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Comparison of two different suture knot techniques on postoperative morbidity after impacted mandibular third molar surgery
J Stomatol Oral Maxillofac Surg 121 (2020) 206–212
Available online at
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Original article
Comparison of two different suture knot techniques on postoperative morbidity after impacted mandibular third molar surgery B. Ege a,*, E. Najafov b a b
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Adıyaman University, Adıyaman 02200, Turkey Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 January 2020 Accepted 6 February 2020 Available online 12 February 2020
Introduction: In third molar surgery, one of the most important factors is how the wound was closed. Tight suturing of the wound commonly gives more discomfort to the many patients in terms of postoperative pain, swelling and trismus. The purpose of this study is to investigate the effects of two different knot techniques in suturing after extraction of impacted mandibular third molars (IMTM) on quality of life and postoperative complications such as pain, swelling and trismus. Material and methods: This study was conducted with a randomized and split-mouth design and included 50 patients over the age of 18 in the ASA I group who had bilateral horizontal impacted mandibular third molars. In all patients, the wounds were closed by simple sutures by applying two different knot techniques as locked (Group L, n = 50) and unlocked (Group UL, n = 50) knots. In the postoperative period, pain, swelling, trismus, chewing activity and quality of life were examined. Results: In the group where the unlocked knotting technique was used, significantly better results were obtained in comparison to the group where the locked knotting technique was used for all values (P < 0.05). Conclusion: In preventing postoperative complications that are observed after impacted mandibular third molar surgery and affect the quality of life of patients negatively, suturing of the wound by the method of unlocked knotting is a useful technique that may be preferred.
C 2020 Elsevier Masson SAS. All rights reserved.
Keywords: Impacted third molar Knot techniques Suturing Postoperative morbidity
1. Introduction While impacted mandibular third molar (IMTM) teeth are asymptomatic in some patients, in some others, they may affect quality of life and lead to infections, cavities in adjacent teeth, periodontal destruction, loss of function and occasionally orthodontic problems. For such reasons, IMTM surgery is one of the most frequently performed operations in the field of Oral and Maxillofacial Surgery. After surgery of these teeth, as expected, complications such as pain, swelling and trismus are frequently observed [1,2]. Moreover, unwanted hemorrhages, dry socket in the place of extraction and unwanted situations such as nerve damages may also sometime occur. In many different studies in the literature, it is seen that cryotherapy, ozonotherapy, medical treatment and different incision and flap designs have been used to minimize these complications [3–8]. Most physicians think that the duration of surgery, the degree of difficulty of the tooth and the
* Corresponding author. E-mail address: [email protected] (B. Ege). https://doi.org/10.1016/j.jormas.2020.02.002 C 2020 Elsevier Masson SAS. All rights reserved. 2468-7855/
trauma induced during surgery have an effect on these complaints in the postoperative period. For this reason, postoperative success is very closely related to not only the patient-based individual differences but also factors such as the occupational, theoretical and practical skills of the surgeon, closure of the wound and postoperative oral care [9,10]. Mainly, in primary closure, the wound is hermetically closed by suturing based on main surgical principles. In the secondary closure technique, the socket is in an interaction with the oral cavity, and it facilitates the drainage of inflammation. Regarding the issue of closing the wound, various opinions on different techniques such as primary or secondary closure have been debated for years. In some studies on this topic, primary closure methods with different suturing techniques were compared, and their effects on postoperative complications were examined [11– 16]. While some researchers utilized primary closure by using different suturing techniques, [17] some others preferred the method of secondary healing without using any sutures, and it is reported in general that primary closure causes more pain and swelling [15,16,18,19]. A few studies reported that there is no difference between primary and secondary healing [20].
B. Ege, E. Najafov / J Stomatol Oral Maxillofac Surg 121 (2020) 206–212
Nevertheless, we have experienced that, in addition to the positive characteristics of the method of secondary, or suture-free, healing, it is not a method that can be applied in all patients after all surgical procedures in the oral region, and its usage in the oral region has some limitations. To prevent the risk of the emergence of unwanted complications due to poor oral care when secondary recovery is preferred, we believe that a loose and tieless primary closure method may provide a positive effect on recovery as in the method of secondary closure. This is the first study to assess the effects of different knot techniques of primary closure applied in IMTM surgery. For this purpose, in our study, we investigate the effects of primary closure applied by using two different knotting techniques as locked and unlocked on postoperative complications and quality of life in patients after impacted third molar surgery.
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Other inclusion criteria were: age of 18 years or older; American Society of Anesthesiology (ASA) physical status class I (normally healthy patient); patients with no systemic diseases or medical conditions; no medication use; no discernible active pathology associated with the third molars at the time of surgery; no local inflammation and no acute pericoronitis; patients with healthy dental and periodontal status; not allergic to the drugs or anesthetic agents used in the surgical protocol; patients who were able to understand verbal and written instructions.
2. Materials and methods On the contrary: 2.1. Study design This study was designed and performed as a randomized, prospective, split-mouth clinical study in patients who were referred to the Department of Oral and Maxillofacial Surgery of Adıyaman University for surgical removal of impacted mandibular third molars. This trial was performed in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement (http://www.consort-statement.org/) [21]. This study was conducted according to the ethical principles described in the Declaration of Helsinki, and the research protocol was approved by the Ethics Committee of the University of Adıyaman. Fifty patients with similar bilaterally impacted mandibular third molars were included in this clinical trial. This way, it was aimed to ensure the standardization of the study. The objective of the procedure was explained at the first appointment. Potential complications were discussed, and the anticipated postoperative course was described. Before the study, all patients were informed about the procedures, postoperative recovery times and possible complications. They then signed a written consent form and were also notified of their right to withdraw from the study at any time without prejudice. 2.2. Inclusion and exclusion criteria Preoperative examinations included intraoral and radiographic examination. A panoramic radiograph was taken to assess third molar angulations to the long axis of the second molar. The Winter [22] and Pell and Gregory classifications [23] were used to evaluate the positions of the impacted third molars. Patients with bilateral symmetrically impacted mandibular third molars with horizontal (Winter classification) and class III, C impaction (Pell and Gregory classification) were included (Fig. 1).
Fig. 1. The appearance of bilateral horizontally impacted third molar teeth on panoramic radiography.
ASA > 1; Smoking; allergy or contraindications to the anesthetics employed; presence of systemic disease; antiplatelet or anticoagulant therapy; pregnant or lactating women and women regularly using oral contraceptives; recent (<15 days) local infection in the oral cavity; previous radiation therapy to the maxillofacial region; local pathology (e.g., cyst or tumor) associated with the third molars; patients with poor oral hygiene were excluded from the study.
Patients with apparent differences in the duration of operation between the left and right sides were excluded from the study since this might have masked the possible effect of flap design after surgery. The data of the patients included and not included in the statistical analysis are shown in Fig. 2 (flow diagram). In all cases, the impacted molars were extracted in two sessions, one involving locked suture and the other involving unlocked suture design. A minimum of 1 month was allowed to elapse between the two procedures. The patients selected for the study were randomly assigned into one of the different suturing groups: closure with Locked suture technique on the right side (n = 50); closure with Unlocked suture technique on the left side (n = 50).
2.3. Surgical procedure Treatment was started after we obtained a full medical and dental history and panoramic radiography, as well as a 3dimensional computed tomography scan if indicated. All surgical procedures were performed by the same surgeon (B.E.), a specialist with more than 5 years of experience in oral and maxillofacial surgery in the same operating room using the same surgical instruments, rotary and irrigation devices and materials. Before the procedure, the face was prepared with betadine solution, and standard draping was provided. All patients were washed with 5–10 ml of Chlorhexidine for 2 min preoperatively. All patients received a standardized mandibular block injection with additional infiltration of the buccal nerve. The effective local anesthesia was achieved with 2% lidocaine hydrochloride and 1:200,000 epinephrine (Jetokain; Adeka, Turkey). No preoperative drugs were given in any patients. All surgical procedures were performed in a standardized fashion using a similar technique. A full-thickness envelope flap was used in all patients; a buccal sulcular incision extending from
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Fig. 2. Patient flow diagram according to the CONSORT statement.
the first molar to the second and a distal relieving incision to the mandibular ramus. The flap was reflected, the surgical site was exposed, and any bone overlying the crown of the impacted third molar was removed with a round surgical bur. Then, the tooth was sectioned with a fissure bur. The tooth crown was sectioned under abundant irrigation in all cases. All parts of the tooth were loosened with a lever and removed. After completing extraction, curettage of the socket was performed in addition to irrigation with a sterile saline solution. Care was taken to eliminate any sharp irregular edges and the inter-radicular bone. After achieving proper hemostasis, the flaps were sutured in an interrupted fashion at four points (Fig. 3). Group L (Locked suturing): the flap was repositioned and sutured with the locked technique (straight-reverse-straight) hermetically using 3–0 black silk. Group UL (Unlocked suturing): the flap was repositioned and sutured with the unlocked technique (three straight knots) loosely using 3–0 black silk (Fig. 4). Immediately after surgery, the details of the procedure were recorded by an independent specialist including the suturing time (from the needle entering the tissue to the last knot), total operation time (from taking incision to the last suture) and any intraoperative complications (systemic and local side effects) occurring during the procedure. All patients received postoperative instructions, and Amoxicillin (Largopen 1000 mg, 2 1/day; Bilim); Ibuprofen (Brufen 400 mg, 3 1/day; Abbott); 0.2% chlorhexidine gluconate (Klorhex 30 mL, 2 1/day; Drogsan)
Fig. 3. Incision line and wound closure.
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Fig. 4. The view of knot (straight or reverse) techniques used: A. Unlocked Group; B. Locked Group.
were prescribed to all patients for 5, 7 and 5 days, respectively. Postoperative recommendations included soft diet and oral hygiene instructions using a 0.2% chlorhexidine mouth rinse. The sutures were removed on the postoperative day 7. The patients underwent surgery on only the right side at a given appointment, with the left side being operated on after a period of 4 weeks. 2.4. Outcome measures
2.7. Trismus Trismus was measured between the incisal edges of the upper and lower central incisors when the patient was seated upright, and the orbito-meatal line was parallel to the floor. Preoperative evaluation was performed by measuring the distance between the mesial-incisal corners of the upper and lower central incisors at the maximum opening of the jaws, on postoperative days 1, 2 and 7.
The surgeon could not be blinded due to the nature of the interventions. One specialist, responsible for calculation and not involved in the selection and intervention of participants, performed all the measurements. The data collection methods were as follows: The patients were recalled on postoperative days 1, 2 and 7, during when trismus, swelling, wound healing and chewing activity were evaluated. Additional follow-up visits were arranged through the department, depending on requirements. 2.5. Pain All patients were additionally given a 5-point visual analog scale (VAS) form. This comprised from no pain on the left to the extremely severe pain on the right. The patients were asked to indicate the point on the scale best corresponding to their own pain at the 2nd, 4th, 6th and 12th hours and on the postoperative days 1, 2, 3 and 7. Moreover, the usage of additional analgesic drugs after the surgical procedure was recorded. 2.6. Swelling Swelling measurements were taken with a 3–0 silk thread and millimeter ruler before surgery and on the postoperative days 1, 2 and 7. Linear measurements were made between the angle of the mandible and the following points: tragus, ala of nose, outer corner of eye, labial commissure and mentus [24] (Fig. 5).
Fig. 5. 5-point measurement method of postoperative facial edema.
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2.8. Chewing activity On postoperative days 1, 2 and 7, the specialist evaluated the degree of chewing with a 5-point scale comprised from ‘none chewing’ on the left to the ‘perfect chewing’ on the right. 2.9. Alveolar Osteitis Postoperative swelling, edema and pain are commonly seen in the first days after surgery, and there is the possibility of patients to interpret this condition as alveolitis due to their subjective opinion. So, the surgical site was evaluated as presence or absence of alveolitis according to Blum’s criteria on day 7 [25]. 2.10. Quality of life (QOL) questionnaire and satisfaction degree The QOL questionnaire was applied to the patients on the postoperative days 2 and 7. The patients were asked to answer the questions and rate their experience regarding the third molar surgery on a 5-point scale. After both surgical procedures, all patients were measured with a 5-point scale (from ‘Bad’ on the left to the ‘Perfect’ on the right) to determine which side passed better. 2.11. Statistical analysis Statistical analyses were carried out in the SPSS 25.0 software. In the comparison of the clinical findings obtained from the locked and unlocked methods in the same patients, for the continuous variables, paired-samples t-test was utilized, and the results are given as mean std. deviation. Wilcoxon test was used for the discrete variables. The results are given as median (min–max) and arithmetic mean. The categorical variables were compared using chisquared test or Fisher’s exact Chi2 test, and the results are expressed as frequencies and percentages. P-value < 0.05 was considered statistically significant. 3. Results Among the patients included in our study, 24 (age range: 18– 35) were male, and 26 (age range: 18–34) were female. The patients included in our study had a homogenous distribution in terms of sex and age, and there was no statistically significant difference between the groups (Table 1) (P > 0.05). There was a significant difference between the groups in terms of duration of suturing (P < 0.05). However, this time was irrelevant when evaluated clinically (34 seconds). There was no significant difference between the groups in terms of the total durations of operations (Table 2) (P > 0.05). In terms of postoperative pain, there were significant differences between the groups at the 4th, 6th and 12th hours and on Table 1 Demographic information of patients. Sex
n
Age range
mean SD
P
M F
24 26
18–35 18–34
22.79 3.79 21.77 3.81
0.346
the 1st, 2nd and 3rd days. There was less pain in the unlocked suture group in comparison to the locked suture group (Table 3) (P < 0.05). There was no significant difference between the groups at the 2nd hour and on the 7th day (P > 0.05). No significant differences were found between the groups in the preoperative period in terms of three important postoperative sequelae (swelling, mouth opening and chewing activity). Postoperative swelling was measured on the 1st, 2nd and 7th postoperative days. There was a significant difference between the groups. There was significantly less postoperative swelling in the unlocked suture group on the 1st and 2nd days (Table 4) (P < 0.05). There was no significant difference between the groups on the 7th days. Regarding the amount of mouth opening, there were significant differences between the two groups on the 1st and 2nd postoperative days. Similarly, there was no significant difference between the groups on the 7th days. In the unlocked suture group, there was less trismus, meaning more mouth opening, in comparison to the locked suture group (Table 4) (P < 0.05). Likewise, chewing activity was checked in terms of the life comfort of the patients, and there was a significant difference between the groups on the 1st and 2nd days, and on the 7th day. The unlocked suture group had significantly better chewing activity than the locked suture group (Table 5) (P < 0.05). Regarding alveolitis, it was observed that one patient in each group developed alveolitis on the 7th day. Based on the analysis of satisfaction levels and quality of life, there was also a significant Table 3 Comparison of the groups in terms of postoperative pain. Postoperative paina
2nd hour 4th hour 6th hour 12th hour Day 1 Day 2 Day 3 Day 7 a
Unlocked (n = 50)
P
2 3 2 1 3 2 1 0
(1–5) (1–5) (0–5) (0–5) (0–5) (0–4) (0–3) (0–2)
2.50 2.82 2.34 1.16 2.58 1.84 1.14 0.54
2 1 1 0 1 0 0 0
(0–5) (0–4) (0–4) (0–2) (0–2) (0–2) (0–2) (0–3)
2.46 1.40 1.04 0.24 0.68 0.40 0.16 0.36
0.911 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 0.098
Wilcoxon test was used.
Table 4 Comparison of groups in terms of mouth opening and swelling values. Mouth openinga (mm)
Locked (n = 50)
Unlocked (n = 50)
P
37.80 3.40 27.20 4.57 30.73 2.87 33.31 4.47
0.521 0.000 0.000 0.327
98.00 5.87 104.14 6.38 102.80 6.07 100.24 6.45
0.845 0.000 0.000 0.302
mean SD Preop Day 1 Day 2 Day 7
38.22 3.57 22.67 4.72 24.42 4.99 32.59 4.03
Swellinga (mm)
mean SD
Preop Day 1 Day 2 Day 7
98.08 6.30 117.38 6.95 114.42 7.11 101.54 6.71
a
Two dependent sample t tests were used.
Table 5 Comparison of groups in terms of chewing activity.
M: male; F: female; SD: standard deviation. Table 2 Total suturing and operation times.
Chewing activitya
Locked (n = 50)
Unlocked (n = 50)
P
Median (min–max) Arithmetic mean
Time (min)
Locked (n = 50)
Unlocked (n = 50)
P
Suturing timea Total operation timea
3.47 0.80 8.82 2.60
3.13 0.60 8.19 2.14
0.033 0.098
Min: minutes. a Two dependent sample t tests were used
Locked (n = 50)
Median (min–max) Arithmetic mean
Preop Day 1 Day 2 Day 7 a
3 0 0 1.5
Wilcoxon test was used.
(0–4) (0–1) (0–1) (0–3)
2.84 0.26 0.46 1.44
3 1 1 2
(0–4) (0–2) (0–3) (0–4)
2.96 0.82 1.48 1.70
0.380 < 0.001 < 0.001 0.278
B. Ege, E. Najafov / J Stomatol Oral Maxillofac Surg 121 (2020) 206–212 Table 6 Quality of life and satisfaction of patients after the procedure. Quality of lifea
Locked (n = 50)
Unlocked (n = 50)
P
Median (min–max) Arithmetic mean Day 2 Day 7 Satisfaction Levela a
4 (2–6) 3.86 2 (0–3) 1.58 1 (0–3) 1.16
2 (0–3) 1.10 0 (0–1) 0.24 3 (2–4) 2.68
<0.001 <0.001 <0.001
Wilcoxon test was used.
difference between the groups (Table 6) (P < 0.05). The unlocked suture group had better results than the locked suture group in terms of both features. The locked suture group used more than twice as additional rescue analgesics than the unlocked group (21 tablets vs. 10 tablets). 4. Discussion The pain, swelling and trismus that occur following IMTM surgery affect the quality of life of patients in the postoperative period negatively. This is why, in the literature, several different studies have been carried out to minimize postoperative complications [3–5,11,12,20,26]. One of such areas of study is the issue of suturing of the operation area. This study also discusses this issue. In our study with a split-mouth design, we investigated the effects of two different suturing techniques on these complications that are seen after impacted third molar surgery in fifty patients. For this purpose, we included individuals with ASA I physical status, no bad habits and bilateral impacted teeth on the same position. There was no significant difference in terms of sex and age distributions among the patients who were included in our study. This showed that the groups were homogenously distributed. As a result of our study, between the groups where locked and unlocked sutures were used, the duration of suturing was found to be shorter in the group where unlocked sutures were used. We believe that this might have been caused by that knots may fail while applying locked knots, and the knotting process may need to be repeated. There was no significant difference between the groups in terms of operation durations. This showed us that similar surgical procedures were applied in both groups. There were no significant differences between the groups in terms of postoperative complications in preoperative period. This showed us that the distribution of the patients was homogeneous and balanced. However, there were significant differences between the groups in terms of complications on the postoperative days. It was determined that there were significantly lower amounts of pain, swelling and trismus in the unlocked suturing group on especially days 1 and 2. As a result of this, chewing functions on the side of the unlocked suture were affected less, and the patients were able to chew better. On the 7th postoperative day, there was no significant difference in terms of these sequelae. These results showed that the different knot techniques were more effective in the early period. It is seen in studies in the literature that different closure techniques have been utilized to minimize postoperative complications. One of such cases is the comparison of the primary and secondary closure methods. Dubois et al. compared these two techniques in a split-mouth study on 56 patients and reported that less pain and less swelling in the postoperative period occurred in patients where secondary closure was applied [11]. Danda et al. [12] in their study with a similarly split-mouth design on 93 patients, applied primary closure on one side and secondary closure on the other side for the patients whose bilateral impacted third molar teeth were extracted. As a result, they found significantly less postoperative pain and swelling formation on the side of secondary closure. Pachipulusu et al. [13] also found similar results. Hashemi et al. [14] similarly examined postopera-
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tive pain and swelling values when they did not use any sutures. They did not apply any suture on one side of the patients, while they closed the other side primarily with 3 sutures. The reported less pain and swelling on the side where no sutures were used on the 3rd and 7th postoperative days. Likewise, when Osunde et al. [15] used the same no suture technique in their study, they reported lower rates of trismus, as well as postoperative swelling and pain. Waite and Cherala [16] examined 1280 tooth extractions without applying sutures and showed that the no-suture technique provided better results in the postoperative period. The common result from these studies is that secondary healing, that is, not using any sutures, provides highly satisfactory results, but for most clinicians, it is not easy to use this technique in the clinical conditions. This is because, in this technique, the oral hygiene of the patient and postoperative wound care must be on a highly good level. Otherwise, development of unwanted issues such as secondary infection in the wound site after extraction, alveolitis and halitosis is possible. In this sense, with the purpose of eliminating these factors that limit the usage of the secondary healing method, in our study, we examined the effectiveness of the unlocked suturing technique in comparison to tight primary closure. While the secondary healing method was not used in our study, the results we obtained showed that there were significantly lower rates of pain, swelling and trismus in the unlocked suture group in comparison to the locked suture group. We believe that this situation was caused mainly by that unlocked sutures are loosened in time in the recovery period, and they allow drainage from the edges of the wound. These results were also similar to those obtained by studies where the effectiveness of secondary healing was compared to that of primary closure. Khande et al. [18] investigated the effects of primary and secondary wound closure on the postoperative period. In the study on 60 patients, while tight closure was applied by sutures in one group, the flap was attached with one suture in the other. There was a significant difference between the two groups in terms of the postoperative pain and swelling values. Pain and swelling were lower in the group where single sutures were used. In similarity to these results, Hollan and Hindle [19] also showed that more pain and swelling occurred in cases where wounds were primarily closed. Looking at studies so far, it is seen that the effectiveness of secondary healing without sutures and primary closure was examined in general. However, in the daily practice of dentistry, it is a known fact that patient monitoring is difficult in secondary healing without using sutures, and unwanted complications may occur especially in patients with poor oral hygiene. Therefore, although it has been reported theoretically in the literature that the results of suture-free and secondary wound healing methods are better, in clinical practice, most clinicians still prefer primary closure. We also believe that a suture technique that would not only have the positive effect of the suture-free technique in terms of pain, swelling and mouth opening but also achieve primary closure to an extent that would protect the wound from the negative effects of poor oral hygiene may be a good alternative that could be preferred. In the literature, the effects of various suture techniques on postoperative sequelae were also investigated. While there was no significant difference between the groups in terms of pain, swelling and trismus in a study that compared the mattress and simple suturing techniques, it was observed that mattress suture was more effective on postoperative wound healing [17]. However, rather than the suture technique to be used, the effects of using locked or unlocked knots in these sutures have not been investigated yet. We believe that this situation may be effective on postoperative complications, whereas the results we obtained supported this idea of ours. In contrast to Acar et al. [17] in our study, in terms of pain, swelling and trismus, these sequelae were
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less frequently observed in the group where unlocked knots were used on days 1 and 2. Nevertheless, these results still cannot precisely reveal whether or not different suturing techniques to be used would be effective on postoperative complications. For this reason, there is a need for studies where both different suturing techniques and different knot techniques are comparatively investigated. On the other hand, studies have reported better wound healing without sutures. It is believed that this could have been caused by that unlocked knots loosen over time, allow passive drainage, and therefore, hematoma does not accumulate much in the tissue. Ricard et al. reported 2 alveolitis and 2 infection cases in their primary closure group [27]. Akota et al. reported a higher risk of alveolitis formation when wounds were primarily closed [28]. However, Bello et al. did not find a significant difference in terms of alveolitis [29]. There are also other studies which reached the same conclusions [11,30]. Similarly, we also determined that only one patient in each group developed alveolitis on the 7th postoperative day. As in all surgical procedures, IMTM surgery has various complications that affect quality of life negatively such as pain, restriction in mouth opening and swelling [1,2,31]. These complications are very closely related to the quality of life of the patient, and studies have shown that postoperative quality of life increased in closure techniques where these complications were seen less frequently [15,16,18,19]. Based on the data we obtained, in the locked group, the patients needed more analgesic drugs than the unlocked group, and we observed more effective results in the positive direction for all variables in the unlocked knot group. In parallel to all these assessments, the postoperative quality of life and satisfaction levels of the patients were significantly better in the unlocked knot group. We believe that especially the lower pain, swelling and trismus values in the unlocked knot group were effective in reaching these results. While studies that we examined have shown that primary, namely tight, closure of wounds does not have any advantage, and in contrast, secondary healing has more acceptable and better outcomes for patients, the tight primary closure technique is still prevalently being used by dentists in impacted third molar surgery today. In our study, in comparison to primarily closing the wound after third molar surgery by using locked knots, still using primary closure but utilizing unlocked knots provided a significantly positive contribution on the postoperative pain, swelling and mouth opening parameters observed in the recovery period. 5. Conclusion As the unlocked suture technique provided less hermetic closure, it affected the postoperative quality of life and comfort of the patient significantly less. In addition to all these reasons, with the simple and easy implementation of primary closure by unlocked knots, we believe that this technique may be a good alternative to secondary healing in cases of poor oral hygiene and where it is necessary to primarily close the wound, and we recommend its usage. Disclosure of interest The authors declare that they have no competing interest.
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J Craniofac Surg 2017;28:e657–61. [18] Khande K, Saluja H, Mahindra U. Primary and secondary closure of the surgical wound after removal of ımpacted mandibular third molars. J Oral Maxillofac Surg 2011;10:112. [19] Holland CS, Hindle MO. The influence of closure or dressing of third molar socket on postoperative swelling and pain. Br J Oral Maxillofac Surg 1984;22: 65–71. [20] Suddhasthira T, Chaiwat S, Sattapongsda P. The comparison study of primary and secondary closure technique after removal of impacted mandibular third molars. Thai J Oral Maxillofac Surg 1991;5:67–77. [21] Sculz KF, Altman DG, Moher D. COnsort Group. CONSORT 2010 statement: updated guielines for reporting parallel group randomised trials. Int J Surg 2011;9:672–7. [22] Winter GB. Impacted mandibular third molars. St Louis: American Medical Book Co; 1926. [23] Pell GJ. Gregory BT. Impacted mandibular third molars: classification and modified techniques for removal. Dent Dig 1933;39:330–8. [24] Neupert EA, 3rd, Lee JW, Philput CB, Gordon JR. Evaluation of dexamethasone for reduction of postsurgical sequelae of third molar removal. J Oral Maxillofac Surg 1992;50:1177–82. [25] Blum IR. Conyemporary view on dry socket (alveolar osteitis); a clinical appraisal of stanardization, aetiopathogenesis and management: a critical review. Int J Oral Maxillofac Surg 2002;231:309–17. [26] Rakprasitkul S, Pairuchivej V. Mandibular third molar surgery with primary closure and tube drain. Int J Oral Maxillofac Surg 1997;26:187–90. [27] Ricard AS, Nau O, Veyret A, Majoufre-Lefe`bvre C, Laurentjoye M. Comparison between closure and absence of closure after removal of fully impacted mandibular third molar: a prospective randomized study. Rev Stomatol Chir Maxillofac Chir Orale 2015;116:12–7. [28] Akota I, Alvsaker B, Bjornland T. The effect of locally applied gauze drain imprenated with chlortetracycline ointment in mandibular third molar surgery. Acta Odontol Scand 1998;56:25–9. [29] Bello SA, Olaitan AA, Ladeinde AL. A randomised comparison of the efect of partial and total wound closure techniques on postoperative morbidity after mandibular third molar surgery. J Oral Maxillofac Surg 2011;69:e24–30. [30] Pasqualini D, Cocero N, Castella A, Mela L, Bracco P. Primary and secondary closure of the surgical wound after removal of impacted mandibular third molars; a comparative study. Int J Oral Maxillofac Surg 2005;34:52–7. [31] McGrath C, Comfort MB, Lo EC, Luo Y. Changes in life quality following third molar surgery–the immediate postoperative period. Br Dent J 2003;194:265–8.
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Original article
Comparison of two different suture knot techniques on postoperative morbidity after impacted mandibular third molar surgery B. Ege a,*, E. Najafov b a b
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Adıyaman University, Adıyaman 02200, Turkey Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 January 2020 Accepted 6 February 2020 Available online 12 February 2020
Introduction: In third molar surgery, one of the most important factors is how the wound was closed. Tight suturing of the wound commonly gives more discomfort to the many patients in terms of postoperative pain, swelling and trismus. The purpose of this study is to investigate the effects of two different knot techniques in suturing after extraction of impacted mandibular third molars (IMTM) on quality of life and postoperative complications such as pain, swelling and trismus. Material and methods: This study was conducted with a randomized and split-mouth design and included 50 patients over the age of 18 in the ASA I group who had bilateral horizontal impacted mandibular third molars. In all patients, the wounds were closed by simple sutures by applying two different knot techniques as locked (Group L, n = 50) and unlocked (Group UL, n = 50) knots. In the postoperative period, pain, swelling, trismus, chewing activity and quality of life were examined. Results: In the group where the unlocked knotting technique was used, significantly better results were obtained in comparison to the group where the locked knotting technique was used for all values (P < 0.05). Conclusion: In preventing postoperative complications that are observed after impacted mandibular third molar surgery and affect the quality of life of patients negatively, suturing of the wound by the method of unlocked knotting is a useful technique that may be preferred.
C 2020 Elsevier Masson SAS. All rights reserved.
Keywords: Impacted third molar Knot techniques Suturing Postoperative morbidity
1. Introduction While impacted mandibular third molar (IMTM) teeth are asymptomatic in some patients, in some others, they may affect quality of life and lead to infections, cavities in adjacent teeth, periodontal destruction, loss of function and occasionally orthodontic problems. For such reasons, IMTM surgery is one of the most frequently performed operations in the field of Oral and Maxillofacial Surgery. After surgery of these teeth, as expected, complications such as pain, swelling and trismus are frequently observed [1,2]. Moreover, unwanted hemorrhages, dry socket in the place of extraction and unwanted situations such as nerve damages may also sometime occur. In many different studies in the literature, it is seen that cryotherapy, ozonotherapy, medical treatment and different incision and flap designs have been used to minimize these complications [3–8]. Most physicians think that the duration of surgery, the degree of difficulty of the tooth and the
* Corresponding author. E-mail address: [email protected] (B. Ege). https://doi.org/10.1016/j.jormas.2020.02.002 C 2020 Elsevier Masson SAS. All rights reserved. 2468-7855/
trauma induced during surgery have an effect on these complaints in the postoperative period. For this reason, postoperative success is very closely related to not only the patient-based individual differences but also factors such as the occupational, theoretical and practical skills of the surgeon, closure of the wound and postoperative oral care [9,10]. Mainly, in primary closure, the wound is hermetically closed by suturing based on main surgical principles. In the secondary closure technique, the socket is in an interaction with the oral cavity, and it facilitates the drainage of inflammation. Regarding the issue of closing the wound, various opinions on different techniques such as primary or secondary closure have been debated for years. In some studies on this topic, primary closure methods with different suturing techniques were compared, and their effects on postoperative complications were examined [11– 16]. While some researchers utilized primary closure by using different suturing techniques, [17] some others preferred the method of secondary healing without using any sutures, and it is reported in general that primary closure causes more pain and swelling [15,16,18,19]. A few studies reported that there is no difference between primary and secondary healing [20].
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Nevertheless, we have experienced that, in addition to the positive characteristics of the method of secondary, or suture-free, healing, it is not a method that can be applied in all patients after all surgical procedures in the oral region, and its usage in the oral region has some limitations. To prevent the risk of the emergence of unwanted complications due to poor oral care when secondary recovery is preferred, we believe that a loose and tieless primary closure method may provide a positive effect on recovery as in the method of secondary closure. This is the first study to assess the effects of different knot techniques of primary closure applied in IMTM surgery. For this purpose, in our study, we investigate the effects of primary closure applied by using two different knotting techniques as locked and unlocked on postoperative complications and quality of life in patients after impacted third molar surgery.
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Other inclusion criteria were: age of 18 years or older; American Society of Anesthesiology (ASA) physical status class I (normally healthy patient); patients with no systemic diseases or medical conditions; no medication use; no discernible active pathology associated with the third molars at the time of surgery; no local inflammation and no acute pericoronitis; patients with healthy dental and periodontal status; not allergic to the drugs or anesthetic agents used in the surgical protocol; patients who were able to understand verbal and written instructions.
2. Materials and methods On the contrary: 2.1. Study design This study was designed and performed as a randomized, prospective, split-mouth clinical study in patients who were referred to the Department of Oral and Maxillofacial Surgery of Adıyaman University for surgical removal of impacted mandibular third molars. This trial was performed in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement (http://www.consort-statement.org/) [21]. This study was conducted according to the ethical principles described in the Declaration of Helsinki, and the research protocol was approved by the Ethics Committee of the University of Adıyaman. Fifty patients with similar bilaterally impacted mandibular third molars were included in this clinical trial. This way, it was aimed to ensure the standardization of the study. The objective of the procedure was explained at the first appointment. Potential complications were discussed, and the anticipated postoperative course was described. Before the study, all patients were informed about the procedures, postoperative recovery times and possible complications. They then signed a written consent form and were also notified of their right to withdraw from the study at any time without prejudice. 2.2. Inclusion and exclusion criteria Preoperative examinations included intraoral and radiographic examination. A panoramic radiograph was taken to assess third molar angulations to the long axis of the second molar. The Winter [22] and Pell and Gregory classifications [23] were used to evaluate the positions of the impacted third molars. Patients with bilateral symmetrically impacted mandibular third molars with horizontal (Winter classification) and class III, C impaction (Pell and Gregory classification) were included (Fig. 1).
Fig. 1. The appearance of bilateral horizontally impacted third molar teeth on panoramic radiography.
ASA > 1; Smoking; allergy or contraindications to the anesthetics employed; presence of systemic disease; antiplatelet or anticoagulant therapy; pregnant or lactating women and women regularly using oral contraceptives; recent (<15 days) local infection in the oral cavity; previous radiation therapy to the maxillofacial region; local pathology (e.g., cyst or tumor) associated with the third molars; patients with poor oral hygiene were excluded from the study.
Patients with apparent differences in the duration of operation between the left and right sides were excluded from the study since this might have masked the possible effect of flap design after surgery. The data of the patients included and not included in the statistical analysis are shown in Fig. 2 (flow diagram). In all cases, the impacted molars were extracted in two sessions, one involving locked suture and the other involving unlocked suture design. A minimum of 1 month was allowed to elapse between the two procedures. The patients selected for the study were randomly assigned into one of the different suturing groups: closure with Locked suture technique on the right side (n = 50); closure with Unlocked suture technique on the left side (n = 50).
2.3. Surgical procedure Treatment was started after we obtained a full medical and dental history and panoramic radiography, as well as a 3dimensional computed tomography scan if indicated. All surgical procedures were performed by the same surgeon (B.E.), a specialist with more than 5 years of experience in oral and maxillofacial surgery in the same operating room using the same surgical instruments, rotary and irrigation devices and materials. Before the procedure, the face was prepared with betadine solution, and standard draping was provided. All patients were washed with 5–10 ml of Chlorhexidine for 2 min preoperatively. All patients received a standardized mandibular block injection with additional infiltration of the buccal nerve. The effective local anesthesia was achieved with 2% lidocaine hydrochloride and 1:200,000 epinephrine (Jetokain; Adeka, Turkey). No preoperative drugs were given in any patients. All surgical procedures were performed in a standardized fashion using a similar technique. A full-thickness envelope flap was used in all patients; a buccal sulcular incision extending from
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Fig. 2. Patient flow diagram according to the CONSORT statement.
the first molar to the second and a distal relieving incision to the mandibular ramus. The flap was reflected, the surgical site was exposed, and any bone overlying the crown of the impacted third molar was removed with a round surgical bur. Then, the tooth was sectioned with a fissure bur. The tooth crown was sectioned under abundant irrigation in all cases. All parts of the tooth were loosened with a lever and removed. After completing extraction, curettage of the socket was performed in addition to irrigation with a sterile saline solution. Care was taken to eliminate any sharp irregular edges and the inter-radicular bone. After achieving proper hemostasis, the flaps were sutured in an interrupted fashion at four points (Fig. 3). Group L (Locked suturing): the flap was repositioned and sutured with the locked technique (straight-reverse-straight) hermetically using 3–0 black silk. Group UL (Unlocked suturing): the flap was repositioned and sutured with the unlocked technique (three straight knots) loosely using 3–0 black silk (Fig. 4). Immediately after surgery, the details of the procedure were recorded by an independent specialist including the suturing time (from the needle entering the tissue to the last knot), total operation time (from taking incision to the last suture) and any intraoperative complications (systemic and local side effects) occurring during the procedure. All patients received postoperative instructions, and Amoxicillin (Largopen 1000 mg, 2 1/day; Bilim); Ibuprofen (Brufen 400 mg, 3 1/day; Abbott); 0.2% chlorhexidine gluconate (Klorhex 30 mL, 2 1/day; Drogsan)
Fig. 3. Incision line and wound closure.
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Fig. 4. The view of knot (straight or reverse) techniques used: A. Unlocked Group; B. Locked Group.
were prescribed to all patients for 5, 7 and 5 days, respectively. Postoperative recommendations included soft diet and oral hygiene instructions using a 0.2% chlorhexidine mouth rinse. The sutures were removed on the postoperative day 7. The patients underwent surgery on only the right side at a given appointment, with the left side being operated on after a period of 4 weeks. 2.4. Outcome measures
2.7. Trismus Trismus was measured between the incisal edges of the upper and lower central incisors when the patient was seated upright, and the orbito-meatal line was parallel to the floor. Preoperative evaluation was performed by measuring the distance between the mesial-incisal corners of the upper and lower central incisors at the maximum opening of the jaws, on postoperative days 1, 2 and 7.
The surgeon could not be blinded due to the nature of the interventions. One specialist, responsible for calculation and not involved in the selection and intervention of participants, performed all the measurements. The data collection methods were as follows: The patients were recalled on postoperative days 1, 2 and 7, during when trismus, swelling, wound healing and chewing activity were evaluated. Additional follow-up visits were arranged through the department, depending on requirements. 2.5. Pain All patients were additionally given a 5-point visual analog scale (VAS) form. This comprised from no pain on the left to the extremely severe pain on the right. The patients were asked to indicate the point on the scale best corresponding to their own pain at the 2nd, 4th, 6th and 12th hours and on the postoperative days 1, 2, 3 and 7. Moreover, the usage of additional analgesic drugs after the surgical procedure was recorded. 2.6. Swelling Swelling measurements were taken with a 3–0 silk thread and millimeter ruler before surgery and on the postoperative days 1, 2 and 7. Linear measurements were made between the angle of the mandible and the following points: tragus, ala of nose, outer corner of eye, labial commissure and mentus [24] (Fig. 5).
Fig. 5. 5-point measurement method of postoperative facial edema.
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2.8. Chewing activity On postoperative days 1, 2 and 7, the specialist evaluated the degree of chewing with a 5-point scale comprised from ‘none chewing’ on the left to the ‘perfect chewing’ on the right. 2.9. Alveolar Osteitis Postoperative swelling, edema and pain are commonly seen in the first days after surgery, and there is the possibility of patients to interpret this condition as alveolitis due to their subjective opinion. So, the surgical site was evaluated as presence or absence of alveolitis according to Blum’s criteria on day 7 [25]. 2.10. Quality of life (QOL) questionnaire and satisfaction degree The QOL questionnaire was applied to the patients on the postoperative days 2 and 7. The patients were asked to answer the questions and rate their experience regarding the third molar surgery on a 5-point scale. After both surgical procedures, all patients were measured with a 5-point scale (from ‘Bad’ on the left to the ‘Perfect’ on the right) to determine which side passed better. 2.11. Statistical analysis Statistical analyses were carried out in the SPSS 25.0 software. In the comparison of the clinical findings obtained from the locked and unlocked methods in the same patients, for the continuous variables, paired-samples t-test was utilized, and the results are given as mean std. deviation. Wilcoxon test was used for the discrete variables. The results are given as median (min–max) and arithmetic mean. The categorical variables were compared using chisquared test or Fisher’s exact Chi2 test, and the results are expressed as frequencies and percentages. P-value < 0.05 was considered statistically significant. 3. Results Among the patients included in our study, 24 (age range: 18– 35) were male, and 26 (age range: 18–34) were female. The patients included in our study had a homogenous distribution in terms of sex and age, and there was no statistically significant difference between the groups (Table 1) (P > 0.05). There was a significant difference between the groups in terms of duration of suturing (P < 0.05). However, this time was irrelevant when evaluated clinically (34 seconds). There was no significant difference between the groups in terms of the total durations of operations (Table 2) (P > 0.05). In terms of postoperative pain, there were significant differences between the groups at the 4th, 6th and 12th hours and on Table 1 Demographic information of patients. Sex
n
Age range
mean SD
P
M F
24 26
18–35 18–34
22.79 3.79 21.77 3.81
0.346
the 1st, 2nd and 3rd days. There was less pain in the unlocked suture group in comparison to the locked suture group (Table 3) (P < 0.05). There was no significant difference between the groups at the 2nd hour and on the 7th day (P > 0.05). No significant differences were found between the groups in the preoperative period in terms of three important postoperative sequelae (swelling, mouth opening and chewing activity). Postoperative swelling was measured on the 1st, 2nd and 7th postoperative days. There was a significant difference between the groups. There was significantly less postoperative swelling in the unlocked suture group on the 1st and 2nd days (Table 4) (P < 0.05). There was no significant difference between the groups on the 7th days. Regarding the amount of mouth opening, there were significant differences between the two groups on the 1st and 2nd postoperative days. Similarly, there was no significant difference between the groups on the 7th days. In the unlocked suture group, there was less trismus, meaning more mouth opening, in comparison to the locked suture group (Table 4) (P < 0.05). Likewise, chewing activity was checked in terms of the life comfort of the patients, and there was a significant difference between the groups on the 1st and 2nd days, and on the 7th day. The unlocked suture group had significantly better chewing activity than the locked suture group (Table 5) (P < 0.05). Regarding alveolitis, it was observed that one patient in each group developed alveolitis on the 7th day. Based on the analysis of satisfaction levels and quality of life, there was also a significant Table 3 Comparison of the groups in terms of postoperative pain. Postoperative paina
2nd hour 4th hour 6th hour 12th hour Day 1 Day 2 Day 3 Day 7 a
Unlocked (n = 50)
P
2 3 2 1 3 2 1 0
(1–5) (1–5) (0–5) (0–5) (0–5) (0–4) (0–3) (0–2)
2.50 2.82 2.34 1.16 2.58 1.84 1.14 0.54
2 1 1 0 1 0 0 0
(0–5) (0–4) (0–4) (0–2) (0–2) (0–2) (0–2) (0–3)
2.46 1.40 1.04 0.24 0.68 0.40 0.16 0.36
0.911 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 0.098
Wilcoxon test was used.
Table 4 Comparison of groups in terms of mouth opening and swelling values. Mouth openinga (mm)
Locked (n = 50)
Unlocked (n = 50)
P
37.80 3.40 27.20 4.57 30.73 2.87 33.31 4.47
0.521 0.000 0.000 0.327
98.00 5.87 104.14 6.38 102.80 6.07 100.24 6.45
0.845 0.000 0.000 0.302
mean SD Preop Day 1 Day 2 Day 7
38.22 3.57 22.67 4.72 24.42 4.99 32.59 4.03
Swellinga (mm)
mean SD
Preop Day 1 Day 2 Day 7
98.08 6.30 117.38 6.95 114.42 7.11 101.54 6.71
a
Two dependent sample t tests were used.
Table 5 Comparison of groups in terms of chewing activity.
M: male; F: female; SD: standard deviation. Table 2 Total suturing and operation times.
Chewing activitya
Locked (n = 50)
Unlocked (n = 50)
P
Median (min–max) Arithmetic mean
Time (min)
Locked (n = 50)
Unlocked (n = 50)
P
Suturing timea Total operation timea
3.47 0.80 8.82 2.60
3.13 0.60 8.19 2.14
0.033 0.098
Min: minutes. a Two dependent sample t tests were used
Locked (n = 50)
Median (min–max) Arithmetic mean
Preop Day 1 Day 2 Day 7 a
3 0 0 1.5
Wilcoxon test was used.
(0–4) (0–1) (0–1) (0–3)
2.84 0.26 0.46 1.44
3 1 1 2
(0–4) (0–2) (0–3) (0–4)
2.96 0.82 1.48 1.70
0.380 < 0.001 < 0.001 0.278
B. Ege, E. Najafov / J Stomatol Oral Maxillofac Surg 121 (2020) 206–212 Table 6 Quality of life and satisfaction of patients after the procedure. Quality of lifea
Locked (n = 50)
Unlocked (n = 50)
P
Median (min–max) Arithmetic mean Day 2 Day 7 Satisfaction Levela a
4 (2–6) 3.86 2 (0–3) 1.58 1 (0–3) 1.16
2 (0–3) 1.10 0 (0–1) 0.24 3 (2–4) 2.68
<0.001 <0.001 <0.001
Wilcoxon test was used.
difference between the groups (Table 6) (P < 0.05). The unlocked suture group had better results than the locked suture group in terms of both features. The locked suture group used more than twice as additional rescue analgesics than the unlocked group (21 tablets vs. 10 tablets). 4. Discussion The pain, swelling and trismus that occur following IMTM surgery affect the quality of life of patients in the postoperative period negatively. This is why, in the literature, several different studies have been carried out to minimize postoperative complications [3–5,11,12,20,26]. One of such areas of study is the issue of suturing of the operation area. This study also discusses this issue. In our study with a split-mouth design, we investigated the effects of two different suturing techniques on these complications that are seen after impacted third molar surgery in fifty patients. For this purpose, we included individuals with ASA I physical status, no bad habits and bilateral impacted teeth on the same position. There was no significant difference in terms of sex and age distributions among the patients who were included in our study. This showed that the groups were homogenously distributed. As a result of our study, between the groups where locked and unlocked sutures were used, the duration of suturing was found to be shorter in the group where unlocked sutures were used. We believe that this might have been caused by that knots may fail while applying locked knots, and the knotting process may need to be repeated. There was no significant difference between the groups in terms of operation durations. This showed us that similar surgical procedures were applied in both groups. There were no significant differences between the groups in terms of postoperative complications in preoperative period. This showed us that the distribution of the patients was homogeneous and balanced. However, there were significant differences between the groups in terms of complications on the postoperative days. It was determined that there were significantly lower amounts of pain, swelling and trismus in the unlocked suturing group on especially days 1 and 2. As a result of this, chewing functions on the side of the unlocked suture were affected less, and the patients were able to chew better. On the 7th postoperative day, there was no significant difference in terms of these sequelae. These results showed that the different knot techniques were more effective in the early period. It is seen in studies in the literature that different closure techniques have been utilized to minimize postoperative complications. One of such cases is the comparison of the primary and secondary closure methods. Dubois et al. compared these two techniques in a split-mouth study on 56 patients and reported that less pain and less swelling in the postoperative period occurred in patients where secondary closure was applied [11]. Danda et al. [12] in their study with a similarly split-mouth design on 93 patients, applied primary closure on one side and secondary closure on the other side for the patients whose bilateral impacted third molar teeth were extracted. As a result, they found significantly less postoperative pain and swelling formation on the side of secondary closure. Pachipulusu et al. [13] also found similar results. Hashemi et al. [14] similarly examined postopera-
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tive pain and swelling values when they did not use any sutures. They did not apply any suture on one side of the patients, while they closed the other side primarily with 3 sutures. The reported less pain and swelling on the side where no sutures were used on the 3rd and 7th postoperative days. Likewise, when Osunde et al. [15] used the same no suture technique in their study, they reported lower rates of trismus, as well as postoperative swelling and pain. Waite and Cherala [16] examined 1280 tooth extractions without applying sutures and showed that the no-suture technique provided better results in the postoperative period. The common result from these studies is that secondary healing, that is, not using any sutures, provides highly satisfactory results, but for most clinicians, it is not easy to use this technique in the clinical conditions. This is because, in this technique, the oral hygiene of the patient and postoperative wound care must be on a highly good level. Otherwise, development of unwanted issues such as secondary infection in the wound site after extraction, alveolitis and halitosis is possible. In this sense, with the purpose of eliminating these factors that limit the usage of the secondary healing method, in our study, we examined the effectiveness of the unlocked suturing technique in comparison to tight primary closure. While the secondary healing method was not used in our study, the results we obtained showed that there were significantly lower rates of pain, swelling and trismus in the unlocked suture group in comparison to the locked suture group. We believe that this situation was caused mainly by that unlocked sutures are loosened in time in the recovery period, and they allow drainage from the edges of the wound. These results were also similar to those obtained by studies where the effectiveness of secondary healing was compared to that of primary closure. Khande et al. [18] investigated the effects of primary and secondary wound closure on the postoperative period. In the study on 60 patients, while tight closure was applied by sutures in one group, the flap was attached with one suture in the other. There was a significant difference between the two groups in terms of the postoperative pain and swelling values. Pain and swelling were lower in the group where single sutures were used. In similarity to these results, Hollan and Hindle [19] also showed that more pain and swelling occurred in cases where wounds were primarily closed. Looking at studies so far, it is seen that the effectiveness of secondary healing without sutures and primary closure was examined in general. However, in the daily practice of dentistry, it is a known fact that patient monitoring is difficult in secondary healing without using sutures, and unwanted complications may occur especially in patients with poor oral hygiene. Therefore, although it has been reported theoretically in the literature that the results of suture-free and secondary wound healing methods are better, in clinical practice, most clinicians still prefer primary closure. We also believe that a suture technique that would not only have the positive effect of the suture-free technique in terms of pain, swelling and mouth opening but also achieve primary closure to an extent that would protect the wound from the negative effects of poor oral hygiene may be a good alternative that could be preferred. In the literature, the effects of various suture techniques on postoperative sequelae were also investigated. While there was no significant difference between the groups in terms of pain, swelling and trismus in a study that compared the mattress and simple suturing techniques, it was observed that mattress suture was more effective on postoperative wound healing [17]. However, rather than the suture technique to be used, the effects of using locked or unlocked knots in these sutures have not been investigated yet. We believe that this situation may be effective on postoperative complications, whereas the results we obtained supported this idea of ours. In contrast to Acar et al. [17] in our study, in terms of pain, swelling and trismus, these sequelae were
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less frequently observed in the group where unlocked knots were used on days 1 and 2. Nevertheless, these results still cannot precisely reveal whether or not different suturing techniques to be used would be effective on postoperative complications. For this reason, there is a need for studies where both different suturing techniques and different knot techniques are comparatively investigated. On the other hand, studies have reported better wound healing without sutures. It is believed that this could have been caused by that unlocked knots loosen over time, allow passive drainage, and therefore, hematoma does not accumulate much in the tissue. Ricard et al. reported 2 alveolitis and 2 infection cases in their primary closure group [27]. Akota et al. reported a higher risk of alveolitis formation when wounds were primarily closed [28]. However, Bello et al. did not find a significant difference in terms of alveolitis [29]. There are also other studies which reached the same conclusions [11,30]. Similarly, we also determined that only one patient in each group developed alveolitis on the 7th postoperative day. As in all surgical procedures, IMTM surgery has various complications that affect quality of life negatively such as pain, restriction in mouth opening and swelling [1,2,31]. These complications are very closely related to the quality of life of the patient, and studies have shown that postoperative quality of life increased in closure techniques where these complications were seen less frequently [15,16,18,19]. Based on the data we obtained, in the locked group, the patients needed more analgesic drugs than the unlocked group, and we observed more effective results in the positive direction for all variables in the unlocked knot group. In parallel to all these assessments, the postoperative quality of life and satisfaction levels of the patients were significantly better in the unlocked knot group. We believe that especially the lower pain, swelling and trismus values in the unlocked knot group were effective in reaching these results. While studies that we examined have shown that primary, namely tight, closure of wounds does not have any advantage, and in contrast, secondary healing has more acceptable and better outcomes for patients, the tight primary closure technique is still prevalently being used by dentists in impacted third molar surgery today. In our study, in comparison to primarily closing the wound after third molar surgery by using locked knots, still using primary closure but utilizing unlocked knots provided a significantly positive contribution on the postoperative pain, swelling and mouth opening parameters observed in the recovery period. 5. Conclusion As the unlocked suture technique provided less hermetic closure, it affected the postoperative quality of life and comfort of the patient significantly less. In addition to all these reasons, with the simple and easy implementation of primary closure by unlocked knots, we believe that this technique may be a good alternative to secondary healing in cases of poor oral hygiene and where it is necessary to primarily close the wound, and we recommend its usage. Disclosure of interest The authors declare that they have no competing interest.
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