
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