Accepted Manuscript

The effect of one-suture and suture-less techniques on post-operative healing

following third molar surgery.

Dr. Saleh Alkadi, BDS(Hons), MFDS RCSI, D.Ch.Dent, FFD RCSI, Prof. Leo Stassen,
FRCS(I), FDSRCS, MA, FTCD, FFSEM, FFDRCSI, FICD

PII: S0278-2391(18)31298-9
DOI: https://doi.org/10.1016/j.joms.2018.12.001
Reference: YJOMS 58543

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 21 March 2018

Revised Date: 26 October 2018
Accepted Date: 1 December 2018

Please cite this article as: Alkadi S, Stassen L, The effect of one-suture and suture-less techniques on
post-operative healing following third molar surgery., Journal of Oral and Maxillofacial Surgery (2019),
doi: https://doi.org/10.1016/j.joms.2018.12.001.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT
Title: The effect of one-suture and suture-less techniques on post-operative healing
following third molar surgery.

Author: Dr. Saleh Alkadi BDS(Hons), MFDS RCSI, D.Ch.Dent, FFD RCSI
Specialist Oral Surgeon, Dept of Oral and Maxillofacial Surgery, St. Finbarr's
Hospital, Cork, Ireland.
Email: alkadis@tcd.ie
Tel: +353860875470

PT
Co-author: Prof. Leo Stassen FRCS(I), FDSRCS, MA, FTCD, FFSEM, FFDRCSI, FICD
Professor/Chair of Oral and Maxillofacial Surgery, Dept of Oral and

RI
Maxillofacial Surgery, St James's Hospital, Dublin 8, Ireland; Department of Oral and
Maxillofacial Surgery, Dublin Dental University Hospital, Lincoln Place, Dublin 2, Ireland.

U SC
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
Abstract
Objective: Wound closure technique for lower third molar surgery (LTMS) is an operative
factor that influences wound healing and early post-operative complications. This study
investigates two closure techniques; partial closure using one suture and the suture-less
technique, after using a modified buccal envelope flap for LTMS.

PT
Materials and methods: This is a prospective, randomized, double-blind, split mouth
controlled trial. Partial closure using one suture was compared to the suture-less technique.

RI
Surgical sites were divided into two groups, Group A: one suture, and Group B: suture-less.
Each patient received both treatments at the same time. During the first post-operative week,

SC
all patients were asked to daily assess pain, facial swelling, and bleeding, using self-
assessment scales. All patients attended follow-up appointment at one week, to objectively

U
assess facial swelling and wound healing, and at one month, to assess wound healing.
AN
Analysis of data was carried out using the statistical package SPSS (IBM SPSS Statistics 24).
A p value ≤ 0.05 was accepted as statistically significant.
M

Results: Thirty- seven patients, who had bilateral impacted third molars of similar surgical difficulty,
were recruited. Thirty-four successfully completed the study. The results showed a statistically
D

significant difference between the two techniques in a) post-operative pain at day five (p =
TE

0.046), and six (p = 0.034), b) socket healing at one week (p = 0.002), and one month (p =
0.014), and c) soft tissue healing at one week (p = 0.016).
EP

Conclusion: One-suture technique for LTMS is superior to the suture-less technique in

reduction of post-operative pain, and improving wound healing during early post-operative
C

period. There is no difference between the two techniques in reduction of post-operative

AC

swelling.
 ACCEPTED MANUSCRIPT

Introduction

Lower third molar surgery is one of the most common surgical procedure in oral and

maxillofacial surgery.[1] As for any other surgical procedures, it has its own risks and post-

PT
operative complications, that influence the recovery period, and affect the patient’s quality of

RI
life.[2, 3] Pain, limitation of mouth opening, and clinical evidence of facial swelling have a

significant effect on the oral health related quality of life during the immediate post-operative

SC
period.[4] Wound healing after lower third molar surgery has a significant clinical

importance for the clinician, as delayed healing and wound dehiscence make hygiene more

U
difficult and may require more intense follow-up treatment, which potentially extends the
AN
time of post-surgical care.[5]
M

The type of healing of the surgical wound is one of the factors most closely linked to post-

operative complication, following lower third molar surgery. [6] There are two mechanisms
D

for healing in the surgical site that can take place, primary or secondary. The type of wound
TE

healing is determined by the closure technique utilized, and the number of sutures used by the

surgeon. In secondary healing, a communication between the socket and the oral cavity is
EP

maintained by using no suture, or by closing the flap partially, using a small number of
C

sutures.[7-19] This secondary healing could also be achieved by removing a wedge of

AC

mucosa over the extraction socket. [6, 20-25] In primary healing, the socket is closed

completely (primary closure/complete closure), with the overlying mucosal flap hermetically

sealed, to achieve primary healing of the socket. A surgeon uses two to three sutures to

achieve this primary closure, and, sometimes, a modification to the flap design is necessary to

facilitate advancing the flap over the extraction socket. [13, 15, 20, 21] Placement of a
 ACCEPTED MANUSCRIPT
dressing, or insertion of a drain into the lower third molar surgical wound have been used to

modify wound healing, and alleviate post-operative complications. [26-29]

Surgeons in favor of primary closure claim that it decreases the risk of post-operative

infection, while those who are supporting secondary closure suggest that it allows for better

drainage of inflammatory exudates, which results in reduced pain, and less swelling. [30]

PT
This conflicting opinions have evolved into a wide variety of partial closure techniques, that

RI
have been tested, and compared to the traditional complete closure technique in several

recent clinical trials. [30]

SC
The purpose of this study was to investigate the effect of a partial wound closure technique,
using different number of sutures, on post-operative complications, following lower third
molar surgery. We hypothesized that there is no difference between using one suture after

U
lower third molar surgery and suture-less lower third molar surgery, in terms of degree of
wound healing and post-operative complications. The specific aims of the study were to
AN
compare the two techniques in terms of the following outcomes: 1) post-operative pain
during the first week, 2) post-operative facial swelling during the first week, 3) wound
healing at one week and at one month post-surgery, 4) periodontal condition of the adjacent
M

lower second molar at one month, 5) post-operative bleeding during the first week, and 6)
post-operative infection and dry socket during the first week.
D
TE

Materials and Methods

Ethical approval for this clinical trial was granted from SJH/AMNCH Research Ethics Joint
EP

Committee in Ireland.
C

Sample and study design

AC

In order to investigate the effect of wound closure technique, through using

different number of sutures, on the post-operative complications, following lower third
molar surgery, we carried out this prospective, randomised, double-blind, split-mouth
controlled study. The study population was composed of all patients who require the removal
of both lower third molars only, at the Department of Oral and Maxillofacial Surgery in the
Dublin Dental University Hospital between May 2016 and April 2017. who require the
removal of both lower third molars only. To be included in the study sample, patients had to
fulfil the following requirements:
1) Patient is suitable for treatment under local anesthetic with intravenous conscious dental

sedation
 ACCEPTED MANUSCRIPT
2) Full thickness mucoperiosteal flap required, with bone removal, with or without tooth

sectioning for removal of both lower third molars, which have similar eruptive state and

similar difficulty

3) ASA Grade I or II

4) No known congenital or acquired bleeding tendency

PT
5) Aged between 18 and 45

RI
6) Participants, who are willing to cooperate with the requirements of the study protocol.

Patients were excluded as study subjects if :

SC
1) patient does not want to take part in the study, or is unable to give informed
consent for the procedure involved
2) patient does not require the removal of both lower third molars in line with NICE

U
guidelines
3) patient is not suitable for treatment under local anaesthetic with intravenous
AN
conscious sedation.
4) patient has a medical condition that could be complicated by the procedure (ASA
>II).
M

5) Surgery does not require a full thickness mucoperiosteal flap or bone removal.
6) patient is under 18 years of age or over 45 years of age.
7) patient is pregnant or a nursing mother.
D

8) patient who has an allergy or cannot tolerate the antibiotic and the analgesics used
in the study.
TE

Surgical sites were randomized into one of two Groups using random-numbers table
EP

generated using a random sequence generator: Group A: Sites received one suture, and Group

B: suture-less sites.
C
AC

Power calculation

The sample size in previous similar published studies have ranged from 19 to 50 patients,

with an average of 37 patients, who required 74 surgical removals of lower third molars [9-

12]. In order to detect a difference in the mean change in pain severity and facial swelling

between the two treatment groups, a Power Calculation has shown that at least thirty-one
 ACCEPTED MANUSCRIPT
participants with sixty-two surgical sites, were needed to achieve an Alpha of 0.05 and Power

of at least 0.9.

Variables and outcomes measurement

Demographic variables

PT
The following demographic variables were collected : age, gender, body mass index (BMI),
smoking status, ASA grade, OCP use, and ethnicity distribution within the study population.

RI
Primary subjective outcomes

SC
All participants were questioned as close as possible to post-operative hour 12, 24 and then

daily up to the seventh day from completion of the surgery using a standardized

U
questionnaire, to assess post-operative bleeding, post-operative discomfort, post-operative
AN
swelling, and the patient adherence to the use of post-operative medications and mouth rinse.
M

The degree of pain and discomfort was rated by the participant for each side using an eleven-

point Numeric Rating Scale (NRS) where 0 indicates “no pain” and 10 indicates worst
D

imaginable pain (Fig.1). [31] The degree of facial swelling for each side was also evaluated
TE

by the participants using six-point Visual Analogue Scale (VAS), where 0 indicates “no

swelling”, and 5 indicates “extreme severe swelling” (Fig. 2).[32] The degree of bleeding
EP

was evaluated for each side by counting the number of gauzes needed to stop bleeding on the
C

day of surgery and the following post-operative days. Also, participants recorded the day on
AC

which they felt bleeding had stopped completely.

Primary objective outcomes

Facial swelling was evaluated using the method described by Montebugnoli et al in 2004, and

by Szolnoky et al in 2007 [33, 34]. In this method the patient is placed in neutral head
 ACCEPTED MANUSCRIPT
position, six baseline linear measurements are recorded in (mm) on each side of the face by

using a special measuring tape to measure the linear distances between six reproducible

anatomical landmarks (Fig. 3).[35] One examiner recorded all measurements for all

participants pre-operatively, and at one week post-operatively. The difference between the

two reading was used to give an objective evaluation of the amount of residual facial

PT
swelling, at one week post-operatively.

RI
Three clinicians, who are specialist oral-maxillofacial surgeons, evaluated the post-operative

wound healing independently. All clinicians were informed of the study protocol, and were

SC
calibrated, and trained on using the indices according to the description of the evaluation

criteria using clinical photos. All clinicians were independent observers and were not

U
involved in any aspects of the surgical procedure, or site allocation to either group.
AN
Agreement on evaluation was achieved between the assessors when they were asked to assess
M

the same patient. The surgeon, who performed the surgery, removed the suture before the

other assessors carried out the wound healing assessment.

D

The degree of socket epithelization was graded by the examiner at one week and one month
TE

post-operatively using standardized tick sheet (Fig. 4).

The extent of soft tissue healing at the surgical site was evaluated at one week post-
EP

operatively using the Healing Index for Soft Tissue by Landry in 1985. [36] This index
C

grades healing into five grades, depending on the color of tissues, epithelialization of wound
AC

margins, presence of bleeding on palpation, granulation, and suppuration (Fig. 5).

One examiner carried out periodontal examination for lower second molar using a William’s

probe. Pocket depth (PD) and Clinical Attachment Level (CAL) were recorded at three

buccal sites; mesio-buccal, mid-buccal and disto-buccal. All measurements were recorded

pre-operatively, and at one month post-operatively.

 ACCEPTED MANUSCRIPT
Secondary outcomes

Operative time

The duration of surgery for each side was recorded in minutes, which corresponded to the

period between starting the incision and placement the suture in Group A, and between

starting the incision and replacing the flap to its original position in Group B.

PT
Surgical difficulty

RI
The difficulty level of the surgery as perceived by the surgeon, was rated by the surgeon

at the completion of each surgery using a four-point category rating scale: low, medium,

SC
difficult, and very difficult. Also, the level of surgical trauma was recorded based on three

grade difficulty scale: easy, medium, and difficult.

U
AN
Surgical protocol
M

Each participant underwent surgical removal of bilateral lower third molars only, under local

anesthetic and IV conscious sedation, at the same operative visit. All procedures were
D

performed by the same surgeon (3rd Specialist Registrar in Oral Surgery), and under similar
TE

operative conditions. Each participant received the following pre-operative oral medications:

amoxicillin 500 mg, paracetamol 1 g, ibuprofen 400 mg and 10 mL of 0.2% chlorhexidine

EP

mouth wash.
C

In theatre, and immediately before the removal of both lower third molars, the surgical sites
AC

were allocated to the two intervention groups using the aforementioned randomization

method. This allocation was carried out by a nurse and was informed to the surgeon

immediately before starting the surgery. Additionally, a coin was tossed to randomly

determine which side the surgeon would start the surgical procedure on. Heads indicated the

right side, and tails indicated the left side. After IV access was established using a 22G or a

20 G cannula, a conscious sedation agent, midazolam, was administered incrementally and

 ACCEPTED MANUSCRIPT
titrated against the patient’s response. Surgical drapes were placed with the patient’s eyes

totally covered. Anesthesia was achieved using lidocaine hydrochloride 2% with epinephrine

1:80,000. Two 2.2 mL cartridges were administered – one for the inferior alveolar and lingual

nerves, and one for buccal nerve. A buccal envelope flap using Stassen’s modification (Fig.

6) was raised through crevicular incision from the distal of the third molar to the papilla

PT
between the first and second molar, including the papillae between the first, second and third

RI
molars. A small distal reliving incision was made from the position that the distobuccal cusp

of the third molar would occupy if the tooth were in a vertical position to a maximum of 5

SC
mm in length. Lingual nerve protection, when needed, was provided by raising a lingual flap

using a Mitchell’s trimer and protected using a Howarth’s retractor as advised by Rogers and

U
Stassen [37]. Bone removal was carried out using a tungsten carbide fissure bur (HP Oral
AN
Surgery TF 702, DENTSPLY, Switzerland), in a straight handpiece, under sterile 0.9 normal
M

saline continuous irrigation. When necessary, sectioning of the crown and roots was

performed. Once the tooth removal has been completed, removal of granulation tissue and
D

gentle curettage of the socket were carried out, and followed by gentle irrigation using a
TE

twenty-mL sterile saline wash. The flap was then repositioned. Surgical sites in Group A

received one suture just distal to the lower second molar placed through the buccal and
EP

lingual papilla (Ethicon, 3-0 coated vicryl rapide W9935, Johnson & Johnson, Belgium) (Fig.
C

7). Surgical sites in Group B did not receive any suture. Direct pressure was applied to the
AC

surgical site using sterile gauze moistened with 0.9 normal saline. Once the first site had

been completed, the surgeon performed the surgical removal on the opposite side using the

same technique. For each surgical site, the operator recorded operative details, operative

time, perceived level of difficulty, and degree of surgical trauma using a three-grade

difficulty scale described by O’Neill and Stassen in 2014 (Fig. 8).[38] Post-operatively,

participants were instructed to use the following oral medications: amoxicillin 500 mg, three
 ACCEPTED MANUSCRIPT
times daily for five days, paracetamol 1 g and ibuprofen 400 mg, six hourly for three days,

and then as needed. They were also instructed to use chlorhexidine mouth wash 0.2%, 10mL,

once daily, and salty mouth rinse, three times daily, for one week. Patients were reviewed at

one week, and one month following the procedure.

PT
Statistical methods

RI
Analysis of data was carried out using the statistical package SPSS (IBM SPSS Statistics 24).

A p value ≤ 0.05 was accepted as statistically significant. A Wilcoxon Signed Ranks Test was

SC
used to assess for differences in pain and swelling, as rated by the patient, between the two

groups. It was also used to assess for the difference between the two groups in socket healing

U
and soft tissue healing. A McNemar’s Test was used to assess differences in food
AN
impaction. Dependent t-tests were conducted to assess for difference in swelling measured at
M

one week, bleeding, and a change in periodontal condition for lower second molar. We used

Spearman Rho Correlation test rather than multivariate analysis, to assess the effect of
D

surgical difficulty and operative time on the measured outcomes, as the use of multivariate
TE

analysis requires a larger sample size.

EP

Results
C

Sample size and characteristics

AC

Out of 37 participants enrolled in this trial, 35 participants underwent bilateral lower third

molar surgeries. Two were excluded, and one was lost at one month follow-up. Of those, who

were excluded, one was excluded as surgical procedure of one side took longer time than

usual, and the surgery on the other side was postponed, another participant was excluded, as

one of the inclusion criteria was lost on the day of surgery.

 ACCEPTED MANUSCRIPT

The sample consisted of 25 females, and ten males, with an age range of 18 to 37, and a mean

age of 26.6 (SD = 4.85). BMI of participants ranged from 18.7 to 39.9 (M = 25.25, SD =

4.87). All patients but one were Caucasian (97%) and one (3%) was Afro-American.

Twenty-nine patients (83%) were ASA grade I, while six patients (17%) were graded ASA II.

PT
Seven patients (20%) were regular smokers. Of the female participants, ten (40%) were on

RI
the contraceptive pills. The use of the split-mouth design created no statistically significant

difference between the two investigated groups in age, gender, BMI, OCP use, smoking, and

SC
ASA grade.

U
The mean operative time for the sutured side was 21.5 minutes with a range of 7 to 36
AN
minutes; while the mean operative time for the suture-less side was 19.5 minutes with a range
M

of 7 to 50 minutes. There was no statistical significant difference in operative time between

the sutured side (M = 21.49, SD = 7.83) and the suture-less side (M = 19.51, SD = 9.15), t
D

(34) = 1.022, p = 0.314. There was also no statistical significant difference in surgical
TE

difficulty between the two investigated groups (z = -0.660, p = 0.505).

EP

Dry socket and infection

C

Seven cases of dry socket were reported in this clinical trial (10%), three patients developed
AC

bilateral dry sockets, and one patient suffered dry socket at the suture-less side. No cases of

infection arouse during the evaluation period.

 ACCEPTED MANUSCRIPT
Post-operative pain

There was a statistically significant difference in post-operative pain between the two groups

on the fifth day, z = -1.99, p = 0.046, and on the sixth day, z = -2.12, p = 0.034. Pain severity

was greater on the non-sutured side (Table. 1; Fig. 9). The results of Spearman Correlation

(Table. 2) indicate that, as the difference in the degree of surgical difficulty increased, so did

PT
the difference in severity of pain from day one to day six. In addition, as the difference in

RI
operative time increased, so did the pain severity at five of the seven measurement periods.

SC
Facial swelling

For post-operative facial swelling as perceived by the patient, there were no differences

U
between the sutured and non-sutured sides at all evaluation days (all p > 0.05) (Table. 3; Fig.
AN
10). The results of Spearman Correlation (Table. 4) indicate that the greater the difference
M

between sutured and non-sutured sides in operative time and degree of surgical difficulty, the

greater the difference in post-operative swelling perceived by the patient on day one through
D

six (all p <0 .05). For post-operative facial swelling measured at one week, there was no
TE

significant differences between the suture and non-suture conditions at all measured lines (all

p >0 .05) (Table. 5; Fig. 11).

C EP

Post-operative bleeding
AC

There were no significant differences in the number of gauzes required to address the

bleeding (all p >0 .05). There was also no significant difference in the duration of bleeding,

t(34) = -1.14, p = 0.263( Table. 6).

Wound healing
 ACCEPTED MANUSCRIPT
For socket healing, there was greater degree of healing for the sockets under the suture

condition when compared to the non-suture condition at one week, z = -3.10, p = 0.002, and

one month z = -2.45, p = 0.014 (Fig.12; Fig.13). Also, surgical sites evidenced a greater level

of soft tissue healing at one week under the suture condition, z = -2.41, p = 0.016 (Fig.14).

The results of Spearman Rho Correlation showed no relationship between operative time or

PT
surgical difficulty, with degree of socket and soft tissue healing (all p >0 .05). Although non-

RI
suture sites showed more food impaction than sutured sites at one week and one month, there

was no significant difference between the two conditions at one week, p = 0.508 and at one

SC
month, p = 1.00. There were no differences between the two conditions in the three measures

of periodontal status for lower second molar at one month, all p >0 .05 (Table. 7).

U
AN
Discussion
M

Closure technique is an operative factor that has been linked to early post-operative

complications after lower third molar surgery. [21, 26] When compared to primary closure,
D

secondary closure techniques have shown better reduction in post-operative pain [6, 8-12, 14-
TE

17, 19-27, 39], post-operative swelling [6, 8-14, 17, 19-27, 39], and trismus [8, 14-17, 22-24,

27, 39, 40] following lower third molar surgery.

EP

Suture-less technique, a relatively new secondary closure technique, has shown good
C

outcomes following lower third molar surgery. [7] Regardless of the flap design used for
AC

lower third molar surgery, suture-less technique has proven to be superior to primary closure

technique in reducing post-operative pain, swelling, and trismus. [8-12, 39] In addition to its

desirable effect on post-operative complications, suture-less technique decreases surgical

time, minimizes the trauma resulting from soft tissue manipulation, and decreases direct

costs. [7]

In this clinical trial, we investigated the effect of closure technique on post-operative

 ACCEPTED MANUSCRIPT
complications, and wound healing following lower third molar surgery. We compared

two secondary closure techniques; partial wound closure using one suture and the suture-less

technique, after using a modified buccal envelope flap for accessing lower third

molar surgery.

PT
Post-operative pain

RI
In this clinical trial, we used an 11-point Numeric Rating Scale (NRS), to assess pain

severity, at seven different time points- hour twelve, day one, two, three, four, five and six.

SC
The validity of this pain scale has been demonstrated and proven to correlate significantly

with other pain scales such as the Visual Analogue Scale (VAS).[41-44] In addition to its

U
easy administration to the patient, it is more useful than other scales for audit ,and research.
AN
[45]
M

Across seven evaluation time points in this clinical trial, the pain intensity was reported to be
D

a maximum at twelve hours post-operatively, this is in agreement with findings from several
TE

studies in the literature which suggest that pain following lower third molar surgery reaches

its maximum intensity in the first twelve hours. [46]

C EP

The difference in pain scores between the two techniques from day one to day four was not
AC

significant (p > 0.05) in this clinical trial. This is in agreement with the findings by De

Brabander and Cattaneo in 1988, who compared two secondary closure techniques; wedge

mucosa excision to wedge mucosa excision with tube drain, and found no statistical

significant difference in pain intensity at day two and day seven between the two techniques.

[47] This could be explained by the fact that acute inflammatory response peaks within
 ACCEPTED MANUSCRIPT
seventy-two hours after the surgery and then diminishes gradually, and in both techniques,

there is an outlet for these inflammatory mediators to be washed out.

The results of this clinical trial demonstrated a significant difference in the median pain

scores, between the two closure techniques, at day five and day six post-operatively (p ≤

PT
0.05). Greater pain scores were reported in the suture-less sides at day five (p = 0.046) and

RI
day six (p = 0.034). This could be related to the delayed wound healing being observed in the

suture-less sites at one week following the surgery. Delayed healing could result in a longer

SC
period of discomfort and continuous pain which is caused by hypersensitivity in the exposed

distal root surface of the adjacent second molar. [5]

U
AN
M

In previous studies, the suture-less technique has been found to have a decreased pain

intensity during the early few days following lower third molar surgery when compared to
D

primary closure. [8-12, 39] These findings have been also reported when the one-suture
TE

technique is compared to the primary closure technique, one suture technique has

demonstrated significant reduction in pain intensity during the first seventy-two hours after
EP

the surgery. [14] However, there are no previously published studies comparing the suture-
C

less technique to the one-suture, or other secondary closure techniques.

AC

Post-operative swelling

There are different methods described in the literature to measure facial swelling following

third molar surgery, some of them are easy to use, while the others are sophisticated or too

complex for clinical use.[6] These methods use either subjective or objective evaluation.
 ACCEPTED MANUSCRIPT
Objective methods used in previous studies include photographic techniques [48], Magnetic

Resonance Imaging (MRI) [49], stereo-photographic techniques [50, 51], ultrasound [52],

facebow apparatus [26], cephalostat [32], 3-D optical scanning technique [53], and

craniometrics measurements using different methods. [35, 47, 54] In 1982, Dubois et al used

a two-grade scale as a self-assessment method by the patient to measure the swelling

PT
following lower third molar surgery. A few years later, Henrikson et al in 1985 proposed the

RI
use of VAS as a subjective method to measure facial swelling, when they compared the effect

of two anti-inflammatory drugs, on the post-operative complications, following lower third

SC
molar surgery.[55] This self-assessment method has been proven to be reliable and accurate

in assessing facial swelling, when compared to observer assessment [56], or 3-dimesional

U
mechanical measurement using an extra-oral cephalostat. [32] In later clinical trials,
AN
subjective evaluation of swelling by the patient has been utilized using different scales, for
M

measuring facial swelling, following lower third molar surgery. [6, 19, 20, 22, 24, 25, 28, 57]
D

In this clinical trial, we used two methods to evaluate facial swelling; 1) objective method to
TE

measure swelling at one week time using craniometrics measurements described by

Montebugnoli et al in 2004 [33] and used also by Szolnoky et al in 2007 [34], and 2) a
EP

subjective self-assessment method using VAS described by Berge [32] , to assess swelling
C

from post-operative day one to day six by the patient.

AC

In the present study, the reported facial swelling reaches its maximum at forty-eight hours

post-operatively, these results match those observed in earlier studies, which suggest that

facial swelling following lower third molar surgery reaches its maximum intensity at forty-

eight hours following the surgery. [14, 16, 19, 29, 58-60]
 ACCEPTED MANUSCRIPT
The result of this clinical trial revealed no significant difference between the two techniques

in facial swelling as measured by the patient from day one to day six (p > 0.05). Also, there

was no significant difference between the two techniques in the objective facial swelling

measurements at one week (p > 0.05). These results are consistent with those of De

Brabander and Cattaneo in 1988, who compared two secondary closure techniques, and

PT
found no statistical significant differences in facial swelling at day two, and day seven

RI
between the two techniques. [47] A possible explanation for this might be that both

techniques investigated in the present study have an outlet for the accumulated fluids and the

SC
inflammatory exudates to escape, which results in reduced post-operative facial swelling.

[30]

U
AN
Several studies have reported significantly less post-operative facial swelling in suture-less
technique when compared to primary wound closure following lower third molar surgery. [8-
M

12, 39] This significant reduction in facial swelling has been also reported in the one-suture
technique when compared to the primary closure technique, where the former has shown
significant reduction in facial swelling during the first seventy-two hours after lower third
D

molar surgery. [14] Although these findings have been also reported when other partial
closure techniques are compared to primary closure [13, 17, 19], other studies showed no
benefits of secondary closure over primary closure technique in reducing facial swelling
TE

following lower third molar surgery. [15, 16, 18, 40]

EP

Wound healing

Different methods have been used in the literature to assess wound healing following lower
C

third molar surgery, these methods include: recording dehiscence at the incision lines [6, 21,
AC

24], time to achieve satisfactory healing [24, 26], mucosal attachment level and periodontal

health around the adjacent lower second molar [11, 15, 21], presence of infection or dry

socket [6, 11, 20, 21, 39, 57, 61], the need for additional treatment [26], food debris

lodgment, and cleansablility of the extraction socket. [9, 21, 23, 39]
 ACCEPTED MANUSCRIPT
Unlike the previously mentioned studies, which did not use specific scale to assess wound

healing, Rakprasitkul and Pairuchvej in 1997, described a four-grade index to assess wound

healing following lower third molar surgery, this index depends on degree of wound

breakdown, and exposure of the extraction socket. [28]

PT
The wound healing in the present clinical trial was assessed by measuring different clinical

RI
parameters. The parameters comprise degree of socket healing, soft tissue healing, presence

of infection or dry socket, presence of food impaction within the socket, and periodontal

SC
health at the buccal site of the adjacent lower second molar.

U
The assessment of socket healing was carried out using a five-grade index to measure the
AN
degree of socket epithelization, which was designed specifically for the purpose to be used by
M

investigators in this study.

D

The results of this trial demonstrated a statistically significant better socket healing on sites
TE

received one suture, at one week (p = 0.002) and one month (p = 0.014) following lower third

molar surgery. Incision line dehiscence and flap displacement were reported at one week
EP

post-operatively in five suture-less flap (14.3%) and one sutured flap (2.9%).
C
AC

The degree of soft tissue healing at the surgical site was evaluated using Landry’s index [36],

in which each surgical site is given a score from one to five , the higher the score the better

the healing of soft tissue at that surgical site. The results of this study showed a statistically

significant better soft tissue healing at one week post-operatively, on sites received one

suture, compared to suture-less sites (p = 0.016).

 ACCEPTED MANUSCRIPT
There are no previous published studies in the literature comparing wound healing between

secondary closure techniques. Some investigators reported better wound healing associated

with primary closure, when compared to various secondary closure techniques [21, 24, 26],

Rakprasitkul and Pairuchvej in 1997 reported no difference in wound healing, when

compared primary closure alone to primary closure with tube drain placement.[28]

PT
RI
Seven cases of dry socket were reported in this clinical trial (10%), three patients developed

bilateral dry sockets, and one patient suffered dry socket at the suture-less side. No cases of

SC
infection arouse during the evaluation period. When compared to primary closure technique,

Hashemi et al in 2012 reported no dry socket in the suture-less group, or the primary closure

U
group [11], Ricard et al in 2015 reported two cases of dry socket and two cases of infection in
AN
the primary closure group, and no cases reported in the suture-less group. [39]
M

Interestingly, a study by Akota et al in 1998 reported a significant increase in dry socket

incidence when the wound closed primarily, when compared to the wounds that received
D

gauze drain. [57]

TE

A few studies have reported a higher incidence of food impaction in the suture-less technique
EP

[9, 39], and other secondary closure techniques [23], when compared to primary closure.
C

The results of this trial showed no significant difference between the two techniques with
AC

food impaction within the socket at one week (p = 0.508) and one month (p = 1.00) post-

operatively.

Looking at the periodontal condition buccal to the adjacent lower second molar at one month

following the surgery, there were no statistically significant differences in the change from

pre-operative values of the pocket depth (p = 0.484), and clinical attachment level (CAL) (p
 ACCEPTED MANUSCRIPT
= 0.875) between the two groups. Comparing suture-less technique to primary closure at six

month following lower third molar surgery, Hashemi et al in 2012 reported no significant

change in pocket depth around the lower second molar from pre-operative value on either

technique. [11] Interestingly, three months following lower third molar surgery, Xavier et al

in 2008 reported greater pocket depths at three sites on the buccal surface of lower second

PT
molar in primary closure compared to secondary closure, and this difference was statistically

RI
significant at one site. [15]

SC
Post-operative bleeding

A subjective method was used to compare post-operative bleeding between the two

U
techniques in this clinical trial. The patient was asked to count the number of gauzes used to
AN
stop bleeding, for each surgical site, on each day post-operatively, also, the patient reported
M

the time needed to achieve a bleeding-free surgical site. The results of this trial showed no

significant difference between the two techniques in post-operative bleeding. There were no
D

reported cases of excessive bleeding that needed any intervention through a local dentist or
TE

the emergency department at the dental hospital. These results are in line with those observed

by Hashemi et al in 2012, who reported no cases of excessive bleeding, when they compared
EP

the suture-less technique to the primary closure. [11] The same observation was reported by
C

Pasqualini et al in 2005, who compared secondary closure to the primary closure technique,
AC

they reported no cases of hemorrhage in either technique.[6] Contrary to Pasqualini et al ,

Bello et al in 2011 reported a significant higher incidence of reactionary bleeding at forty-

eight hours in the secondary closure technique cases when compared to primary closure. [13]
 ACCEPTED MANUSCRIPT
Using a four-grade scale to measure post-operative bleeding , Rakprasitkul and Pairuchve in

1997 reported less bleeding in patients who received a tube drain when compared to patients

receiving primary closure only. [28]

Effect of surgical difficulty and operative time

PT
In this clinical trial, we were able to demonstrate a strong correlation between the level of

RI
surgical difficulty measured on the difficulty index and the operative time measured in

minutes. This finding seems to be consistent with other research, which stated that the

SC
duration of lower third molar surgery reflects its level of difficulty [62, 63], and hence

operative time has been used in several studies as a tool to measure the difficulty of surgery.

[3, 64-67]
U
AN
M

The results of this trial showed that, as the difference in the degree of surgical difficulty

increased between lower third molar surgeries, so did the difference in severity of post-
D

operative pain from day one to day six. In addition, as the difference in operative time
TE

increased, so did the pain severity at five of the seven measurement periods.

This agrees with most of the studies, which reported increased pain severity and discomfort
EP

when lower third molar surgery takes longer time [13, 47, 68-71], and when the lower third
C

molar surgery reaches a higher level of difficulty. [70, 72-74]

AC

The results demonstrate that differences in operative time and degree of surgical difficulty are

related to differences in post-operative swelling; the greater the difference between lower

third molar surgeries in operative time and degree of difficulty, the greater the difference in

post-operative swelling. These results are in keeping with previous studies, which showed
 ACCEPTED MANUSCRIPT
more post-operative swelling in difficult lower third molar surgery [75], or when surgery

takes longer time. [76, 77]

Limitations and future direction

One of this study limitations is the short follow-up period which was not long enough to

PT
fully assess the periodontal condition around the lower second molar. We were unable

RI
to measure the PD and CAL at the distal site of the second molar as the wound healing

has not been completed at one month time following the surgery. Ideally, an additional

SC
three to six-month follow-up appointment is required to investigate the periodontal

condition at the distal surface of the lower second molar. We were also unable to investigate

U
the effect of the two closure techniques on the post-operative trismus, as both treatments were
AN
carried out at the same time. A clinical trial of parallel-group design is required in order to
M

investigate the effect.

D

Conclusion
TE

The results of this trial demonstrated that post-operative pain and wound healing are

influenced by the type of the closure technique used by the surgeon. The results also showed
EP

that operative time and difficulty of surgery have an impact on the severity of post-operative
C

complication.
AC

The results of this clinical trial suggest that the placement of one suture, distal to the lower

second molar, after raising a buccal envelope flap (Stassen modification) for lower third

molar surgery, is superior to the suture-less technique, in decreasing post-operative pain and

enhancing wound healing. Further research is required to compare the one-suture technique

to suture-less technique and to the primary closure technique. A multi-centric, double blind

trial with large cohort size, and split-mouth design would be the ideal.
 ACCEPTED MANUSCRIPT

References:

1. Jerjes W, Upile T, Nhembe F, Gudka D, Shah P, Abbas S, McCarthy E, Patel S, Mahil J,

Hopper C: Experience in third molar surgery: an update. Br Dent J 209:E1, 2010

2. Colorado-Bonnin M, Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C: Quality of

PT
life following lower third molar removal. International journal of oral and maxillofacial

RI
surgery 35:343, 2006

3. White RP, Jr., Shugars DA, Shafer DM, Laskin DM, Buckley MJ, Phillips C: Recovery

SC
after third molar surgery: clinical and health-related quality of life outcomes. J Oral

U
Maxillofac Surg 61:535, 2003
AN
4. McGrath C, Comfort MB, Lo EC, Luo Y: Changes in life quality following third molar

surgery--the immediate postoperative period. Br Dent J 194:265, 2003

M

5. Jakse N, Bankaoglu V, Wimmer G, Eskici A, Pertl C: Primary wound healing after

D

lower third molar surgery: Evaluation of 2 different flap designs. Oral Surgery, Oral
TE

Medicine, Oral Pathology, Oral Radiology, and Endodontology 93:7, 2002

6. Pasqualini D, Cocero N, Castella A, Mela L, Bracco P: Primary and secondary closure

EP

of the surgical wound after removal of impacted mandibular third molars: a comparative

study. Int J Oral Maxillofac Surg 34:52, 2005

C
AC

7. Waite PD, Cherala S: Surgical outcomes for suture-less surgery in 366 impacted third

molar patients. Journal of oral and maxillofacial surgery 64:669, 2006

8. Osunde OD, Adebola RA, Saheeb BD: A comparative study of the effect of suture-less

and multiple suture techniques on inflammatory complications following third molar

surgery. Int J Oral Maxillofac Surg 41:1275, 2012

 ACCEPTED MANUSCRIPT
9. Quadri A, Quadri S, Khan T: Comparative Study of Post-operative Complications in

Third Molar Surgery with and without Sutures: A Prospective Study. Int J Sci Stud 4:168,

2016

10. Kazemian M, Eshghpour M, Ilkhani S, Ghadirimoghaddam N: The Effect of Sutureless

Surgery on Postoperative Pain and Swelling Following Mandibular Third Molar Surgery.

PT
Journal of Dental Materials and Techniques 5:63, 2016

RI
11. Hashemi HM, Beshkar M, Aghajani R: The effect of sutureless wound closure on

SC
postoperative pain and swelling after impacted mandibular third molar surgery. Br J Oral

Maxillofac Surg 50:256, 2012

U
12. Damodar ND, Nandakumar H, Srinath NM: Postoperative recovery after mandibular
AN
third molar surgery: a criteria for selection of type of surgical site closure. Gen Dent 61:e9,

2013
M

13. Bello SA, Olaitan AA, Ladeinde AL: A randomized comparison of the effect of partial
D

and total wound closure techniques on postoperative morbidity after mandibular third
TE

molar surgery. J Oral Maxillofac Surg 69:e24, 2011

14. Osunde OD, Saheeb BD, Adebola RA: Comparative study of effect of single and
EP

multiple suture techniques on inflammatory complications after third molar surgery. J Oral
C

Maxillofac Surg 69:971, 2011

AC

15. Xavier RL, Vasconcelos BC, Caubi AF, Porto GG, Maurette MA: Passive drainage

through the vestibular oblique incision in impacted inferior third molar surgery: a

preliminary study. Acta Odontol Latinoam 21:57, 2008

16. Anighoro E, Gbotolorun O, Adewole R, Arotiba G, Effiom O: Assessment of the effect

of wound closure technique on postoperative sequaele and complications after impacted

mandibular third molar extraction. Open Journal of Stomatology 3:527, 2013

 ACCEPTED MANUSCRIPT
17. Refo'a Y, Ouatik N, Golchin F, Mahboobi N: Comparing primary and secondary

wound healing discomfort after mandibular third molar surgery: a randomized, double-blind

clinical trial. Gen Dent 59:310, 2011

18. Gay-Escoda C, Gomez-Santos L, Sanchez-Torres A, Herraez-Vilas JM: Effect of the

suture technique on postoperative pain, swelling and trismus after removal of lower third

PT
molars: A randomized clinical trial. Med Oral Patol Oral Cir Bucal 20:e372, 2015

RI
19. Sanchis Bielsa JM, Hernandez-Bazan S, Penarrocha Diago M: Flap repositioning

SC
versus conventional suturing in third molar surgery. Med Oral Patol Oral Cir Bucal 13:E138,

2008

U
20. Danda AK, Krishna Tatiparthi M, Narayanan V, Siddareddi A: Influence of primary and
AN
secondary closure of surgical wound after impacted mandibular third molar removal on

postoperative pain and swelling--a comparative and split mouth study. J Oral Maxillofac
M

Surg 68:309, 2010

D

21. Dubois DD, Pizer ME, Chinnis RJ: Comparison of primary and secondary closure
TE

techniques after removal of impacted mandibular third molars. J Oral Maxillofac Surg

40:631, 1982
EP

22. Maria A, Malik M, Virang P: Comparison of primary and secondary closure of the
C

surgical wound after removal of impacted mandibular third molars. J Maxillofac Oral Surg
AC

11:276, 2012

23. Kakadia U, Patel K, Kumar K, Khare G, Patel N: A Comparative Study of Primary

Versus Secondary Closure After Removal of Lower Third Molar. International Journal of

Clinical Dental Science 4, 2013

 ACCEPTED MANUSCRIPT
24. Khande K, Saluja H, Mahindra U: Primary and secondary closure of the surgical

wound after removal of impacted mandibular third molars. J Maxillofac Oral Surg 10:112,

2011

25. Chaudhary M, Singh M, Singh S, Singh SP, Kaur G: Primary and secondary closure

technique following removal of impacted mandibular third molars: A comparative study.

PT
Natl J Maxillofac Surg 3:10, 2012

RI
26. Holland CS, Hindle MO: The influence of closure or dressing of third molar sockets on

SC
post-operative swelling and pain. Br J Oral Maxillofac Surg 22:65, 1984

27. Egbor PE, Saheeb BD: A Prospective Randomized Clinical Study of the Influence of

U
Primary Closure or Dressing on Post-operative Morbidity after Mandibular Third Molar
AN
Surgery. Niger J Surg 20:59, 2014

28. Rakprasitkul S, Pairuchvej V: Mandibular third molar surgery with primary closure
M

and tube drain. Int J Oral Maxillofac Surg 26:187, 1997

D

29. Chukwuneke FN, Oji C, Saheeb DB: A comparative study of the effect of using a
TE

rubber drain on postoperative discomfort following lower third molar surgery. Int J Oral

Maxillofac Surg 37:341, 2008

EP

30. Carrasco-Labra A, Brignardello-Petersen R, Yanine N, Araya I, Guyatt G: Secondary

C

versus primary closure techniques for the prevention of postoperative complications

AC

following removal of impacted mandibular third molars: a systematic review and meta-

analysis of randomized controlled trials. Journal of Oral and Maxillofacial Surgery 70:e441,

2012

31. McCaffery M, Pasero C: Pain: clinical manual . St Louis, MO: Mosby. (ed., Inc, 1999,
 ACCEPTED MANUSCRIPT
32. Berge TI: Visual analogue scale assessment of postoperative swelling. A study of

clinical inflammatory variables subsequent to third-molar surgery. Acta Odontol Scand

46:233, 1988

33. Montebugnoli L, Servidio D, Miaton R, Cuppini A, Baffioni R, Peronace V, Sanasi V,

Cozzi M: An objective method of assessing facial swelling in patients with dental abscesses

PT
treated with clarithromycin. Minerva stomatologica 53:263, 2004

RI
34. Szolnoky G, Szendi-Horváth K, Seres L, Boda K, Kemény L: Manual lymph drainage

SC
efficiently reduces postoperative facial swelling and discomfort after removal of impacted

third molars. Lymphology 40:138, 2007

U
35. Neupert EA, 3rd, Lee JW, Philput CB, Gordon JR: Evaluation of dexamethasone for
AN
reduction of postsurgical sequelae of third molar removal. J Oral Maxillofac Surg 50:1177,

1992
M

36. Landry RG: Effectiveness of Benzydamine HC1 in the Treatment of Periodontal Post-
D

surgical Patients. Faculty of Dentistry, University of Toronto, 1985

TE

37. Rogers S, Stassen LF: Lingual nerve strain during lingual flap reflection and nerve

protection: a human cadaver study. (ed., Trinity College Dublin, 2010,

EP

38. O'Neil M, Stassen LF: Post-operative Analgesia Following Lower Third Molar Surgery:
C

A Radomised, Controlled, Single-blind Trial Assessing the Use of Post-operative Infiltration

AC

of Intermediate-acting and Long-acting Local Anaesthesia. (ed., Trinity College Dublin, 2014,

39. Ricard AS, Nau O, Veyret A, Majoufre-Lefebvre C, Laurentjoye M: [Comparison

between closure and absence of closure after removal of fully impacted mandibular third

molar: a prospective randomized study]. Rev Stomatol Chir Maxillofac Chir Orale 116:12,

2015
 ACCEPTED MANUSCRIPT
40. Suddhasthira T, Chaiwat S, Sattapongsda P: The comparison study of primary and

secondary closure technique after removal of impacted mandibular third molars. Thai J Oral

Maxillofac Surg 5:67, 1991

41. Kremer E, Atkinson JH, Ignelzi RJ: Measurement of pain: patient preference does not

confound pain measurement. Pain 10:241, 1981

PT
42. Jensen MP, Karoly P, Braver S: The measurement of clinical pain intensity: a

RI
comparison of six methods. Pain 27:117, 1986

SC
43. Jensen MP, Karoly P, O'Riordan EF, Bland F, Jr., Burns RS: The subjective experience

of acute pain. An assessment of the utility of 10 indices. Clin J Pain 5:153, 1989

U
44. Seymour RA: The use of pain scales in assessing the efficacy of analgesics in post-
AN
operative dental pain. Eur J Clin Pharmacol 23:441, 1982

45. Williamson A, Hoggart B: Pain: a review of three commonly used pain rating scales. J
M

Clin Nurs 14:798, 2005

D

46. Seymour RA, Meechan JG, Blair GS: An investigation into post-operative pain after
TE

third molar surgery under local analgesia. Br J Oral Maxillofac Surg 23:410, 1985

47. de Brabander EC, Cattaneo G: The effect of surgical drain together with a secondary
EP

closure technique on postoperative trismus, swelling and pain after mandibular third molar
C

surgery. Int J Oral Maxillofac Surg 17:119, 1988

AC

48. Van Gool AV, Ten Bosch JJ, Boering G: A photographic method of assessing swelling

following third molar removal. Int J Oral Surg 4:121, 1975

49. Llewelyn J, Ryan M, Santosh C: The use of magnetic resonance imaging to assess

swelling after the removal of third molar teeth. Br J Oral Maxillofac Surg 34:419, 1996

50. Pedersen A, Maersk-Moller O: Volumetric determination of extraoral swelling from

stereophotographs. A method study in the buccal area. Int J Oral Surg 14:229, 1985
 ACCEPTED MANUSCRIPT
51. Mocan A, Kisnisci R, Ucok C: Stereophotogrammetric and clinical evaluation of

morbidity after removal of lower third molars by two different surgical techniques. J Oral

Maxillofac Surg 54:171, 1996

52. Holland CS: The development of a method of assessing swelling following third molar

surgery. Br J Oral Surg 17:104, 1979

PT
53. Rana M, Gellrich NC, Ghassemi A, Gerressen M, Riediger D, Modabber A: Three-

RI
dimensional evaluation of postoperative swelling after third molar surgery using 2 different

SC
cooling therapy methods: a randomized observer-blind prospective study. J Oral Maxillofac

Surg 69:2092, 2011

U
54. Amin MM, Laskin DM: Prophylactic use of indomethacin for prevention of
AN
postsurgical complications after removal of impacted third molars. Oral Surgery, Oral

Medicine, Oral Pathology 55:448, 1983

M

55. Henrikson PA, Thilander H, Wahlander LA: Voltaren as an analgesic after surgical
D

removal of a lower wisdom tooth. Int J Oral Surg 14:333, 1985

TE

56. Berge TI: The use of a visual analogue scale in observer assessment of postoperative

swelling subsequent to third-molar surgery. Acta Odontol Scand 47:167, 1989

EP

57. Akota I, Alvsaker B, Bjornland T: The effect of locally applied gauze drain
C

impregnated with chlortetracycline ointment in mandibular third-molar surgery. Acta

AC

Odontol Scand 56:25, 1998

58. Bamgbose BO, Akinwande JA, Adeyemo WL, Ladeinde AL, Arotiba GT, Ogunlewe MO:

Effects of co-administered dexamethasone and diclofenac potassium on pain, swelling and

trismus following third molar surgery. Head Face Med 1:11, 2005
 ACCEPTED MANUSCRIPT
59. van der Westhuijzen AJ, Becker PJ, Morkel J, Roelse JA: A randomized observer blind

comparison of bilateral facial ice pack therapy with no ice therapy following third molar

surgery. Int J Oral Maxillofac Surg 34:281, 2005

60. Troullos ES, Hargreaves KM, Butler DP, Dionne RA: Comparison of nonsteroidal anti-

inflammatory drugs, ibuprofen and flurbiprofen, with methylprednisolone and placebo for

PT
acute pain, swelling, and trismus. J Oral Maxillofac Surg 48:945, 1990

RI
61. Ayad W, Johren P, Dieckmann J: [Results of a comparative prospective randomized

SC
study of surgical removal of mandibular wisdom teeth with and without rubber drainage].

Fortschr Kiefer Gesichtschir 40:134, 1995

U
62. Jain N, Thomas S, Prabhu S, Jain S, Pathak AD, Pillai A, Satpathy M: Influence of tooth
AN
sectioning technique and various risk factors in reducing the IAN injury following surgical

removal of an impacted mandibular third molar. Oral Maxillofac Surg 20:149, 2016
M

63. Valmaseda-Castellon E, Berini-Aytes L, Gay-Escoda C: Inferior alveolar nerve damage

D

after lower third molar surgical extraction: a prospective study of 1117 surgical extractions.
TE

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 92:377, 2001

64. Diniz-Freitas M, Lago-Mendez L, Gude-Sampedro F, Somoza-Martin JM, Gandara-Rey

EP

JM, Garcia-Garcia A: Pederson scale fails to predict how difficult it will be to extract lower
C

third molars. Br J Oral Maxillofac Surg 45:23, 2007

AC

65. Benediktsdottir IS, Wenzel A, Petersen JK, Hintze H: Mandibular third molar removal:

risk indicators for extended operation time, postoperative pain, and complications. Oral

Surg Oral Med Oral Pathol Oral Radiol Endod 97:438, 2004

66. Alvira-Gonzalez J, Figueiredo R, Valmaseda-Castellon E, Quesada-Gomez C, Gay-

Escoda C: Predictive factors of difficulty in lower third molar extraction: A prospective

cohort study. Med Oral Patol Oral Cir Bucal 22:e108, 2017
 ACCEPTED MANUSCRIPT
67. Renton T, Smeeton N, McGurk M: Factors predictive of difficulty of mandibular third

molar surgery. Br Dent J 190:607, 2001

68. Pedersen A: Interrelation of complaints after removal of impacted mandibular third

molars. Int J Oral Surg 14:241, 1985

69. Berge TI, Gilhuus-Moe OT: Per- and post-operative variables of mandibular third-

PT
molar surgery by four general practitioners and one oral surgeon. Acta Odontol Scand

RI
51:389, 1993

SC
70. Oikarinen K, Rasanen A: Complications of third molar surgery among university

students. J Am Coll Health 39:281, 1991

U
71. Hellem S, Nordenram A: Prevention of postoperative symptoms by general antibiotic
AN
treatment and local bandage in removal of mandibular third molars. Int J Oral Surg 2:273,

1973
M

72. Lago-Mendez L, Diniz-Freitas M, Senra-Rivera C, Gude-Sampedro F, Gandara Rey JM,

D

Garcia-Garcia A: Relationships between surgical difficulty and postoperative pain in lower

TE

third molar extractions. J Oral Maxillofac Surg 65:979, 2007

73. Phillips C, White RP, Jr., Shugars DA, Zhou X: Risk factors associated with prolonged
EP

recovery and delayed healing after third molar surgery. J Oral Maxillofac Surg 61:1436, 2003
C

74. Yuasa H, Sugiura M: Clinical postoperative findings after removal of impacted

AC

mandibular third molars: prediction of postoperative facial swelling and pain based on

preoperative variables. Br J Oral Maxillofac Surg 42:209, 2004

75. Osunde OD, Saheeb BD: Effect of age, sex and level of surgical difficulty on

inflammatory complications after third molar surgery. J Maxillofac Oral Surg 14:7, 2015
 ACCEPTED MANUSCRIPT
76. Capuzzi P, Montebugnoli L, Vaccaro MA: Extraction of impacted third molars. A

longitudinal prospective study on factors that affect postoperative recovery. Oral Surg Oral

Med Oral Pathol 77:341, 1994

77. van Gool AV, Ten Bosch JJ, Boering G: Clinical consequences of complaints and

complications after removal of the mandibular third molar. Int J Oral Surg 6:29, 1977

PT
RI
Figures legend

SC
Fig. 1. Eleven-point Numeric Rating Scale (NRS) for pain (McCaffery and Pasero, 1999).

Fig. 2. VAS scale for swelling with references given to patient (Berge, 1988).

U
Fig. 3. Facial measurements for evaluation of facial swelling (Szolnoky et al., 2007).
AN
Fig. 4. Grades of socket healing.

Fig. 5. Healing Index for Soft Tissue by Landry (Landry, 1985).

M

Fig. 6. Modified buccal envelope flap for lower third molar surgery.

a) Envelope incision, b) 5 mm disto-buccal extension from site of the distobuccal cusp

D

with no extension into the cheek. It protects a high lying lingual nerve, if it lies over
TE

the retromolar triangle as it occasionally does, c) it allows subperiosteal dissection of

EP

the retromolar tissues from retromolar triangle with a Mitchell’s trimmer, d) it gives a

very clean and clear access to the impacted lower third molar, the bone and provides
C

easy access to the subperiosteal lingual tissue, if retraction is required.

AC

Fig. 7. Suture site in one-suture technique.

Fig. 8. Surgical Difficulty Scale (O’Neill and Stassen 2014).

Fig. 9. Median pain ratings for suture and non-suture conditions.

Fig. 10. Median facial swelling for suture and non-suture conditions.

(0 = no swelling, 1 = slight swelling, 2= mild swelling, 3 = severe swelling, 4= very severe

swelling).
 ACCEPTED MANUSCRIPT
Fig. 11. Means for differences between pre-operative and post-operative values for facial

swelling measurements from lines 1 to 6.

Fig. 12. Histogram of socket healing for suture and non-suture conditions at one week.

Fig. 13. Histogram of socket healing for suture and non-suture conditions at one month.

Fig. 14. Histogram of soft tissue healing for suture and non-suture conditions at one week.

PT
RI
U SC
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
Tables

Table 1. Means and standard deviations and results of the Wilcoxon Signed Rank Tests for
pain perceived by patient on days one to six under suture and non-suture conditions.

Std.
Time Condition Mean z p
Deviation

PT
12 Hours Suture 4.85 2.45 -.628 .530
Non-Suture 5.25 2.41

RI
24 Hours Suture 4.57 2.06 -1.10 .270
Non-Suture 4.34 2.09

SC
48 Hours Suture 4.65 2.09 -.811 .417
Non-Suture 4.51 1.96

U
72 Hours Suture 4.28 2.44 -.230 .818
AN
Non-Suture 4.45 2.48

Day 4 Suture 3.80 2.50 -1.29 .196

M

Non-Suture 4.51 2.60

Day 5 Suture 3.25 2.64 -1.99 .046*

D

Non-Suture 4.34 2.65

TE

Day 6 Suture 2.65 2.32 2.12 .034*

Non-Suture 3.74 2.58
* p ≤ 0.05
C EP
AC
 ACCEPTED MANUSCRIPT

Table 2. Spearman Rho Correlations between differences in operative time and

difficulty of surgery with differences in pain perceived by the patient from day one to day six

12 Hours 24 Hours 48 Hours 72 Hours Day 4 Day 5 Day 6

r .372 .367 .522** .321 .342 .386 .306

PT
Operative Time p .028* .030* .001* .060 .045* .022* .074
n 35 35 35 35 35 35 35

RI
r .365 .386 .516** .541** .535** .519** .514**
Difficulty Scale p .031* .022* .001* .001* .001* .001* .002*
n 35 35 35 35 35 35 35

SC
* p ≤ 0.05
** r = 0.4 to 0.59 indicates moderate correlation

U
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

Table 3. Means and standard deviations and results of Wilcoxon Signed Rank Tests for
swelling perceived by patient days one to six under suture and non-suture conditions.

Std.
Time Condition Mean z p
Deviation
Suture 2.62 1.330 -1.31 .190
Day 1
Non-Suture 2.40 1.264

PT
Suture 2.74 1.357 -1.33 .183
Day 2
Non-Suture 2.48 1.291

RI
Suture 2.28 1.250 -.835 .404
Day 3

SC
Non-Suture 2.11 1.182

Suture 1.74 1.244 -.806 .420

Day 4

U
Non-Suture 1.60 1.034
AN
Suture 1.05 .937 -.068 .946
Day 5
Non-Suture 1.11 .963
M

Suture .828 .857 -.847 .397

Day 6
Non-Suture .742 .852
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

Table 4. Spearman Rho Correlations between differences in operative time and difficulty of
surgery with differences in swelling perceived by patient from day one to day six.

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

** ** ** ** **
r .537 .501 .536 .538 .395 .478
* * * * * *

PT
Operative Time p .001 .002 .001 .001 .019 .004
n 35 35 35 35 35 35
** ** ** ** ** **
r .514 .426 .469 .543 .453 .433

RI
* * * * * *
Difficulty Scale p .002 .011 .005 .001 .006 .009
n 35 35 35 35 35 35
* p ≤ 0.05

SC
** r = 0.4 to 0.59 indicates moderate correlation

U
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

Table 5. Means, standard deviations, and dependent t-tests for difference in facial swelling
measurements.

Line Condition Mean Std. Deviation t p

Suture .1200 .272 1.062 .296
Line 1
Non-Suture .0657 .250

PT
Suture .1343 .341 1.917 .064
Line 2
Non-Suture -.0171 .315

RI
Suture .0829 .434 .865 .393
Line 3
Non-Suture -.0086 .393

SC
Suture .1371 .548 1.172 .249
Line 4
Non-Suture .0029 .586

U
AN
Suture .2200 .829 .576 .568
Line 5
Non-Suture .1371 .586
M

Suture .0743 .604 1.462 .153

Line 6
Non-Suture -.1400 .796
D

Total* Suture .7686 2.102 1.893 .067

Non-Suture .0400 2.001
TE

* Total = summation of lines 1 to 6.

C EP
AC
 ACCEPTED MANUSCRIPT

Table 6. Means and standard deviations and results of the t-tests for number of gauzes used
through days one to five and duration of bleeding under suture and non-suture conditions.

Std.
Time Condition Mean t p
Deviation

PT
Suture 1.42 1.70 -1.23 .227
Day 1
Non-Suture 1.74 2.22

RI
Suture .657 1.37 .683 .499
Day 2
Non-Suture .571 1.17

SC
Suture .057 .338 .442 .661
Day 3
Non-Suture .028 .169

U
Suture .000 .000 a
Day 4
Non-Suture .000 .000
AN
Suture .000 .000 a
Day 5
Non-Suture .000 .000
M

Bleeding Suture 1.31 .529 -1.14 .263

D

duration Non-Suture 1.40 .553

a = no t-test could be computed due to no variation in gauze usage under both conditions.
TE
C EP
AC
 ACCEPTED MANUSCRIPT

Table 7. Means, standard deviations and results of the t-tests for measures of periodontal
status of lower second molar at one month under suture and non-suture conditions.

Std.
Parameter Condition Mean t p
Deviation

Average PD Suture 1.42 1.70 -.708 .484

change Non-Suture 1.74 2.22

PT
CAL Suture .657 1.37 -.159 .875
change Non-Suture .571 1.17

RI
Suture .057 .338 -.903 .373
Deepest PD

SC
Non-Suture .028 .169
change

U
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC
 ACCEPTED MANUSCRIPT

PT
RI
U SC
AN
M
D
TE
EP
C
AC