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
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.
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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
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Co-author: Prof. Leo Stassen FRCS(I), FDSRCS, MA, FTCD, FFSEM, FFDRCSI, FICD
Professor/Chair of Oral and Maxillofacial Surgery, Dept of Oral and
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Maxillofacial Surgery, St James's Hospital, Dublin 8, Ireland; Department of Oral and
Maxillofacial Surgery, Dublin Dental University Hospital, Lincoln Place, Dublin 2, Ireland.
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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.
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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.
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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,
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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
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assess facial swelling and wound healing, and at one month, to assess wound healing.
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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.
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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
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significant difference between the two techniques in a) post-operative pain at day five (p =
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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).
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swelling.
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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-
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operative complications, that influence the recovery period, and affect the patient’s quality of
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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
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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
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difficult and may require more intense follow-up treatment, which potentially extends the
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time of post-surgical care.[5]
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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
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for healing in the surgical site that can take place, primary or secondary. The type of wound
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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
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maintained by using no suture, or by closing the flap partially, using a small number of
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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
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dressing, or insertion of a drain into the lower third molar surgical wound have been used to
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]
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This conflicting opinions have evolved into a wide variety of partial closure techniques, that
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have been tested, and compared to the traditional complete closure technique in several
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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
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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
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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
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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.
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Ethical approval for this clinical trial was granted from SJH/AMNCH Research Ethics Joint
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Committee in Ireland.
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sedation
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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
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5) Aged between 18 and 45
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6) Participants, who are willing to cooperate with the requirements of the study protocol.
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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
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guidelines
3) patient is not suitable for treatment under local anaesthetic with intravenous
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conscious sedation.
4) patient has a medical condition that could be complicated by the procedure (ASA
>II).
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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.
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8) patient who has an allergy or cannot tolerate the antibiotic and the analgesics used
in the study.
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Surgical sites were randomized into one of two Groups using random-numbers table
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generated using a random sequence generator: Group A: Sites received one suture, and Group
B: suture-less sites.
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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
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participants with sixty-two surgical sites, were needed to achieve an Alpha of 0.05 and Power
of at least 0.9.
Demographic variables
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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.
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Primary subjective outcomes
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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
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questionnaire, to assess post-operative bleeding, post-operative discomfort, post-operative
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swelling, and the patient adherence to the use of post-operative medications and mouth rinse.
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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
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imaginable pain (Fig.1). [31] The degree of facial swelling for each side was also evaluated
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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
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was evaluated for each side by counting the number of gauzes needed to stop bleeding on the
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day of surgery and the following post-operative days. Also, participants recorded the day on
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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
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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
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swelling, at one week post-operatively.
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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
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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
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involved in any aspects of the surgical procedure, or site allocation to either group.
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Agreement on evaluation was achieved between the assessors when they were asked to assess
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the same patient. The surgeon, who performed the surgery, removed the suture before the
The degree of socket epithelization was graded by the examiner at one week and one month
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The extent of soft tissue healing at the surgical site was evaluated at one week post-
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operatively using the Healing Index for Soft Tissue by Landry in 1985. [36] This index
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grades healing into five grades, depending on the color of tissues, epithelialization of wound
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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
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.
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Surgical difficulty
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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,
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difficult, and very difficult. Also, the level of surgical trauma was recorded based on three
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Surgical protocol
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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
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performed by the same surgeon (3rd Specialist Registrar in Oral Surgery), and under similar
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operative conditions. Each participant received the following pre-operative oral medications:
mouth wash.
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In theatre, and immediately before the removal of both lower third molars, the surgical sites
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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
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
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between the first and second molar, including the papillae between the first, second and third
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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
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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
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Stassen [37]. Bone removal was carried out using a tungsten carbide fissure bur (HP Oral
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Surgery TF 702, DENTSPLY, Switzerland), in a straight handpiece, under sterile 0.9 normal
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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
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gentle curettage of the socket were carried out, and followed by gentle irrigation using a
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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
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lingual papilla (Ethicon, 3-0 coated vicryl rapide W9935, Johnson & Johnson, Belgium) (Fig.
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7). Surgical sites in Group B did not receive any suture. Direct pressure was applied to the
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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
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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
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Statistical methods
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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
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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
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and soft tissue healing. A McNemar’s Test was used to assess differences in food
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impaction. Dependent t-tests were conducted to assess for difference in swelling measured at
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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
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surgical difficulty and operative time on the measured outcomes, as the use of multivariate
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Results
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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
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.
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Seven patients (20%) were regular smokers. Of the female participants, ten (40%) were on
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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
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ASA grade.
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The mean operative time for the sutured side was 21.5 minutes with a range of 7 to 36
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minutes; while the mean operative time for the suture-less side was 19.5 minutes with a range
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the sutured side (M = 21.49, SD = 7.83) and the suture-less side (M = 19.51, SD = 9.15), t
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(34) = 1.022, p = 0.314. There was also no statistical significant difference in surgical
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Seven cases of dry socket were reported in this clinical trial (10%), three patients developed
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bilateral dry sockets, and one patient suffered dry socket at the suture-less side. No cases of
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
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the difference in severity of pain from day one to day six. In addition, as the difference in
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operative time increased, so did the pain severity at five of the seven measurement periods.
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Facial swelling
For post-operative facial swelling as perceived by the patient, there were no differences
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between the sutured and non-sutured sides at all evaluation days (all p > 0.05) (Table. 3; Fig.
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10). The results of Spearman Correlation (Table. 4) indicate that the greater the difference
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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
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six (all p <0 .05). For post-operative facial swelling measured at one week, there was no
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significant differences between the suture and non-suture conditions at all measured lines (all
Post-operative bleeding
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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,
Wound healing
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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
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surgical difficulty, with degree of socket and soft tissue healing (all p >0 .05). Although non-
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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
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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).
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Discussion
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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,
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secondary closure techniques have shown better reduction in post-operative pain [6, 8-12, 14-
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17, 19-27, 39], post-operative swelling [6, 8-14, 17, 19-27, 39], and trismus [8, 14-17, 22-24,
Suture-less technique, a relatively new secondary closure technique, has shown good
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outcomes following lower third molar surgery. [7] Regardless of the flap design used for
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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
time, minimizes the trauma resulting from soft tissue manipulation, and decreases direct
costs. [7]
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.
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Post-operative pain
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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.
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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
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easy administration to the patient, it is more useful than other scales for audit ,and research.
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[45]
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Across seven evaluation time points in this clinical trial, the pain intensity was reported to be
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a maximum at twelve hours post-operatively, this is in agreement with findings from several
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studies in the literature which suggest that pain following lower third molar surgery reaches
The difference in pain scores between the two techniques from day one to day four was not
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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
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seventy-two hours after the surgery and then diminishes gradually, and in both techniques,
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 ≤
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0.05). Greater pain scores were reported in the suture-less sides at day five (p = 0.046) and
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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
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period of discomfort and continuous pain which is caused by hypersensitivity in the exposed
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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
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primary closure. [8-12, 39] These findings have been also reported when the one-suture
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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
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the surgery. [14] However, there are no previously published studies comparing the suture-
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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.
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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
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following lower third molar surgery. A few years later, Henrikson et al in 1985 proposed the
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use of VAS as a subjective method to measure facial swelling, when they compared the effect
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molar surgery.[55] This self-assessment method has been proven to be reliable and accurate
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mechanical measurement using an extra-oral cephalostat. [32] In later clinical trials,
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subjective evaluation of swelling by the patient has been utilized using different scales, for
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measuring facial swelling, following lower third molar surgery. [6, 19, 20, 22, 24, 25, 28, 57]
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In this clinical trial, we used two methods to evaluate facial swelling; 1) objective method to
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Montebugnoli et al in 2004 [33] and used also by Szolnoky et al in 2007 [34], and 2) a
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subjective self-assessment method using VAS described by Berge [32] , to assess swelling
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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]
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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
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found no statistical significant differences in facial swelling at day two, and day seven
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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
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inflammatory exudates to escape, which results in reduced post-operative facial swelling.
[30]
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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-
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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
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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
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Wound healing
Different methods have been used in the literature to assess wound healing following lower
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third molar surgery, these methods include: recording dehiscence at the incision lines [6, 21,
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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]
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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
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The wound healing in the present clinical trial was assessed by measuring different clinical
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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
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health at the buccal site of the adjacent lower second molar.
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The assessment of socket healing was carried out using a five-grade index to measure the
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degree of socket epithelization, which was designed specifically for the purpose to be used by
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The results of this trial demonstrated a statistically significant better socket healing on sites
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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
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post-operatively in five suture-less flap (14.3%) and one sutured flap (2.9%).
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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
secondary closure techniques. Some investigators reported better wound healing associated
with primary closure, when compared to various secondary closure techniques [21, 24, 26],
compared primary closure alone to primary closure with tube drain placement.[28]
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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
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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
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group [11], Ricard et al in 2015 reported two cases of dry socket and two cases of infection in
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the primary closure group, and no cases reported in the suture-less group. [39]
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incidence when the wound closed primarily, when compared to the wounds that received
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A few studies have reported a higher incidence of food impaction in the suture-less technique
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[9, 39], and other secondary closure techniques [23], when compared to primary closure.
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The results of this trial showed no significant difference between the two techniques with
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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
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= 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
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molar in primary closure compared to secondary closure, and this difference was statistically
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significant at one site. [15]
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Post-operative bleeding
A subjective method was used to compare post-operative bleeding between the two
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techniques in this clinical trial. The patient was asked to count the number of gauzes used to
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stop bleeding, for each surgical site, on each day post-operatively, also, the patient reported
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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
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reported cases of excessive bleeding that needed any intervention through a local dentist or
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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
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the suture-less technique to the primary closure. [11] The same observation was reported by
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Pasqualini et al in 2005, who compared secondary closure to the primary closure technique,
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eight hours in the secondary closure technique cases when compared to primary closure. [13]
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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
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In this clinical trial, we were able to demonstrate a strong correlation between the level of
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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
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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]
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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-
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operative pain from day one to day six. In addition, as the difference in operative time
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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
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when lower third molar surgery takes longer time [13, 47, 68-71], and when the lower third
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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
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more post-operative swelling in difficult lower third molar surgery [75], or when surgery
One of this study limitations is the short follow-up period which was not long enough to
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fully assess the periodontal condition around the lower second molar. We were unable
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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
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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
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the effect of the two closure techniques on the post-operative trismus, as both treatments were
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carried out at the same time. A clinical trial of parallel-group design is required in order to
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Conclusion
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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
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that operative time and difficulty of surgery have an impact on the severity of post-operative
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complication.
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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.
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Figures legend
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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).
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Fig. 3. Facial measurements for evaluation of facial swelling (Szolnoky et al., 2007).
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Fig. 4. Grades of socket healing.
Fig. 6. Modified buccal envelope flap for lower third molar surgery.
with no extension into the cheek. It protects a high lying lingual nerve, if it lies over
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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
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Fig. 10. Median facial swelling for suture and non-suture conditions.
swelling).
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Fig. 11. Means for differences between pre-operative and post-operative values for facial
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.
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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
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12 Hours Suture 4.85 2.45 -.628 .530
Non-Suture 5.25 2.41
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24 Hours Suture 4.57 2.06 -1.10 .270
Non-Suture 4.34 2.09
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48 Hours Suture 4.65 2.09 -.811 .417
Non-Suture 4.51 1.96
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72 Hours Suture 4.28 2.44 -.230 .818
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Non-Suture 4.45 2.48
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Operative Time p .028* .030* .001* .060 .045* .022* .074
n 35 35 35 35 35 35 35
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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
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* p ≤ 0.05
** r = 0.4 to 0.59 indicates moderate correlation
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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
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Suture 2.74 1.357 -1.33 .183
Day 2
Non-Suture 2.48 1.291
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Suture 2.28 1.250 -.835 .404
Day 3
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Non-Suture 2.11 1.182
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Non-Suture 1.60 1.034
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Suture 1.05 .937 -.068 .946
Day 5
Non-Suture 1.11 .963
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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.
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Operative Time p .001 .002 .001 .001 .019 .004
n 35 35 35 35 35 35
** ** ** ** ** **
r .514 .426 .469 .543 .453 .433
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* * * * * *
Difficulty Scale p .002 .011 .005 .001 .006 .009
n 35 35 35 35 35 35
* p ≤ 0.05
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** r = 0.4 to 0.59 indicates moderate correlation
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Table 5. Means, standard deviations, and dependent t-tests for difference in facial swelling
measurements.
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Suture .1343 .341 1.917 .064
Line 2
Non-Suture -.0171 .315
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Suture .0829 .434 .865 .393
Line 3
Non-Suture -.0086 .393
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Suture .1371 .548 1.172 .249
Line 4
Non-Suture .0029 .586
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Suture .2200 .829 .576 .568
Line 5
Non-Suture .1371 .586
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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
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Suture 1.42 1.70 -1.23 .227
Day 1
Non-Suture 1.74 2.22
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Suture .657 1.37 .683 .499
Day 2
Non-Suture .571 1.17
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Suture .057 .338 .442 .661
Day 3
Non-Suture .028 .169
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Suture .000 .000 a
Day 4
Non-Suture .000 .000
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Suture .000 .000 a
Day 5
Non-Suture .000 .000
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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
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CAL Suture .657 1.37 -.159 .875
change Non-Suture .571 1.17
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Suture .057 .338 -.903 .373
Deepest PD
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Non-Suture .028 .169
change
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