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British Journal of Oral and Maxillofacial Surgery 50 (2012) 256258

The effect of sutureless wound closure on postoperative pain

and swelling after impacted mandibular third molar surgery
Hamid Mahmood Hashemi a, , Majid Beshkar b , Reihaneh Aghajani c
a Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
b Department of Oral and Maxillofacial Surgery, Craniomaxillofacial Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran,
Iran
c Department of Prosthodontics, Azad University, Tehran, Iran

Accepted 28 April 2011

Available online 1 June 2011

Abstract

Our aim was to assess the influence of sutureless and multiple-suture closure of wounds on postoperative complications after extraction of
bilateral, impacted, mandibular third molars in 30 patients in a split mouth study. After the teeth had been removed, on one side the flap was
replaced but with no suture to hold it in place (study side), and on the other side the wound was closed primarily with three sutures (control
side). Recorded complications included pain, swelling, bleeding, and formation of periodontal pockets. The results showed that patients had
significantly less postoperative pain and swelling when no sutures were used (p = 0.005). There were no signs of excessive bleeding or oozing
postoperatively on either side. Six months postoperatively there was no significant difference in the depth of the periodontal pocket around
the second molar.
2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Pain; Swelling; Surgical wound; Third molar

Introduction minimum number of sutures to allow a drainage path to be

Extraction of impacted teeth is one of the most common
operations in oral and maxillofacial surgery. Postoperative
pain and swelling are common, and so surgeons have always
sought to use techniques that lessen them. Damage to the
capillary vessels and the release of inflammatory cytokines
as a result of the trauma lead to increased permeability of ves-
sels, which results in accumulation of serosanguinous fluid
and exudate.1 With this in mind, it is plausible to hypothesise
that the maintenance of a pathway to drain the inflammatory
exudates and fluids after extraction may lead to less postoper-
ative pain and swelling. Placing drains in the surgical wound
at the end of the procedure, and closing the wound with the
Corresponding author. Tel.: +98 21 2610 4392.
E-mail addresses: hamid5212@yahoo.com (H.M. Hashemi),
majid.beshkar@yahoo.com (M. Beshkar).
maintained, are two ways of draining exudate. We used the
latter method in this clinical split mouth study to test the
above hypothesis.
Patients and methods
We designed a randomised clinical trial using a split mouth
design, by which the subjects served as their own con-
trols. The study sample was derived from the patients
referred for management of impacted third molars to the
department of Oral and Maxillofacial Surgery, Faculty of
Dentistry, Tehran University of Medical Sciences, Tehran,
Iran, September 2008 to January 2010. The ethics commit-
tee of Tehran University of Medical Sciences approved the
study design, and informed consent was obtained from all
patients.

0266-4356/$ see front matter 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2011.04.075

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 H.M. Hashemi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 256258 257

Table 1 Table 2
Patients studied (n = 30). Mean (range) swelling (mm) (n = 30 in each group).
Variable Number (%) Day Study group Control group
Sex 1 1.7 (0.62.7) 3.1 (0.46.8)
Male 8 (27) 3 10 (6.613.4) 18 (14.721.8)
Female 22 (73) 7 5 (2.87.2) 9.2 (6.611.7)
Age (years)
Mean 22
Range 1924 tistical Package for Social Sciences, version 8.0, for Windows
(SPSS, Chicago, IL, USA).

The inclusion criterion was bilateral, bony, mandibular Results

third molars that were fairly similar in terms of angulation,
degree of impaction, and estimated difficulty of removal. Thirty patients who required removal of bilateral, bone-
Exclusion criteria included: the presence of any medical prob- impacted mandibular third molars were included in the study
lem that would contraindicate extraction; the presence of (Table 1). There was significantly less swelling and pain
any pathological lesion in the area of the impacted teeth; on the third (p = 0.005) and seventh (p = 0.005) postoper-
and soft tissue impaction that did not require removal during ative days in the study group than in the control group
extraction of the tooth. (Tables 2 and 3).
One of the two impacted mandibular third molars in each None of the patients developed postoperative infection or
patient was randomly allocated to the study or the control alveolar osteitis, or both, in either the control or the study
group. One single surgeon from the faculty extracted all the side. None of the patients reported excessive bleeding or ooz-
teeth, with strict attention to infection control. The teeth were ing postoperatively on either side. Six months after extraction
extracted under local anaesthesia with 2% lignocaine and there were no significant differences from preoperative values
1:100,000 epinephrine. Full thickness mucoperiosteal trian- (p = 0.005) between the depths of periodontal pockets around
gular flaps were used to gain access to the site of impaction. the second molars on either group. The depth of the periodon-
Bone was removed and teeth sectioned with burs under con- tal pocket around the second mandibular molar was less than
stant irrigation with sterile normal saline. After each tooth 3 mm on both sides in all patients.
had been removed the site was irrigated with equal amounts
of sterile normal saline on both sides. On the study side the
flap was replaced in its original position but no suture was Discussion
inserted to hold it in place. In the control group one 3/0 silk
suture was inserted over the releasing incision, and two oth- In a recent split mouth study, Danda et al.2 compared the
ers were placed over the distal arms of the flap to achieve influence on postoperative pain and swelling of primary and
primary closure. Teeth on the two sides were extracted at the secondary closure of the extraction wound after removal of
same session. A small gauze pad was placed over the wound impacted mandibular third molars. In the primary closure
on each side and the patient was instructed to bite on it for group, 2 sutures were placed on the distal arm of the inci-
40 min. sion and one on the mesial arm of the incision. In the
All patients were given amoxicillin 500 mg 3 times daily secondary closure group, a wedge of mucosa distal to the
for 5 days and acetaminophen 500 mg 4 times daily for 3 second molar was removed and then only 1 suture was
days postoperatively. They were instructed to use an ice pack placed on the distal arm of the incision and 1 suture on
over the skin of the extraction site for the first 6 h. They were the mesial arm. The results showed that patients in the
also instructed to rinse their mouth with 0.2% chlorhexidine
for 5 days after extraction. Preoperatively, and 1, 3, and 7 Table 3
days postoperatively, the distance from the corner of mouth Pain scores in the two groups (n = 30 in each).
to the most inferior part of the ear lobe was measured (mm) Day Pain score
over the skin as an indicator of the amount of swelling at
0 1 2 4
the surgical site. All measurements were made on both sides
and compared with the preoperative values. For assessment Day 1
Study 28 (93) 0 2 (7) 0
of postoperative pain, patients were provided with a visual Control 22 (73) 8 (27) 0 0
analogue scale (VAS) with 6 scores. A score of zero indicated Day 3
no pain while a score of 5 indicated extremely severe pain. Study 12 (40) 12 (40) 6 (20) 0
These data were also collected on the first, third, and seventh Control 2 (7) 10 (33) 14 (47) 4 (13)
postoperative days. Day 7
Study 24 (80) 6 (20) 0 0
The significance of differences between the sides was Control 14 (47) 12 (40) 4 (13) 0
assessed using Students paired t test with the help of the Sta-

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258 H.M. Hashemi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 256258
secondary closure group had significantly less pain and
swelling postoperatively than those in the primary closure
group. This study was similar to ours in terms of objec-
tives, study design, and results. However, an advantage of
our study was that we evaluated swelling objectively (mm)
while Danda et al.2 evaluated it subjectively using a VAS.
We also provided results from the 6-month follow up, which
showed that secondary wound healing did not increase the
depth of the pocket around the second molar. Waite and
Cherala3 evaluated the outcomes of 1280 extractions of third
molars when no sutures were used for wound closure (suture-
less technique), and showed that the sutureless technique
gave favourable results in terms of postoperative compli-
cations. Dubois et al.4 also conducted a split mouth study
and showed that secondary closure resulted in reduced pain,
swelling, and discomfort in the immediate postoperative
period.
In a similar study, Pasqualini et al.5 found that hermeti-
cally suturing the flap after removal of impacted mandibular
third molars resulted in significantly more pain and swelling
postoperatively than when the surgical wound was allowed to
heal secondarily. They did not use a split mouth design or an
objective method to evaluate the amount of swelling between
patients.
Several other studies have also assessed the effect on post-
operative complications of inserting a drain into the wound
after removal of impacted third molars. Cerqueira et al.6
found that the use of a drain significantly reduced the amount
of postoperative swelling but did not significantly reduce
the amount of pain and trismus. In a randomised crossover
study, Saglam7 found that inserting a drain reduced postop-
erative facial swelling. The degree of trismus was greater in
the no drain group, but the difference was not significant.
The results of a study by Chukwuneke et al.8 indicated that
the use of a rubber drain reduced postoperative discomfort
in the form of swelling and trismus, but seemed to have
no effect on pain. Rakprasitkul et al.9 compared the inser-
tion of a small tube drain with primary wound closure (drain
group) with simple primary wound closure (no drain group).
They found no significant difference in the severity of pain
between the two groups, and there was significantly less
facial swelling in those in the drain group. The number of
patients with wound breakdown, oedema, and bleeding was
also less in the drain than in the no drain group. However, de
Brabander et al.10 found that insertion of a drain and allow-
ing the surgical wound to heal secondarily has no significant
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influence on the amount of postoperative pain, swelling, or
trismus.
In conclusion, the results of our study indicate that, after
extraction of impacted mandibular third molars, allowing the
surgical wound to heal secondarily with no sutures is bene-
ficial in terms of reducing the amount of postoperative pain
and swelling. Considering the results of other studies, we
suggest that maintaining or creating a path through which
inflammatory exudates could be drained from the site may
help to reduce postoperative complications after extraction
of impacted teeth.
Conict of interest
The authors have no conflict of interest.
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