Evaluation of Postoperative Complications after Mandibular Third Molar Extraction without Suture and its Association with Age and Gender
Keerthana Balaji1, Pradeep D2*
1 Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
2 Associate Professor, Department of Oral and Maxillofacial Surgery, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
*Corresponding Author
Pradeep D,
Associate Professor, Department of Oral and Maxillofacial Surgery, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
Tel: +91 9789936383
E-mail: pradeep@saveetha.com
Received: July 30, 2021; Accepted: August 10, 2021; Published: August 17, 2021
Citation:Keerthana Balaji, Pradeep D. Evaluation of Postoperative Complications after Mandibular Third Molar Extraction without Suture and its Association with Age and Gender Int J Dentistry Oral Sci. 2021;8(8):3832-3838. doi: dx.doi.org/10.19070/2377-8075-21000785
Copyright: Pradeep D©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Extraction of impacted teeth is one of the most common operations in oral and maxillofacial surgery. Assessment of the effectiveness of sutureless closure of wounds on postoperative complications after extraction of mandibular third molars. This is a Retrospective study conducted in the university setting. This study included patients who reported to private dental hospital for the removal of mandibular third molars. Inclusion criteria of this study included patients who required removal of mandibular third molars and exclusion criteria included patients with drug allergies and patients who are pregnant or currently lactating. Data was collected and tabulated in excel. Data was analysed using IBM SPSS Statistical Analyzer(23.0 version) Frequency distribution and descriptive analysis were carried out. The association between the variables was analysed and assessed using Pearson Chi-square test. P value < 0.05 was considered to be statistically significant. Patients experienced less postoperative complications in wound closure without suture compared to wound closure with suture. Secondary closure has significant advantage over primary closure based on postoperative pain and swelling.
2.Introduction
3.Conclusion
4.References
Keywords
Post Operative Pain; Mandibular Third Molars; Primary Closure; Secondary Closure.
Introduction
Extraction of impacted teeth is one of the most common operations
in oral and maxillofacial surgery. Postoperative pain and
swelling are the most common complications [2]. The other postoperative
complications include Trismus, Alveolar Osteitis, Extended
Hemorrhage. The severity of these symptoms is dependent
on multiple factors such as the operative time, the difficulty of
the procedure, the extent of the ostectomy, the oral hygiene status
of the patient and the competence of the surgeon[5]. Post operative
pain and swelling are mainly due to inflammatory processes
initiated by surgical trauma. Damage to the capillary vessels and
the release of inflammatory cytokines as a result of trauma lead
to increased permeability of vessels which results in accumulation
of sero-sanguinous fluid and exudate [25, 24, 39]. Post operative
complications can be a burden for both patients and surgeons
and may result in a loss of productivity because at least 45% of
patients require multiple visits to the surgeon. It can also be costly
in terms of the clinic time required to manage the patient’s symptoms.
Many individuals rate the pain of tooth extraction as very
severe or intolerable. The pain of tooth extraction varies among
individuals depending upon their anxiety level and each extraction
of an individual may be quite different [24, 53]. Post-operative
healing can be primary healing or secondary healing [14]. Primary
healing or primary closure is the complete reapposition of the
third molar flaps post surgery using suturing.Postoperative healing
in extraction with sutures depend on the flap design used.This
is healing by primary intention [6,35]. In secondary intention the
socket remains in communication with the oral cavity [38]. This is
healing by secondary intention. Secondary closure of the wound
aids in drainage of fluid from the socket thereby reducing postoperative
pain and swelling.This is mostly employed in excision
of salivary gland and salivary duct swelling such as ranula [10, 29].
The main purpose of suture in primary closure is to provide an
intimate contact of gingival tissue around second molar, control
of haemorrhage, to avoid food lodgement, wound dehiscence
and to prevent infection of socket. All suture materials produce
tissue response which varies according to the anatomical site in which they are used ranging from extractions to trauma and osteotomies
[15, 8, 1, 18]. Sometimes, Suturing may also create a oneway
valve that allows for debris to enter the socket but not easily
escape which will further cause infection [50, 26].
Previously our team has a rich experience in working on various
research projects across multiple disciplines. (Jain, 2017 [18]);
(Varghese, Ramesh and Veeraiyan, 2019 [54]); (Ashok and Ganapathy,
2019 [3]); (Padavala and Sukumaran, 2018 [30]); (Ke et al.,
2019 [21]); (Ezhilarasan, 2018 [11]); (Krishnan et al., 2018 [22]);
(Ezhilarasan, Sokal and Najimi, 2018 [13); (Pandian, Krishnan
and Kumar, 2018 [32]); (Ramamurthy and Mg, 2018 [42]); (Gupta,
Ariga and Deogade, 2018 [16]); (Vikram et al., 2017 [57]); (Paramasivam,
Vijayashree Priyadharsini and Raghunandhakumar,
2020 [33]); (Palati et al., 2020 [31]); (Samuel, Acharya and Rao,
2020 [48]). Now the growing trend in this area motivated us to
pursue this project.
The aim of the study was to compare the effect of Suture less
closure of the surgical wound after removal of mandibular third
molar on post-operative pain, swelling, extended haemorrhage
and dry socket to closure with sutures.
Results & Discussion
The study included 296 participants who underwent extraction of
mandibular third molars. In regard to age, majority of the study
population that is 37.5% and 40.2% of patients belonging to the age group 18-40 years showed higher incidence of postoperative
pain and swelling(Figure-1&2) whereas 8.78% and 6.42% of
patients belonging to age group 41-60 years showed higher incidence
of extended hemorrhage and alveolar osteitis after extraction
of mandibular third molar(Figure-3&4). Considering gender,
22.64% of males and 19.93% of females experienced postoperative
pain(Figure-5). Similarly, 18.92% of females and 21.96% of
males were observed to have postoperative swelling after mandibular
third molar extraction(Figure-6).About 7.09% of females and
7.77% of males were observed with extended hemorrhage after
extraction(Figure-7). Among the study population, 8.11% of females
and 7.43% of males had alveolar osteitis(Figure-8). In terms
of type of wound closure, 36.82% of patients experienced postoperative
pain on primary closure while only 5.74% of patients
experienced postoperative pain on secondary closure(Figure-9).
About 40.20% of patients were observed with postoperative
swelling after extraction with sutures while only 0.68% of patients
had swelling after extraction without sutures(Figure-10).On
the contrary, 13.51% of patients were observed with extended
hemorrhage in secondary closure while only 1.35% of patients
were observed with extended hemorrhage in primary closure
(Figure-11).Similarly, 12.16% of patients had alveolar osteitis in
extraction without sutures while only 3.38% of patients had alveolar
osteitis incase of healing with sutures(Figure-12).
Results of this study showed that the main indicators that is postoperative
pain and swelling is higher in case of wound closure
with sutures when compared to wound closure without suture.
Whereas haemorrhage and alveolar osteitis were observed to be
slightly higher in sutureless wound closure which can be attributed
towards inadequate irrigation of extraction socket, remnants
of debris/ bone fragments in the socket, patient’s smoking habit,
oral hygiene practices and systemic disorders. Application of
0.2% chlorhexidine-based gel applied to the alveolar socket once
after extraction and prescribing prophylactic antibiotic courses in
patients with systemic conditions prevent the occurrence of alveolar
osteitis [20, 49, 44].
This result is in agreement with many of those reported in the
literature. Brabander and cattaneo evaluated two different types
of wound closure after removing third molars and concluded that
secondary closure was found to be preferable as it reduces pain
and swelling post surgery[4]. Pasqualini et al obtained results that
indicated that secondary closure of the socket causes less inconvenience
for the patients as it appears to minimise post extraction
swelling and pain [34]. In a split mouth study on 56 patients
conducted by Dubois et al showed that secondary closure was
found to minimise swelling and pain in the immediate postoperative
period, helping to reduce patient discomfort [9]. Holland and
Hindle showed that post operative pain and swelling markedly
less in secondary closure compared to primary closure [17]. In
contrast, Suddhasthira et al reported no differences according to
the type of wound healing [52]. Rakprasitkul and pairuch vej observed
no statistically significant differences in pain and swelling
between two groups of patients who underwent primary closure
and secondary closure [40]. Some authors suggested primary closure
of the flap, but keeping a drain in place during 72 hours while
the technique has no impact upon post operative pain, it has been
proven to reduce post operative swelling [46]. Therefore, dentists
should have sound knowledge regarding sutureless technique in mandibular third molar extraction and its effect on postoperative
healing [36, 28].
Our institution is passionate about high quality evidence based
research and has excelled in various fields. (Pc, Marimuthu and
Devadoss, 2018 [37]; Ramesh et al., 2018 [43]; Vijayashree Priyadharsini,
Smiline Girija and Paramasivam, 2018 [56]; Ezhilarasan,
Apoorva and Ashok Vardhan, 2019 [12]; Ramadurai et al., 2019
[41]; Sridharan et al., 2019 [51]; Vijayashree Priyadharsini, 2019
[55]; Chandrasekar et al., 2020 [7]; Mathew et al., 2020 [27]; R et
al., 2020 [45]; Samuel, 2021 [47]). We hope this study adds to this
rich legacy.
Figure 1: This bar graph represents the association between age and pain in the extraction socket post mandibular third extraction. X-axis represents the age and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done, p value = 0.000 <0.05 hence the association is statistically significant proving that age influences pain in the extraction socket post mandibular third molar extraction.
Figure 2: This bar graph represents the association between age and postoperative swelling in mandibular third molar extraction. X- axis represents the age and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done, p value = 0.000 <0.05 hence the association is statistically significant proving that age influences postoperative swelling in extraction of mandibular third molars.
Figure 3: This bar graph represents the association between age and extended hemorrhage post mandibular third extraction. X- axis represents the age and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done, p value = 0.000 <0.05 hence the association is statistically significant proving that age influences extended hemorrhage post mandibular third molar extraction.
Figure 4: This bar graph represents the association between age and alveolar osteitis post mandibular third extraction. X- axis represents the age and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done, p value = 0.002 <0.05 hence the association is statistically significant proving that age influences alveolar osteitis post mandibular third molar extraction.
Figure 5: This bar graph represents the association between gender and pain in the extraction socket post mandibular third extraction. X- axis represents the gender and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done, p value = 0.734>0.05 hence the association is not statistically significant proving that gender does not influence pain in the extraction socket post mandibular third molar extraction.
Figure 6: This bar graph represents the association between gender and postoperative swelling in mandibular third extraction. X- axis represents the age and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done, p value = 0.628>0.05 hence the association is not statistically significant proving that gender does not influence postoperative swelling in extraction of mandibular third molar.
Figure 7: This bar graph represents the association between gender and extended hemorrhage post mandibular third extraction. X- axis represents the gender and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done, p value = 0.972>0.05 hence the association is not statistically significant proving that gender does not influence extended hemorrhage post mandibular third molar extraction.
Figure 8: This bar graph represents the association between gender and alveolar osteitis post mandibular third extraction. X- axis represents the gender and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done, p value = 0.535>0.05 hence the association is not statistically significant proving that gender does not influence alveolar osteitis post mandibular third molar extraction.
Figure 9: This bar graph represents the association between type of wound closure and pain in the extraction socket post mandibular third extraction. X- axis represents the type of wound closure and Y-axis represents the number of patients who underwent mandibular third molar extraction.Pearson Chi square test was done, p value = 0.000 <0.05 hence the association is statistically significant proving that type of wound closure influences pain in the extraction socket post mandibular third molar extraction.
Figure 10: This bar graph represents the association between type of wound closure and postoperative pain in mandibular third extraction.X- axis represents the type of wound closure and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done, p value = 0.000 <0.05 hence the association is statistically significant proving that type of wound closure influences postoperative swelling in mandibular third molar extraction.
Figure 11: This bar graph represents the association between type of wound closure and extended hemorrhage post mandibular third extraction.X- axis represents the type of wound closure and Y-axis represents the number of patients who underwent mandibular third molar extraction. Pearson Chi square test was done, p value = 0.000 <0.05 hence the association is statistically significant proving that type of wound closure influences extended hemorrhage post mandibular third molar extraction.
Figure 12: This bar graph represents the association between type of wound closure and pain in the extraction socket post mandibular third extraction. X- axis represents the type of wound closure and Y-axis represents the number of patients who underwent mandibular third molar extraction.Pearson Chi square test was done, p value = 0.002 <0.05 hence the association is statistically significant proving that type of wound closure influences alveolar osteitis post mandibular third molar extraction.
Conclusion
Within the limitations of this study, it can be concluded that postoperative
pain and swelling were observed to be more in patients
who underwent extraction of mandibular third molars with sutures
compared to patients who underwent extractions without
sutures. Experience of pain and postoperative swelling was found
to be higher in the age group 18-40 years.Therefore, Secondary
closure has significant advantages over primary closure in terms
of postoperative pain, swelling and patients comfort.However,
due to small sample size, multicentre studies with large study population
are needed to be conducted for further analysation
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