Comparative Study of Effect of Single and Multiple

J Oral Maxillofac Surg xx:xxx, 2010

Comparative Study of Effect of Single and Multiple Suture Techniques on Inflammatory Complications After Third Molar Surgery Otasowie Daniel Osunde, BDS, FWACS,* Birch D. Saheeb, BDS, FWACS, FDSRCS, FICS,† and Rafel A. Adebola, BDS, FWACS, FDSRCPS‡ Purpose: Pain, swelling, and trismus are the most common complications associated with third molar

surgery. Several methods of alleviation of these complications have been described. The effect of single and multiple suture techniques on these complications was compared in the present study. Patients and Methods: All consecutive patients 18 years of age or older who had been referred for surgical extraction of their impacted teeth between January and December 2007 at the maxillofacial unit of the Aminu Kano Teaching Hospital were recruited and randomized into 2 groups. All selected participants underwent surgical extraction of their impacted teeth by the same surgeon under local anesthesia. The flaps in 1 group were closed by multiple sutures and those in the second group were closed by a single suture. Pain, swelling, and trismus were evaluated at postoperative days 1, 2, 3, 5, and 7. Descriptive and comparative statistical analyses were performed, and the results are presented. Significance was set at P ⬍ .05. Results: A total of 50 subjects participated in the present study. Both groups were comparable in terms of the age distribution (multiple suture group, 26.0 ⫾ 4.73 years; single suture group, 25.8 ⫾ 4.28 years, P ⫽ .755), difficulty index (multiple suture group, 5.0 ⫾ 1.68; single suture group, 4.9 ⫾ 4.79; P ⫽ .935), duration of surgery (multiple suture group, 29. 7 ⫾ 6.11 minutes; single suture group, 30.0 ⫾ 6.04 minutes; P ⫽ .835), and baseline parameters such as facial width (multiple suture group, 10.0 ⫾ 1.32 cm; single suture group, 9.8 ⫾ 0.37 cm; P ⫽ .115), mouth opening (multiple suture group, 4.5 ⫾ 1.32 cm, single suture group, 4.8 ⫾ 0.26 cm; P ⫽ .165), and preoperative pain, which was 0 in both groups. Other comparable variables included impaction type (P ⫽ .210) and indication for surgery (P ⫽ .278). A statistically significant difference was found in the level of pain at postoperative days 1, 2, and 3 (P ⬍ .05). A similar significant difference was found in swelling and trismus (P ⬍ .05). At days 5 and 7, no significant differences were found between the 2 groups for all parameters of pain, swelling, and trismus (P ⬎ .05). Conclusion: Our study had a comparable distribution of age, gender, and operative variables, such as the pattern of impaction, preoperative difficulty index, and operative time between patients undergoing the 2 methods of closure. With that, our results have shown that the single suture closure technique was better than the multiple suture technique with regard to postoperative pain, swelling, and trismus. © 2010 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg xx:xxx, 2010 common complications.2 These complications result from the inflammatory response, which is a direct and immediate consequence of the surgical procedure.3

The extraction of the impacted mandibular third molar is a common oral surgical procedure.1 Pain, trismus, and swelling have been reported to be the most *Consultant Oral and Maxillofacial Surgeon, Department of Dental and Maxillofacial Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria. †Professor and Dean, Faculty of Dentistry, University of Benin, Benin, Nigeria; Visiting consultant, Aminu Kano Teaching Hospital, Kano, Nigeria. ‡Consultant Oral and Maxillofacial Surgeon and Head, Department of Dental and Maxillofacial Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria.

Address correspondence and reprint requests to Dr Osunde: Department of Dental and Maxillofacial Surgery, Aminu Kano Teaching Hospital, 3, Hospital Road, Kano, Nigeria; e-mail: otdany@ yahoo.co.uk © 2010 American Association of Oral and Maxillofacial Surgeons

0278-2391/10/xx0x-0$36.00/0 doi:10.1016/j.joms.2010.05.009

1

2 The adverse effects of third molar surgery on quality of life have been reported to show a threefold increase in patients who experience pain, swelling, and trismus alone or combined compared with asymptomatic patients.3,4 Many clinicians have emphasized the necessity for better pain, swelling, and trismus control in patients who undergo third molar surgery.5,6 The closure technique is an operative factor that has been linked to early postoperative complications after third molar surgery. This method, in which room is provided for the evacuation of the inflammatory exudates, will obviously result in less pain, swelling, and trismus. This technique has variously been described as partial closure, secondary closure, and secondary healing by different investigators. The published data have described several methods of achieving partial closure, including excision of mucosa immediately distal to the second molar to create a window, which serves as an outlet for the inflammatory exudates.7,8 Other methods have included a combination of mucosa excision and placement of drains,8 incorporation of drains that could be in the form of a gauze or rubber,9,10 and a “sutureless” technique in which no form of suturing is performed.11 These methods are associated with 1 or more limitations. The effect of a single suture, as a form of partial closure, on postoperative pain, swelling, and trismus appears not to have been studied, as revealed by our literature search. The present study compared the effect of single (partial) and multiple sutures (primary or complete closure) on postoperative complications after impacted mandibular third molar surgery. Our hypothesis was that no statistically significant differences would be found in postoperative pain, swelling, or trismus between the single and multiple sutures techniques in third molar surgery. The aim of the present study was to determine whether statistically significant differences were present in the level of postoperative pain, swelling, and trismus with the 2 closure methods.

Patients and Methods This was a randomized, prospective, double-blind study conducted at the outpatient clinic of the Department of Dental and Maxillofacial Surgery, Aminu Kano Teaching Hospital (Kano, Nigeria) between January and December 2007. Patients referred for surgical extraction of their impacted lower third molars were recruited for the study. The research and ethics committee of the Aminu Kano Teaching Hospital approved the study protocol and informed consent forms. The study protocol was explained to the pa-

EFFECT OF SUTURE TECHNIQUES ON INFLAMMATION

tients in detail, after which they provided written informed consent. Patients referred for surgical extraction of their impacted lower third molars who fulfilled the selection criteria were recruited to the study. The patients were selected consecutively as they presented and were randomized into 2 groups. The patients in the first group underwent the single suture technique and those in the second group underwent the multiple suture technique. The information obtained included age, gender, impaction side, indication for extraction, and presence of any underlying systemic conditions. Other information included the use of drugs such as steroids and oral contraceptives, tobacco and alcohol consumption, Winter’s angulation, the Pell and Gregory ramus and occlusal relations, length of the red line, root pattern, relationship to inferior neurovascular bundle, and Pederson’s difficulty index. PREOPERATIVE EVALUATION

Preoperative measurements of the maximal interincisal distance, pain, and facial width (swelling) were taken and recorded on the data form just before surgery. All measurements were standardized and performed by the researcher. The maximal interincisal distance was measured, using a Vernier-calibrated sliding caliper, from the mesial angle of the incisal edge of the upper right central incisor to a corresponding point in the lower right central incisor. This was measured 3 times, and the mean was calculated. The facial width (swelling) was recorded using a modification of the tape measure method described by Neupart et al,12 as modified by Filho et al.13 The linear distances from the angle of the mandible to the tragus, lateral canthus, alae to nose angle, commisure of the lips, and soft tissue pogonium were measured. Each linear measurement was repeated twice, and the mean was calculated. Pain was evaluated using a 10-cm visual analog scale (VAS). Patients were given the VAS scoring sheet and instructed to mark the point that corresponded to their present pain level. This was also repeated twice, the scores were measured by the researcher, and the mean was calculated. SURGICAL PROTOCOL

At surgery, all selected participants were free from pain and other inflammatory symptoms, including swelling, hyperemia, and decreased mouth opening. Patients with one or more of these symptoms were excluded from the present study. All patients underwent scaling and polishing before the surgical procedure; therefore, the oral hygiene level was standardized. All surgery was performed with the patient under local anesthesia in the same operating room and with similar conditions by the researcher and the

3

OSUNDE, SAHEEB, AND ADEBOLA

same assistant. Anesthesia was achieved with a combination of inferior alveolar, lingual, and buccal nerve blocks, using 2% lidocaine with 1:100,000 dilution of adrenaline. A 3-sided mucoperiosteal flap was raised. The incision was begun at a point (about 6 mm) down the buccal sulcus, at the junction between the middle and posterior thirds of the second molar, and then extended upward to its distobuccal angle. The incision was continued along the gingival sulcus to a point just distal to the third molar and then extended distally and laterally along the external oblique ridge. No lingual flap was incorporated nor was a lingual retractor used. Bone was removed using the buccal guttering technique with a fissure bur on a rotator hand piece under constant irrigation with normal saline. The tooth was elevated using a straight Coupland elevator, and thorough irrigation and debridement were performed. None of the teeth required sectioning. Hemostasis was achieved, and the flaps were closed according to the treatment group. For the multiple 3-0 silk suture group, the sutures were placed at the interdental papilla between the second and third molars and at the distal relieving incision. For the single 3-0 silk suture group, a single suture was placed at the distal relieving incision. The duration of the procedure, starting from the incision to completion of suturing, was recorded in minutes. Both treatment groups received oral antibiotics, analgesics, and instructions to use a warm saline mouthwash. The antibiotics included amoxicillin 250 mg every 8 hours and metronidazole 200 mg every 8 hours for 5 days. Ibuprofen 200 mg every 8 hours for 3 days was prescribed as the analgesic. Any factors or agents that might affect the parameters under study were avoided. This included the use of steroids and ice pack application. All patients received postoperative instructions. The patients were advised to return to the clinic on days 1, 2, 3, 5, and 7 postoperatively to evaluate the degree of pain, swelling, and mouth opening limitation. The patients were also advised to report to the clinic on any day in the case of any unusual discomfort.

Postoperative Evaluation Both groups were evaluated postoperatively for pain, swelling, and trismus by an independent observer who was unaware of the treatment group to which the patients belonged. All patients were asked about their overall pain perception during the healing phase at the follow-up visits, and the patient’s perception was recorded on a 0 to 10-cm VAS according to the perceived degree of pain. The postoperative swelling was assessed using the same method as preoperatively. The postoperative value minus the pre-

operative value indicated the degree of swelling. Mouth opening was measured using the Vernier-calibrated sliding caliper, just as preoperatively. The postoperative value was also subtracted from the preoperative value, with the difference being the degree of trismus. All measurements were performed postoperatively by an independent observer who had no knowledge of the type of closure the patients had undergone. STATISTICAL ANALYSIS

The collected data were analyzed using the Statistical Package for Social Sciences, version 13 (SPSS, Chicago, IL). The analysis included the mean, standard deviation, frequency distribution, and correlation. Comparative statistical analysis was done using the independent sample t test for the continuous variables such as age, Pederson difficulty index, preoperative facial width, maximal interincisal distance, and surgery duration. The Fisher exact test was used for the categorical variables, such as gender, impaction type, impaction side, and indications for surgery. Continuous variables are presented as the mean, standard deviation, and range. Categorical measures are presented as frequency (percentages). Inferential statistical analysis was done for postoperative pain, swelling, and trismus, using analysis of variance for repeated measures. Significance was set at P ⬍ .05.

Results A total of 50 subjects, divided into 2 groups (multiple suture and single suture groups), participated in the present study. Of the 50 subjects, 27 were men (54%) and 23 were women (46%). The Fisher exact test was significant for gender (P ⫽ .041). The recruited participants were generally 18 to 38 years of age, and the difference between the mean ages in both study groups was not statistically significant (P ⬎ .05). The distribution of impaction types and indications for extraction between the single and multiple suture groups was comparable (P ⬎ .05). No tooth was extracted for prophylactic, prosthetic, or orthodontic indications. The preoperative difficulty index ranged from 3 to 8 (multiple suture group, 5.0 ⫾ 1.68; single suture group, 4.9 ⫾ 1.79). The duration of surgery (starting from the first incision to the placing of the last suture) ranged from 18 to 41 minutes (multiple suture group, 29.7 ⫾ 6.11; single suture group, 30.0 ⫾ 6.04). The difference between the mean values of the baseline parameters (mouth opening and facial width), preoperative difficulty index, and duration of surgery in the subjects in both groups was not significant (P ⬎ .05).

4

EFFECT OF SUTURE TECHNIQUES ON INFLAMMATION

Table 1. DEMOGRAPHIC, OPERATIVE, AND BASELINE PATIENT CHARACTERISTICS

Characteristic Gender Male Female Age (yr) Mean ⫾ SD Range Impaction Mesioangular Distoangular Horizontal Vertical Indications Pericoronitis Apical periodontitis Dental caries Pulpitis Dentoalveolar abscess Difficulty index Mean ⫾ SD Range Duration of surgery (min) Mean ⫾ SD Range Mouth opening (cm) Mean ⫾ SD Range Facial width (cm) Mean ⫾ SD Range Mean pain score†

Multiple Sutures

Single Suture

14 (28) 11 (22)

13 (26) 12 (24)

26.2 ⫾ 4.73 18-38

25.8 ⫾ 4.28 19-35

12 (24) 8 (16) 4 (8) 1 (2)

13 (26) 8 (16) 3 (6) 1 (2)

14 (28) 6 (12) 2 (4) 2 (4)

12 (24) 8 (16) 3 (6) 1 (2)

1 (2)

1 (2)

5.0 ⫾ 1.68 3-8

4.9 ⫾ 1.79 3-8

P Value .041* .755 .210

.278

29.7 ⫾ 6.11 18-40

30.0 ⫾ 6.04 20-41

4.5 ⫾ 0.40 4.1-5.4

4.4 ⫾ 0.26 4.2-5.5

10.0 ⫾ 0.32 9.3-10.7 0.00

9.8 ⫾ 0.37 9.3-10.8 0.00

The mean amount of facial swelling differed significantly between the 2 closure techniques at days 1, 2, and 3 (P ⬍ .05). The mean degree of facial swelling on postoperative days 5 and 7 was lower with the secondary closure technique, but the difference was not significant (Table 2). Postoperative swelling changed in a linear fashion from days 1 to 7, with maximal facial swelling by day 2 for both closure techniques. However, the secondary closure technique showed a peak at a slightly lower level compared with primary closure. Similar to the degree of pain and facial swelling, a significant difference was found between the amount of trismus using the multiple suture and single suture techniques on days 1, 2, and 3 (P ⫽ .003, P ⫽ .010, and P ⫽ .023, respectively). The difference between the mean values was not significant on days 5 and 7 (P ⬎ .05). The maximal reduction in mouth opening was observed at day 1 postoperatively. The amount of mouth opening improved steadily, with a trend toward the preoperative values at 1 week postoperatively.

.935

Discussion .835 .165 .115

Abbreviation: SD, standard deviation. Data presented as numbers of patients, with percentages in parentheses, unless otherwise noted. *Statistically significant. †Visual analog score for pain preoperatively was 0 in all patients; therefore, the significance test was not performed. Osunde, Saheeb, and Adebola. Effect of Suture Techniques on Inflammation. J Oral Maxillofac Surg 2010.

The preoperative VAS pain score for all patients in both groups was 0 (Table 1). Table 2 lists the mean score and inferential statistics for pain, swelling, and trismus in the multiple and single suture groups. A significant difference was found in the pain level between the 2 closure techniques at days 1, 2, and 3 (P ⫽ .001, P ⫽ .023, and P ⫽ .025, respectively). However, the difference between the 2 closure techniques on days 5 and 7 was not significant (P ⬎ .05). The pain decreased linearly from day 1 to day 7 and peaked at day 1 postoperatively. At 1 week postoperatively, the mean pain score showed a trend toward the preoperative value for both closure techniques.

The present study compared the postoperative complications after third molar surgery using the multiple and single suture techniques. We hypothesized that no statistically significant differences would be found in the level of postoperative pain, swelling, and trismus in patients who had undergone the single or multiple suture technique after third molar surgery.

Table 2. COMPARISON OF POSTOPERATIVE PAIN, SWELLING, AND TRISMUS IN SINGLE AND MULTIPLE SUTURE GROUPS

Day Pain 1 2 3 5 7 Swelling 1 2 3 5 7 Trismus 1 2 3 5 7

Multiple Suture Group

Single Suture Group

P Value

5.0 ⫾ 0.387 3.1 ⫾ 0.282 1.2 ⫾ 0.118 0.6 ⫾ 0.097 0.2 ⫾ 0.096

4.5 ⫾ 0.313 2.9 ⫾ 0.285 1.1 ⫾ 0.149 0.5 ⫾ 0.104 0.2 ⫾ 0.061

.001* .023* .025* .074 .085

1.2 ⫾ 0.113 1.3 ⫾ 0.106 0.8 ⫾ 0.123 0.5 ⫾ 0.107 0.1 ⫾ 0.024

1.0 ⫾ 0.107 1.2 ⫾ 0.102 0.7 ⫾ 0.145 0.5 ⫾ 0.122 0.1 ⫾ 0.033

.001* .001* .002* .076 .409

1.3 ⫾ 0.093 1.1 ⫾ 0.058 0.9 ⫾ 0.085 0.6 ⫾ 0.133 0.2 ⫾ 0.064

1.2 ⫾ 0.072 1.0 ⫾ 0.062 0.8 ⫾ 0.074 0.5 ⫾ 0.065 0.2 ⫾ 0.102

.003* .010* .023* .171 .480

*Statistically significant at P ⬍ .05. Osunde, Saheeb, and Adebola. Effect of Suture Techniques on Inflammation. J Oral Maxillofac Surg 2010.

OSUNDE, SAHEEB, AND ADEBOLA

We found less pain, swelling, and trismus in patients who had undergone the single suture technique compared with those who had undergone the multiple suture technique. The demographic, baseline, and operative characteristics were similar in both groups, except for gender. The preoperative VAS score for pain for all patients was 0. This resulted from the exclusion of patients with a perceptible level of pain at surgery to not influence the postoperative pain scores. The other possible reason the preoperative VAS score was 0 was that all patients undergoing third molar surgery at our clinic are usually required to put their name on a waiting list because of limited facilities. Such patients normally receive oral antibiotics (amoxicillin 250 mg every 8 hours for 5 days and metronidazole 200 mg every 8 hours for 5 days) and analgesics (paracetamol 1 g every 8 hours for 3 days) before surgery for the temporary relief of pain. A significant difference was found in the extent of pain, swelling, and trismus for the first 3 days after surgery between the multiple and single suture groups. At postoperative days 5 and 7, however, no significant differences were noted between the 2 techniques, even though a lower value for all the parameters was observed for the single suture technique. One possible reason for the lower pain, swelling, and trismus values recorded for the single suture group might have been because of differences in the retention of the inflammatory exudates. In the partial (single suture) closure, the retention of the exudates is less because more room is present for the release of the inflammatory exudates compared with the multiple suture technique. Postoperative pain was significantly less at days 1, 2, and 3 in the patients who had undergone the single suture technique compared with those who underwent the multiple suture technique. This supports the findings of Dubois et al,7 Rakprasitkul and Pairuchvej,9 Holland and Hindle,14 and Pasqualini et al,15 who found less pain with techniques of closure that allowed for evacuation of the inflammatory exudates. Our results, however, were different from those of Chukwuneke et al,16 who found no significant difference between the pain level between closure without a drain and closure with a rubber drain. In the present study, the pain level had peaked at 24 hours postoperatively and then steadily decreased in a linear fashion in both the multiple and the single suture groups, although the peak in the latter group was lower. This supports earlier reported findings from Cerqueira et al,10 Seymour et al,17 and Garcia et al.18 Postoperative swelling was found to be significantly less at days 1, 2, and 3 in the single suture (partial closure) group than in the multiple suture group (P ⬍ .05). This was similar to the findings from

5 Dubois et al,7 de Brabander and Cattaneo,8 Rakprasitkul and Pairuchvej,9 Holland and Hindle,14 Pasqualini et al,15 and Chukwuneke et al,16 who reported less swelling with techniques of closure that allowed for drainage of the inflammatory exudates. Swelling peaked at 48 hours postoperatively and then progressively decreased until little or no swelling was present in the 2 groups at 1 week postoperatively. This was similar to the findings of Bamgbose et al,5 Troullos et al,19 and van der Westhuijzen et al.20 However, it was different from the findings of Pasqualini et al,15 who found that maximal facial swelling occurred 72 hours after surgery. The differences might have resulted from variations in the individual inflammatory response. Comparative studies of primary and secondary closure techniques abound, although most investigators limited their work to the influence of closure techniques on postoperative pain and facial swelling alone, without considering the effect on trismus.7,8,14,15 This particular study is one of the few published that addresses the influence of closure technique on the mouth opening limitation after third molar surgery. The finding of the present study with regard to mouth opening limitation was consistent with that from other reported studies.9,16,21 The published data have described other methods to prevent or control the side effects arising from the inflammatory response after third molar surgery, including surgical and therapeutic interventions. Surgical methods have included mucosa excision,7,8 a sutureless technique,11 and the use of drains with primary closure.9,21 Mucosa excision or insertion of a drain could prolong the duration of surgery and, presumably, cause more discomfort to the patient both in terms of incurring more trauma and having to cope with the presence of a foreign body in form of a tube or gauze inside the mouth for a varying period of 48 to 72 hours after surgery.22 Chukwuneke et al16 recorded a greater pain score for patients who had undergone surgical closure with the insertion of drain, probably because of the irritating effect. In addition, the overall cost of surgery could be increased because of the additional cost of purchasing rubber drains. A technique in which no form of suturing is performed has been described by Waite and Cherala.11 They reviewed the outcomes of surgical extraction of 1,280 third molars in 366 patients without suture placement. They reported less pain because the technique allowed for open drainage of the extraction sockets. This emerging technique has the advantages of reducing the operative time and less tissue manipulation.11 A sutureless technique might, however, be limited to cases in which minimal incisions are used for third molar surgery.11,23,24

6 The therapeutic methods have included application of an ice pack,13,21 parenteral administration of steroids,23 and application of a low-power laser.25 These modalities also have one or more limitations. Ice therapy is a simple, inexpensive, repeatable, and safe treatment modality, but its use is considered contraindicated in patients with cold hypersensitivities and intolerances, such as those with Raynaud phenomenon, areas with impaired circulation, or peripheral vascular disease.26 The application of a low-power laser, although effective in minimizing postoperative swelling and pain, particularly when combined with steroids,25 is not readily available, especially in a developing country such as Nigeria. The administration of steroids after third molar surgery is effective in reducing the postoperative inflammatory response associated with this procedure. However, its use is limited by the fear of interference with the normal healing process and needle phobia, because it is usually given parenterally, and this could add to the overall surgical trauma. Some patients also refuse steroid medications because of a wish to not take extra medication.22 Partial closure, using a single suture, is simple, cost-effective, free of additional medication, free of the physical irritation of a foreign body, less traumatic, and saves operative time. The results of the present study showed a slight improvement in the postoperative parameters of pain, swelling, and trismus in patients who had undergone the single suture technique compared with the multiple suture technique. Although the influence of these significant differences on the clinical outcome might not have been much, our study has demonstrated a simple and drug-free method of minimizing the postoperative discomfort that follows impacted mandibular third molar surgery. Oral surgeons performing such procedures, using the standard third molar incision, should consider the use of a single suture for closure.

EFFECT OF SUTURE TECHNIQUES ON INFLAMMATION

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Acknowledgment We thank the entire staff of the Dental and Maxillofacial Surgery Department of Aminu Kano Teaching Hospital for making this work a reality.

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