Removal dental of?ce. After removal of the

Removal
of impacted mandibular third molar is a routine procedure performed in the
dental of?ce. After removal of the impacted mandibular third molar, the
conventional method is to suture the surgical wound and allow it heal by
primary intention.

 Third molar surgeries are
associated with an unpleasant postoperative experience by the patients,
referred to as postoperative morbidity1, which is more common in the
mandible than in the maxilla.2,3 Postoperative morbidities can be
grouped into immediate postoperative tissue reactions and complications. The
immediate postoperative tissue reactions are characterized by pain, swelling,
trismus, and dysphagia.4,5 Complications, which are unwanted reactions that may not
necessarily follow the surgical procedure, include: bleeding or haemorrhage ,
postoperative infections like dry socket , nerve injury, delayed healing and
the creation of a periodontal pocket in the distal aspect of the adjacent
second molar.

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Page 1

Primary and secondary
closure are used for the wound management after extraction of impacted lower
third molars. There have been many studies to determine the effect of these
wound closure techniques on postoperative pain, swelling and trismus.6,7,8,9,10 Factors
affecting postoperative morbidity have been a topic of extensive research,
focusing mainly on the methodology of the surgery or on the drugs used in
conjunction with the surgery. Wound closure technique in third molar surgery is
an operative factor whose effect has been associated with controversy and can
consist of total closure, in which the mucoperiosteum is hermetically sealed,
or partial closure, in which a window exists or is created to allow healing by
secondary intention. Studies that sought to determine the effect of partial or
total wound closure on immediate postoperative tissue reactions and
complications are few and the results were diverse necessitating further
studies.  It was hypothesized that the wound closure
technique will affect the course of healing after surgical extraction of an
impacted third molar.

This study therefore compares partial and total
wound closure techniques after surgical extraction of impacted mandibular third
molar teeth. It compares the extent of facial swelling and degree of limitation
of mouth opening.

Materials
and methods

A randomized clinical trial was carried out, in
which all consenting adult patients with impacted mandibular third molars
attending Faculty of Dentistry, Melaka Manipal Medical College were recruited.

The
inclusion and exclusion criteria are:

 

 

A.   
Inclusion criteria

–         
All
patients undergoing surgical removal of mesio-angular impacted  mandibular third molars attending Faculty of
Dentistry, Melaka Manipal Medical College

–         
Patients
ranging from the age 20 – 60 years

–         
Healthy patients ( ASA I ) or patients
with systemic mild disease with no functional limitations ( ASA II ).

–         
Patients who are not allergic to the drugs
or anesthetic agent used in the surgical protocol.

B.     Exclusion
criteria

–         
Patients
with systemic diseases falling into ASA III, ASA IV and ASA V category.

–         
Patient
which has systemic
conditions that might have an effect on bone growth and/or periodontal healing
(such as uncontrolled diabetes mellitus or on immunosuppressive medications)

–         
Patients
using antibiotics premedication or any other drugs that would affect wound
healing.

MATERIALS

METHODOLOGY

All the patients were
randomly allocated into 2 groups:

 

l  Group
I, surgical extraction wound closed by partial closure technique

l  Group
II, surgical extraction wound closed by total closure technique.

 

All
the patients undergoing surgical removal of impacted mandibular third molar
tooth will be asked to report to the clinic on day 3, day 7 and any other time
if anything unusual was noticed.

 

Surgical
operations will be carried out by students under the supervision of a
specialist with the patient under local anesthesia. The anesthesia will be
achieved with 3.6 mL of 2% lignocaine with a 1:100,000 dilution of epinephrine.
Anesthesia will be achieved by a combination of inferior alveolar, lingual, and
buccal nerve blocks. Additional volume of anesthesia will be used and properly
documented when necessary. Access will be gained through a 3-sided
mucoperiosteal flap. Ostectomy will be carried out with a fissure bur and
normal saline solution irrigation. With adequate ostectomy, elevation of the
tooth will be carried out, followed by socket toileting. Sectioning of the
tooth will be carried out whenever necessary. The wound closure will be partial
or total depending on which group the patient belonged to. Total closure will
be achieved by suturing that was hermetically carried out, sealing off
communication with the oral cavity. This will be achieved by 5 interrupted
sutures: 1 each placed mesial and distal to the lower second molar, 1 each
placed across the relieving incisions, and another 1 placed across the socket.
Partial closure suturing will be carried out leaving a window communicating
with the oral cavity. Three interrupted sutures will be used : 1 each placed
mesial and distal to the second molar and 1 placed at the vestibular end of the
relieving incision. After the achievement of hemostasis, patients will be given
amoxicillin capsule (Richamox; S&B, Middlesex, UK), 500 mg every 8 hours
for 5 days; metronidazole (Flagyl; S&B), 400 mg every 8 hours for 5 days;
and diclofenac potassium tablets (Cataflam; Novartis, Basel, Switzerland),  50 mg every 8 hours for 3 days. The patients
will be given a standard postoperative instructions and discharged.

 

Evaluation

Ø  Assessment
of mouth opening will be done by measuring the maximum interincisal distance
from the incisal edge of the upper right central incisor to the incisal edge of
the lower right central incisor using a Vernier calliper. Three readings will
be taken for each patient, and the mean will be determined. This constituted
the reading for the particular day. Baseline measurements will be taken just
before surgery, and similar readings will be carried out on days 3 and 7
postoperatively.

Ø  Assessment
of swelling will be done where three line measurements—AC, AD, and BE—will be made
with a flexible tape, and the sum will be found. These measurements will be repeated
3 times, and the mean determined. A baseline measurement will be carried out
just before surgery, and similar measurements will be carried out on days 3 and
7 after surgery. The difference between the postoperative and baseline readings
constituted the degree of swelling for each day.

 

Three line measurements for facial swelling:
– most posterior point at midline on tragus (A)
– lateral canthus of eye (B)
– most lateral point on corner of mouth (C)
– soft tissue pogonium, which is most prominent point at midline on chin
(D)
– most inferior point on angle of mandible (E).
 

 

 

 

 

 

 

 

 

 

 

 

Page 12

Statistical Analysis

Data
entry and analysis is done using Epi
Info™ 7 (7.1.5) software and SPSS system version 12.0.

Mann-
Whitney Test was carry out to analyse the change between 2 groups (partial
closure and complete closure) in every parameter.

Mann-
Whitney Test consists of following:

      a.   Mean
difference (can be positive or negative value)

b.  
Median (Q1-Q3)

c.   P
value

Uses of 5%
probability of chances of deviation ( p value ) are standardized
in this study. The determination of p value >0.05 is the relative
standard value in basis of accepting the null hypothesis.

Friedman test is the
non-parametric alternative to the one-way ANOVA with repeated measures. It is
used to test for
differences between groups (complete closure ad partial closure) when the
dependent variable being measured is ordinal.

Friedman test consists of

a.      
Median (Q1-Q3)  of AC, AD, BE, MO
of 1st day, 3rd day, and 7th day

b.     
P value

 

Uses
of 5% probability of chances of deviation ( p value ) are
standardized in this study. The determination of p value >0.05 is the
relative standard value in basis of accepting the null hypothesis.

ETHICAL
CONSIDERATION

The ethical considerations addressed are:

•     
Ethical approval obtained from Human and Ethics
Committee of Melaka Manipal Medical College.

•     
Informed consent form is collected from the
patient prior to the commencement of the surgical procedure.

Result

Table 1

Sociodemographic Data of
patients undergoing extraction of mandibular teeth at Faculty of Dentistry,
Melaka Manipal Medical College

 

Partial
closure
N=15

Complete
Closure
N=15

 
Age
Mean
(SD)
Min-
Max)

 
 
25.93
(4.61)
20-40

 
 
28.73(7.50)
22-44

 
Sex
(%)
M
F

 
 
5
(45.45)
10
(52.63)
 

 
 
6 (54.5)
9
(47.37)

 

In this
study, a total of 30 patients were treated. In every patient, a single
mesioangular impacted 3rd molar was surgically removed. They were
divided into two groups which is partial closure group and complete closure group.
In partial closure technique, there are 5 males (45.45%) and 10 females
(52.63%) with an age range of 20-40 years old ( Mean: 25.93, SD: 4.61). In complete
closure group, there are 6 males (54.5%) and 9 females (47.37%) with an age
range between 22-44years old (Mean: 28.73, SD: 7.5).

 

Table
2

AC,AD,
BE, Mouth Opening at 1st, 3rd, 7th day between
partial closure and complete closure

 

Partial
Closure
Median (Q1-Q3)

Complete
Closure
Median (Q1-Q3)

P value

1st
day
AC
AD
BE
MO

 
11.8 (11-12.9)
15.2 (14-15.6)
10.9 (8.2-11)
4.1 (3.5-4.5)

 
11.57 (11.45-12.47)
15.03(14.3-15.9)
10.7 (10.17-11.45)
4.1 (4-4.6)

 
0.6184
0.9174
0.4550
0.5332

3RD  day
AC
AD
BE
MO
 

 
12.53 (11.73-13.53)
16 (14.67-16.7)
11.37 (8.8-11.5)
3.5 (3.1-4)
 

 
12.4 (12-13.03)
15.5 (14.8-16.5)
11.53 (10.53-12.07)
3.5 (2.6-3.6)
 

 
0.6629
0.6782
0.2046
0.1140
 

7th
day
AC
AD
BE
MO

 
11.9 (11.23-13)
15.5 (14.33-15.7)
10.9 (8.3-11.11)
3.8 (3.4-4.4)
 
 

 
11.8 (11.3-12.6)
15.2 (14.51-16)
10.97 (10.26-11.5)
3.7 (3-3.83)

 
0.7714
0.8033
0.2715
0.1976

 

The
reference points AC,AD, BE and the  Mouth
Opening were taken on the 1st day before extraction and reassessed
on the 3rd and 7th day. Table 2 shows the P values for
all the reference points among both groups were all less than 0.05 which
indicates that there is no significant difference of postoperative swelling and
limited mouth opening in both groups.

 

 

 

Table 3

AC, AD, BE, MO at 1st, 3rd, 7th
day among groups (Partial Closure and Complete Closure)

Type of Wound Closure

1st day
Median (Q1-Q3)

3rd day
Median (Q1-Q3)

7th day
Median (Q1-Q3)

P value

Partial closure
AC
AD
BE
MO

 
11.8 (11-12.9)
15.2 (14-15.6)
10.9 (8.2-11)
4.1 (3.5-4.5)

 
12.53 (11.73-13.53)
16 (14.67-16.7)
11.37 (8.8-11.5)
3.5 (3.1-4)

 
11.9 (11.23-13)
15.5 (14.33-15.7)
10.9 (8.3-11.11)
3.8 (3.4-4.4)

 

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