“COMPARISON OF POST OPERATIVE SEQUELAE IN PRIMARY ...

I

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

“COMPARISON OF POST OPERATIVE SEQUELAE IN PRIMARY

AND SECONDARY WOUND CLOSURE FOLLOWING IMPACTED

MANDIBULAR THIRD MOLAR SURGERY”

By

Dr. PARTHIBAN PRABAKARAN

Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfilment of the requirements for the degree of

M.D.S (MASTER OF DENTAL SURGERY)

In

ORAL AND MAXILLOFACIAL SURGERY

Under the guidance of

Dr. HARISH KUMAR A

PROFESSOR AND HOD

Department of Oral and Maxillofacial Surgery

The Oxford Dental College, Bangalore

2016-2019

Scanned by CamScanner

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LIST OF ABBREVIATIONS

VAS Visual analogue scale

mm Millimetre

cm Centimetre

S1 Distance between ala and outer corner of the mouth

S2 Distance between tragus and soft tissue pogonion

S3 Distance between Angle of the mandible and the

outer corner of the mouth

S4 Distance between Angle of the mandible and lateral

corner of the eye

mg Milligram

gm Gram

NSAID Non – steroidal anti – inflammatory drug

POD 1 Post operative day 1



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LIST OF TABLES

SL.NO TABLES PAGES

1 Gender distribution of patients studied 31

2 Age distribution of patients studied 32

3 Pain distribution of patients studied (Mann-Whitney

Test)

33

4 Comparison of pain score in the two groups studied

(Student t - test)

34

5 Post operative facial measurements S1 in two groups

studied (Student t - test)

34



35



36



37

9 Mouth opening in two groups studied (Student t - test) 38

10 Comparison of mean VAS scores between different

time intervals in Group 1 & Group 2 using Friedman's

Test

39-40

11 Comparison of mean Swelling Size (in cm) and mouth

opening at different regions between different time

intervals in Group 1 & Group 2 using Repeated

measures of ANOVA Test and Bonferroni's post hoc

analysis

40-41

12 Comparison of mean Mouth Opening (in mm) between

different time intervals in Group 1 & Group 2 using

Repeated measures of ANOVA Test and Bonferroni’s

post hoc analysis

42

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LIST OF FIGURES

Sl.No Figures Pages

1 Materials used for the study 86

2 Armamentarium 86

3 702 Straight BUR and straight

HANDPIECE

87

4 Markings for measurement of facial

swelling.

87

5 Case Photographs (pre-op to post op with

follow up)

88-92

6 Mouth opening measured using vernier

caliper

92

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LIST OF GRAPHS

SL.NO TABLES PAGES

1 Gender distribution of patients studied 31

2 Age distribution of patients studied 32

3 Pain distribution of patients studied (Mann-Whitney

Test)

33

4 Comparison of pain score in the two groups studied

(Student t - test)

33



34



35



36



37

9 Mouth opening in two groups studied (Student t - test) 38

10 Comparison of mean VAS scores between different

time intervals in Group 1 & Group 2 using Friedman's

Test

39-40

11 Comparison of mean Swelling Size (in cm) and mouth

opening at different regions between different time

intervals in Group 1 & Group 2 using Repeated

measures of ANOVA Test and Bonferroni's post hoc

analysis

40-41

12 Comparison of mean Mouth Opening (in mm) between

different time intervals in Group 1 & Group 2 using

Repeated measures of ANOVA Test and Bonferroni’s

post hoc analysis

42

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ABSTRACT

Background and objectives: Pain and swelling are the common problems associated with

removal of impacted mandibular third molars.

One of the factors most closely linked to the intensity of postoperative pain and swelling is the

type of healing of the surgical wound. In primary healing, the socket is covered and sealed

hermetically by the mucosal flap whereas in secondary healing the socket remains in

communication with the oral cavity.

Tight suturing and primary closure in third molar surgery usually gives rise to more postoperative

discomfort to the patient as compared to the self-irrigating opening maintained in secondary

closure. Further the postoperative care and hygiene of the secondary closure site is more easily

managed by the patients as compared to the primary closure site that has dehisced.1

Material and Methods: The study was conducted on out patients reporting to the Department of

Oral and Maxillofacial Surgery, The Oxford Dental College & Hospital, Bommanahalli,

Bangalore. A total of 70 patients with impacted mandibular third molar will be included in the

study. Group1 patients underwent primary closure and group2 patients underwent secondary

closure. The postoperative sequelae such as pain, swelling and trismus in primary and secondary

closure techniques following third molar surgery was compared and analysed between the two

techniques respectively.

Results: Pain, swelling and trismus were evaluated on 1st, 3rd and 7th postoperative days. Patients

with primary closure experienced greater pain, swelling and trismus. The study suggested that

secondary closure minimizes the postoperative edema, pain and trismus and thus reduced patient

discomfort.

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Conclusion: The results obtained in the present study enable us to conclude that, in cases of equal

intra-operative difficulty, open healing of the surgical wound after removal of impacted third

molars produces less post-operative swelling and pain than occurs with closed healing, by

hermetically suturing the socket.

Keywords: Wound closure, Impacted Third Molar, Swelling, Pain, Post – operative sequelae.

INTRODUCTION

Page 1

Impacted teeth are those teeth that are prevented from eruption due to a physical barrier

within the path of eruption. Third molar eruption and continuous positional changes after

eruption can be related not only with race but also with nature of the diet, the intensity of the

use of the masticatory apparatus and possibly due to genetic background. Impaction of

mandibular third molars is a common condition related with different difficulty degree of

extraction and risk of complications.1

The most common impacted teeth are mandibular and maxillary third molars, followed by the

maxillary canines and mandibular premolars. New data suggests that 72.2% of the world

population has at least one impacted tooth (usually lower third molar). Patients between 20

and 30 years of age are the most frequently affected with symptomatic impactions. As age

increases, the phenomenon of impaction is reduced and after the age of 50 it is in a range from

6-14%.2

Although in many cases, removal of impacted teeth can be easily performed, using just an

elevator and forceps, occurrence of potential complications should not be neglected. Clinical

conditions such as position and relationship of the impacted tooth to adjacent teeth and

anatomic structures such as the maxillary sinus, blood vessels, nerves, and anatomic spaces

play an important role in development of complications.2

Pain, trismus, and swelling are the most common postoperative complaints, and these influence

a patient’s quality of life in the days after surgery. It is generally accepted that pain following

third molar surgery reaches moderate to severe intensity within the first 5 hour after surgery.

However, there are studies showing that the postoperative pain reaches its peak intensity during

the first 8 hours after the surgery.2

INTRODUCTION

Page 2

The surgical removal of impacted mandibular third molars is one of the most commonly

performed dento-alveolar procedures, associated with varying degrees of postoperative

discomfort. Minimal trauma to adjacent soft tissues and proper wound closure minimizes pain,

swelling and trismus. These can be controlled by proper administration of local anaesthesia,

good flap reflection, careful bone removal and minimal trauma to adjacent soft tissues with

appropriate wound closure techniques.3

In primary healing the socket is covered and sealed hermetically by the previously raised flap.

In secondary healing, the socket remains in communication with the oral cavity. Conflicting

opinions have been expressed in the literature concerning these two types of healing. Some

authors are in favor of closed healing, by doing primary closure third molar flaps and the socket

is covered and sealed hermetically by a mucosal flap whereas other authors report that primary

healing frequently causes greater pain and swelling than secondary healing, which is achieved

by secondary closure technique where the socket remains in communication with the oral

cavity to facilitate drainage of inflammatory products. Few studies in the literature conclude

that there was no difference in the two types of healing.4

This study was carried out to compare the post operative pain, swelling and trismus in

mandibular impacted third molar surgery which are closed primarily or secondarily after the

surgical removal. In this study Visual analogue scale is used to measure pain and swelling in

determining the values from day 1 to day 7. A data sheet is provided to patients to note the

degree of pain and swelling. 30 patients were treated with primary closure and another 30

patients were treated with secondary closure. The result analysis is done by using statistical

package for social sciences (SPSS).

AIMS AND OBJECTIVES

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Aim of the study:

The purpose of present study is to compare and evaluate the beneficial wound closure technique

in impacted mandibular third molar surgery.

Objectives of the Study:

- To assess and compare primary and secondary wound closure in mandibular impacted third

molar surgery in relation to pain, swelling and trismus.

- To find out which technique is beneficial for the closure after mandibular impacted third molar

surgery.

REVIEW OF LITERATURE

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A clinical study was conducted in 33 patients with impacted and semi-impacted third molars

were studied preoperatively, immediately after removal of the third molars, and 12 months

postoperatively. Notes were made of the amount of plaque, the severity of gingival inflammation

and the depth of the gingival pockets. Twelve months after operation no change was found in the

supporting bony tissue, but significant bony tissue was found between age-matched groups of

patients with and without impacted or semi-impacted third molars, but the clinical condition of

the periodontium was significantly worse in the group with third molars. So they have concluded

that prophylactic removal of impacted and semi-impacted mandibular third molars would seem

to be indicated.5

A randomized clinical study was conducted in 60 patients (37 females, 23 males; age range 18–

40 years) were included in the series. The patients were randomly subdivided into 2 groups of 30

each. All the patients were operated by the same operator under same clinical conditions. Group

1 had 30 patients who underwent primary closure. Group 2 had 30 patients who underwent

secondary closure. Pain, swelling and trismus were evaluated for 1st, 3rd and 7th days after

surgery with a VAS scale. An analysis of immediate findings showed that the patients with

primary closure experienced significantly greater pain, swelling and trismus than that

was experienced by patients with secondary closure. The findings of this study suggest that the

procedure of choice after removal of impacted mandibular third molars is a secondary closure

and healing by secondary intention. A secondary closure appears to minimize the postoperative

edema, pain and trismus and thus contributes to enhanced patient comfort.6

A clinical study was conducted in fifteen patients were periodontal examinations consisting of

measurements of attachment level, level of the gingival margin, and width of the masticatory

mucosa at three locations around the mandibular second molars were measured. The

examinations were done preoperatively, and two, six, and 12 weeks after removal of the

impacted molars. Analyses of variance indicated that there was no significant difference between


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the two flap techniques and, therefore, the choice of flap technique is one of operator preference.

There was a significant decrease in mean sulcus depth at all measured points for either flap

technique, indicating a generally healthier condition around mandibular second molars 12 weeks

after the surgical removal of mandibular third molars.7

A split mouth experimental study was conducted in 30 patients with bilateral mandibular

impactions with one side of the mandible being randomly allocated to one of two flap design

groups. Plaque level, gingival inflammation, probing depth and attachment level measurements

around the second molar were taken at baseline and then at monthly intervals for a period of 6

months. Alveolar bone height was measured from panoramic radiographs. Six months post

surgically, both flap design groups exhibited a statistically significant loss of attachment level on

the distal surface of the second molar with no difference between the two flap groups. The initial

height of the alveolar bone on the distal of the second molar had no influence on the loss of

attachment. It was concluded that the surgical removal of the fully impacted mandibular third

molar led to the loss of attachment on the distal of the second molar; flap design had no influence

on the degree of attachment loss; the initial height of the alveolar bone on the distal of the second

molar had no influence on the loss of attachment.8

A retrospective study comprising 51 cases was conducted where the postoperative examinations

took place 2 and 4 years after the surgical treatment and included both clinical and radiographic

variables. Assessments were made regarding the oral hygiene status, gingival condition and

periodontal tissue breakdown in terms of increased probing depths and intrabony defects.

Comparing the results of the two examinations, no significant changes of the incidence of plaque

and gingivitis were seen on the distal surface of the 2nd molar, nor any significant change

concerning the probing depth. The proximal bone level distal to the second molar was recorded

by radiographic examination with a cut-off periodontal probe as indicator. Two years

postoperatively, 16.7% of the cases aged _< 25 years showed intrabony defects exceeding 4 mm,

compared with 40.7% in the age group >26 years. At the 4-year re-examination, the

corresponding figures were 4.2% and 44.4%, respectively. The improvement concerning the


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alveolar bone level was mainly seen in individuals under 25 years. Some factors affecting the

periodontal healing after impacted lower 3rd molar surgery are discussed.9

A prospective randomized study was done where the insertion of a small surgical tube drain with

primary wound closure (drain group) was compared to a simple primary wound closure (no drain

group) after removal of impacted third molars. Surgery was performed on 23 patients in a

randomized cross-over fashion. The operation time was found to be significantly longer and

mouth opening significantly wider in the immediate postoperative period in the drain group

subjects as compared to the no drain group (P > or = 0.01). There was no significant difference

in the severity of pain between the two groups. Facial swelling was found to be significantly less

in the drain group subjects (P > or = 0.01). The number of patients with wound breakdown,

edema, and bleeding was found to be less in the drain group than in the no drain group. Thus, the

postoperative problems, in general, were less in the small surgical drain group as compared to

the no drain group.10

A prospective study was done in which two hundred forty-nine patients (age 13 to 37 years) at 2

clinical centers underwent surgical removal of third molars. Each patient was given a 21-item

Health-Related Quality of Life instrument (HRQOL) to be completed each postoperative day

(POD) for 14 days. The instrument was designed to assess patients' perception of recovery: pain,

oral function, general activity measures, and other symptoms. Pain dimensions were recorded

with a 7-point Likert-type scale; all other conditions were measured on 5-point Likert-type

scales. The impact of each predictor variable such as age, gender, and length of surgery on

recovery was assessed with Cochran-Mantel-Haenszel statistics, controlling for clinical center.

After the 14-day postoperative period, 201 of the original 249 patients returned the completed

HRQOL instrument; the 48 patients who did not return their diary had third molar conditions and

surgery similar to the 201 patients who responded. On POD 1, 63.5% of patients reported their

worst pain as severe (score, 5 to 7/7) at some time during the day. By POD 7, only 15% of

patients reported their worst pain as severe. Average pain levels were much less; 29% reported

their average pain as severe (score, 5 to 7/7) on POD 1, decreasing to 5.5% by POD 7. Patients


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experienced substantial interference in oral function; chewing, 85%; mouth opening 78.5%, and

speaking 37.5% on POD 1. By POD 6, oral function had improved; chewing, 19%, mouth

opening, 15%; and speaking, 1.5%. General measures also were affected on POD 1; social

activity, 61.5%; recreation, 70.5%; and daily routine, 60%. Patients assumed a more normal

lifestyle by POD 5. Swelling seemed to be at its maximum on PODs 1 and 2 (day 1, 53%; day 2,

61%) and decreased markedly by POD 5 (10%). Food collection in the surgical sites posed the

biggest problem for patients on POD 9 (20%).11

A clinical study of 166 extractions of impacted lower third molars, all vertical and all extracted

by the same surgeon was performed. Each tooth was classified according to the Pell-Gregory

scales of position for the occlusal plane (scale A-C) and the ascending ramus of the mandible

(scale 1-3). The extraction was subsequently rated as 'easy' or 'difficult'. Taking Pell-Gregory

class C as a predictor of a 'difficult' extraction, specificity was 88% but sensitivity was low at

15%. Taking Pell-Gregory class 3 as an indicator of 'difficult', sensitivity was somewhat better

(50%), but at the expense of specificity (62%). Likelihood ratios for the individual classes also

indicated that the scales are of little value for predicting a difficult extraction.12

A clinical study was conducted to compare the influence of two mucoperiosteal flaps on

periodontal healing of adjacent second molars after extraction of impacted mandibular third

molars. An envelope incision with a releasing incision anterior to the second molar (3-cornered

flap) was used on one side and a Szmyd flap on the other side in 14 patients with bilateral

impaction of mandibular third molars. The periodontal health of the second molars was evaluated

before surgery and at 3 and 6 months postoperatively. A William's periodontal probe was used to

measure the pocket depth, clinical attachment level, and bone level of the buccal and mesial

surfaces of the second molars. The postoperative measurements were analyzed by using analysis

of covariance, with the covariables being the preoperative measurements and variation factors

being the type of flap used, the surface measured, and the time since the procedure. No

statistically significant differences were found in comparing measurements of probing depth,

clinical attachment level, or bone level for the 2 types of flap used or the 2 surfaces measured.


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However, there was a statistically significant increase in all 3 measurements from the 3-month to

the 6-month postoperative time.13

A clinical prospective study was carried out to compare 2 flap designs-marginal and para

marginal that are used during impacted third molar surgery. Twenty-seven healthy patients (ages

17 to 31 years) who underwent surgical removal of 4 impacted third molars, including 54 lower

and 54 upper, were included. A marginal flap was used in 1 randomly chosen half of the jaw, and

a para marginal flap was used in the other half. The influence of these flaps on wound healing,

periodontal pocket depth of the adjacent second molar, pain, trismus, and swelling was studied.

Wound dehiscences developed in 8 paramarginal flap cases, whereas none occurred with the use

of a marginal flap. The buccal and distal probing depths of the adjacent second molar were

significantly bigger in marginal flaps at 5 and 10 days after surgery. However, the probing depth

was similar with the use of both techniques at 3 months. Pain, trismus, and swelling were similar

with both techniques. We found no advantages to the use of a paramarginal flap instead of a

traditional marginal flap for removing impacted third molars.14

A retrospective cohort study purpose was conducted to measure associations between

mandibular third molar (M3) status/position and risk for angle fracture. The primary predictor

variable was M3 (present/absent). The secondary predictor variable was M3 position classified

using the Pell and Gregory system. The outcome variable was angle fracture (present/absent).

Appropriate univariate, bivariate, and multivariate logistic regression analyses were computed.

The level of statistical significance was set at P </=.05: The study sample was composed of

1,450 subjects with a mean age of 30.6 +/- 10.4 years (range, 2 to 87 years). The risk of an angle

fracture with and without M3s was 30.1% and 13.7%, respectively (adjusted odds ratio, 2.8; 95%

confidence interval, 2.3 to 3.4; P <.001). Based on the Pell and Gregory classification, varying

M3 position was associated with varying risks of angle fracture (P <.001). The presence of M3s

was associated with a 2.8-fold increased risk for angle fractures. M3 position was associated with

a variable risk for angle fracture. Notably, the deep impactions were not associated with an

increased risk for fracture.15


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In a prospective study of more than 30 months, a total of 528 impacted lower third molars were

surgically removed in 288 patients. All patients were referred to our department by a dentist or a

general practitioner. No patient showed any sign of pain, inflammation, or swelling at the time of

removal. Three groups were established. In the first group, antibiotic treatment with

amoxicillin/clavulanic acid as an oral medication was carried out for 5 days postoperatively. In

the second group, we used clindamycin. In the third group, the patients received no antibiotic

treatment. Clinical and radiologic factors were recorded for each case, and the rationale for

assigning the patients to the groups was strictly random. The surgical technique was the same in

all cases, and the follow-up period was 4 weeks. Parameters that were evaluated were pain,

differences in mouth opening, infection, the occurrence of dry socket, and adverse postoperative

side effects. We could not find any significant difference between the 3 groups regarding the

evaluated parameters, but in 69.6% of the patients with dry socket, the teeth were partially

erupted, which showed a significant difference. The results of our study show that specific

postoperative oral prophylactic antibiotic treatment after the removal of lower third molars does

not contribute to a better wound healing, less pain, or increased mouth opening and could not

prevent the cases of inflammatory problems after surgery, respectively, and therefore is not

recommended for routine use.16

A clinical study was conducted in 153 consecutive surgical extractions of mandibular third

molars performed in 140 patients between April 1998 and March 2001. Fifty-four (35%) of the

153 extractions were performed in male subjects and 99 (65%) in female subjects. The median

age was 27 years. The amount of facial swelling varied depending on age and sex. Severe pain

was associated with depth and preoperative index of difficulty. Average pain was associated with

preoperative index of difficulty. In conclusion, we consider that the short-term outcomes of third

molar operations (swelling and pain) differ depending on patients' characteristics (age and sex)

and preoperative index of difficulty. Further mega-trial studies of the association between

preoperative findings and short-term outcome will help to elucidate the true nature and

magnitude of the association.17


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A randomized control study was conducted in two hundred patients with impacted third molars

were randomly divided into two groups of 100. Panoramic radiographs were taken to assess

degree of eruption and angulation of third molars. Teeth were extracted, and in Group 1 the

socket was closed by hermetically suturing the flap. In Group 2 a 5-6 mm wedge of mucosa

adjacent to the second molar was removed to obtain secondary healing. Swelling and pain were

evaluated for 7 days after surgery with the VAS scale. The statistical analysis (*analysis of

variance for repeated measures, P < 0.05) showed that pain was greater in Group 1, although it

decreased over time similarly in the two groups (P = 0.081, F(6,198) = 3.073*). Swelling was

significantly worse in Group 1 (P < 0.001, F(6,198) = 44.30*). In Group 1, dehiscence of the

mucosa was present in 33% of patients at day 7, and 2% showed signs of re-infection with

suppurative alveolitis at 30 days. Pain and swelling were less severe with secondary healing than

with primary healing.18

A prospective cohort study was conducted in sample of surgeons removing M3s in an

ambulatory care setting. Subjective rankings were made by surveying the surgeons and asking

them to rank each variable's importance on a scale ranging from 0 (not important) to 100

(extremely important). Objective rankings of each variable's importance were made using the

absolute values of coefficients derived from a multivariate linear regression model with

extraction time as the outcome. Appropriate uni-, bi-, and multivariate statistics were computed.

The sample consisted of 14 surgeons who removed 450 M3s from 150 subjects from June 2002

to August 2003. Based on the multivariate linear regression model, variables associated with M3

extraction time were gender, arch location, Winter's classification, tooth morphology, number of

teeth extracted, procedure type, and surgical experience. For these variables, there was a strong,

statistically significant correlation (r = 0.86; P <.01) between the standardized coefficient

absolute values and the surgeons' estimates of importance. There was a large, positive correlation

between variables that surgeons consider most important in determining M3 extraction difficulty

and those exhibiting the most influence over extraction times in a multivariate model.19


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A clinical study was conducted to evaluate the effectiveness of cryotherapy, the therapeutic use

of cold, in reducing undesirable consequences after surgery. Fourteen patients aged 20 to 28

years comprised the sample. The authors extracted two impacted mandibular third molars at

different times from each patient. Immediately after surgery, the patient underwent cryotherapy

on one side for 30 minutes every one and one-half hours for 48 hours when he or she was awake.

The patient did not recieve cryotherapy on the other side. The authors performed clinical

examinations to measure trismus and swelling before surgery, immediately after surgery and 24

and 48 hours after surgery. The authors compared both sides for differences in swelling, pain and

trismus in each patient. The results showed significant statistical differences in two of the five

points that were used to measure the swelling (Wilcoxon nonparametric signed rank test of linear

distances between the angle of the mandible to the pogonion and to the tragus). They found

statistical differences between the two sides in relation to the pain; however, they found no

significant differences in relation to trismus. Cryotherapy was effective in reducing swelling and

pain in this sample. Despite playing no role in the reduction of trismus, cryotherapy was

effective in reducing swelling and pain in this sample, and the authors still recommend it be

used.20

A clinical study where total of 1,280 third molars were removed from 366 patients in an

outpatient setting using intravenous sedation and local anesthesia. A small V-shaped flap was

raised in all cases and no sutures were placed over a 2-year period (2001 to 2003). All people

were contacted by a registered nurse within 24 hr. All records were reviewed by a medical

investigator and IRB approval was obtained. The mean age was 22.14 years, males 39%, females

61%, white 75%, African American 22%, and Asian 3%. Ninety-three people of 366 experienced

at least 1 complaint. Alveolar osteitis was 2.81% for the total teeth extracted and 10.7% for the

mandibular Class IV impactions. A total of 652 mandibular third molars were removed (Class

III, n= 113; Class IV, n= 522). Forty-eight of 366 patients (13.1%) had postoperative diagnosis

of alveolar osteitis. Small flap third molar surgery without sutures is less invasive and saves

time. Delayed healing in oral surgery is not new. The outcome of 1,280 extractions demonstrates

good results.21


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A clinical study was conducted to assess the effects of 4 types of widely used commercial mouth

rinses on third molar surgery-related oral malodor. In this double-blind selective clinical trial, 80

participants (40 women, 40 men) who had undergone third molar surgery were divided into 5

groups, and different mouth rinses were given to each: 0.2% chlorhexidine gluconate (Chx),

0.12% chlorhexidine gluconate with 0.15% benzydamine hydrochloride (Chx+Bzd), 7.5%

polyvinylpyrrolidone iodine (Pvp), 0.15% benzydamine hydrochloride (Bzd), and sterile saline

solution (Ss), with other routine medications. Oral malodor of patients was evaluated with 3

methods; using a Halimeter, an organoleptic method, and patient self-evaluation. Measurements

were performed preoperatively and postoperatively (pre-op, third, eighth, and fifteenth days):

Bad breath parameters systematically increased (P < .05) in all groups after third molar surgery

on the third and eighth days. The Pvp and Ss groups showed higher scores when volatile sulfur

compounds were considered. When organoleptic and patient self-evaluation scores were

considered, the Bzd and Ss groups had higher scores than the others on the third and eighth days.

The difference between the pre-op day and the fifteenth day was not significant in all groups in

terms of all measures.Third molar surgery-related oral malodor increases during the first

postoperative week and decreases to the preoperative level after 15 days. Results from the 3

different methods showed that Chx and Chx+Bzd mouth rinses are more effective mouth rinses

than the others on third molar surgery-related oral malodor.22

A comparative study is made of two types of flaps in semi-impacted third molar surgery and

their relation to the postoperative period (pain, swelling and trismus).Twenty-five healthy

patients were subjected to surgical extraction of both semi-impacted lower third molars, located

in a similar clinical and radiographic position. In 25 cases the wound was sutured using a

reflection flap (healing by first intention), while in the 25 contralateral cases the conventional

technique was used (simple approximation of the wound margins). Pain, swelling and trismus

were evaluated, during the first week of the postoperative period. Results: There was lesser pain,

swelling and trismus after extraction of a semi-impacted third molar when healing took place by

second intention (simple approximation of the margins), than in the case of healing by first

intention (flap repositioning and margin-to-margin suturing). The postoperative course proved


Page 13

worse when using a reflection flap for healing by first intention than on suturing by simple

approximation of the wound margins.23

A clinical study was conducted to compare the influence of primary and secondary closure of the

surgical wound on postoperative pain and swelling after removal of impacted mandibular third

molars. A total of 93 patients with bilaterally impacted mandibular third molars were included in

the present study. All the patients underwent surgical removal of the bilaterally impacted teeth at

the same appointment. Primary closure (group I) was performed on 1 side and secondary closure

(group II) was performed on the other side. All the patients were assessed for pain and swelling

using the visual analog scale, and the data were collected and analyzed with the paired t test after

7 days: The swelling in group I was greater than that in group II, with a statistically significant

difference (P < .001). The pain was worse in group I than in group II; a difference that also was

statistically significant (P < .05). Alveolar osteitis occurred in 4 patients (4.3%) in group I and 3

patients (3.2%) in group II. Our results have shown that the patients in the secondary closure

group had a significantly lesser amount of pain and swelling postoperatively than the primary

closure group.24

A clinical study was conducted to assess the prevalence of periodontal inflammatory disease on

the distal side of second molars after third molar removal and the association between pre

surgical and surgical variables and postsurgical periodontal outcomes. Data before and after

surgery from 2 studies approved by an institutional review board were used. In 1 study, 26

subjects had 4 asymptomatic third molars and in the other 49 subjects had at least 1 mandibular

third molar with symptoms of pericoronitis. Full-mouth periodontal probing data, 6 sites per

tooth, were obtained as a measurement of periodontal status before and after surgery. A probing

depth (PD) <4 mm on either of the 2 possible probing sites on the distal side of any second molar

(D2M) served as an indicator of periodontal inflammatory disease; periodontal health was

defined as all D2M PD <4 mm. Cochran-Mantel-Haenszel row mean score tests compared the

subjects' postsurgical periodontal status (all D2M PD <4 mm and at least 1 D2M PD <4 mm)

with respect to age and time intervals, and the Fisher exact test was used to compare ethnicity,


Page 14

gender, and clinical data at surgery. The McNemar test was used to assess the discordance

between subjects' pre- and postsurgical periodontal status. The level of significance was set at

.05. Of the 75 subjects, 52% were women and 65% were white. The median age at surgery was

23.6 years (interquartile range, 20.9 to 26.6 years). At enrollment, 53 of 75 subjects (71%) had at

least 1 D2M PD <4 mm. Subjects were significantly more likely to have an improved D2M

periodontal status after surgery than a deteriorated status (P < .01). Fewer subjects, 17 of 75

(24%), had at least 1 D2M PD <4 mm after surgery. D2M PD <4 mm was more likely after

surgery if presurgical D2M was PD <4 mm (P < .01). Gender, ethnicity, age, presurgical

symptoms, and data estimating the extensiveness of surgery were not significantly associated

with postsurgical D2M periodontal outcomes. Conclusions: After third molar removal,

periodontal inflammatory disease on the distal of D2Ms was detected significantly less often.

None of the variables examined except for presurgical presence of D2M PD <4 mm were

significantly associated with postsurgical D2M periodontal inflammatory disease.25

A clinical study where the effect of single and multiple suture techniques on these complications

was compared. All consecutive patients 18 years of age or older who had been referred for

surgical extraction of their impacted teeth between January and December 2007 at the

maxillofacial unit of the Aminu Kano Teaching Hospital were recruited and randomized into 2

groups. All selected participants underwent surgical extraction of their impacted teeth by the

same surgeon under local anesthesia. The flaps in 1 group were closed by multiple sutures and

those in the second group were closed by a single suture. Pain, swelling, and trismus were

evaluated at postoperative days 1, 2, 3, 5, and 7. Descriptive and comparative statistical analyses

were performed, and the results are presented. Significance was set at P < .05.A total of 50

subjects participated in the present study. Both groups were comparable in terms of the age

distribution (multiple suture group, 26.0 ± 4.73 years; single suture group, 25.8 ± 4.28 years, P =

.755), difficulty index (multiple suture group, 5.0 ± 1.68; single suture group, 4.9 ± 4.79; P =

.935), duration of surgery (multiple suture group, 29. 7 ± 6.11 minutes; single suture group, 30.0

± 6.04 minutes; P = .835), and baseline parameters such as facial width (multiple suture group,

10.0 ± 1.32 cm; single suture group, 9.8 ± 0.37 cm; P = .115), mouth opening (multiple suture


Page 15

group, 4.5 ± 1.32 cm, single suture group, 4.8 ± 0.26 cm; P = .165), and preoperative pain, which

was 0 in both groups. Other comparable variables included impaction type (P = .210) and

indication for surgery (P = .278). A statistically significant difference was found in the level of

pain at postoperative days 1, 2, and 3 (P < .05). A similar significant difference was found in

swelling and trismus (P < .05). At days 5 and 7, no significant differences were found between

the 2 groups for all parameters of pain, swelling, and trismus (P > .05). Our study had a

comparable distribution of age, gender, and operative variables, such as the pattern of impaction,

preoperative difficulty index, and operative time between patients undergoing the 2 methods of

closure. With that, our results have shown that the single suture closure technique was better than

the multiple suture technique with regard to postoperative pain, swelling, and trismus.26

A clinical study was conducted in 60 patients in terms of healing, postoperative pain and

swelling. Third molar was extracted and in group 1 with 30 patients the socket was closed by

hermetically suturing the flap. In group 2 with 30 patients, a 5 to 6 mm wedge of mucosa distal

to the second molar was removed and interrupted sutures were given to form a triangular

opening distal to second molar. Pain was less in the secondary closure group from day 1 to day 7.

Swelling and trismus was also significantly less in group 2. The results was concluded that open

healing of the surgical wound produces less postoperative complications.27

A split mouth study in 30 patients was conducted where 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.28


Page 16

A randomized prospective split mouth study in 52 participants had bilateral symmetrically

impacted mandibular third molars removed over two sessions was conducted. A buccal envelope

or pedicle flap was randomly assigned to the left or right third molar site. Pre-and postoperative

pain and swelling were recorded using a standardized visual analogue scale, trismus was

measured as the maximum inter-incisal opening distance in millimetres and dry socket was

assessed clinically. Greater continuous pain, pain on maximum opening, and oro-facial swelling

were recorded with the pedicle flap design. Continuous pain resolved significantly faster with

this flap design (p<0.05). Trismus was similar for both flap designs (p>0.05). Five cases of

alveolar osteitis occurred with the envelope flap whilst no cases developed with the pedicle flap,

but the incidence was too small for statistical analysis. The pedicle flap improved some aspects

of postoperative pain experience and reduced the incidence of alveolar osteitis, but further

investigation with a larger sample size is required to evaluate its significance.29

A clinical study was conducted in 121 patients to assess the efficacy of primary and secondary

wound closure technique in terms of postoperative pain, swelling and acute alveolar osteitis

(AO). Two types of wound closures were adopted, primary in group 1 and secondary in group 2.

The amount of increase in facial measurements, pain and empty socket was higher in group1.

Tenderness and halitosis were more prevalent in group2. The study concluded that when the

envelope flap is used, secondary wound closure has insignificant advantages over primary

closure with respect to swelling, pain and (AO).30

MATERIALS AND METHODS

Page 17

MATERIALS:

Mouth mirror

Periodontal probe

Metallic scale

Measurement tape

ARMAMENTERIUM:

2% Lignocaine HCL with 1:2, 00, 000 Adrenaline

Mouth Mirror

Probe

Tweezer

2ml Syringe

Bp Handle No 3

Bp Blade No 15

Molts Periosteal Elevator

Howarth’s Periosteal Elevator

Austin’s retractor

Straight handpeice

No. 702 bur

Coupland elevator

Straight elevator

Needle Holder

Adson’s Tissue Holding Forceps

Suture Cutting Scissors

Silk suture material


Page 18

Fig – 1

Fig - 2 Armamentarium for Extraction of third molar


Page 19

Fig – 3 702 STRAIGHT BUR AND STRAIGHT HANDPIECE

METHODS:

PROCEDURE:

The study will be conducted in The Department of Oral and Maxillofacial Surgery, The Oxford

Dental College and Hospital, Bangalore. This is an in vivo study to compare the postoperative

sequel following mandibular third molar removal using primary and secondary closure

techniques. Following the clearance from the ethical committee of the institution and after

explaining the entire procedure, a detailed written informed consent in the vernacular language

of the patient will be obtained. Patients will then undergo removal of mandibular third molars. It

will include a sample size of 60 patients, divided into two groups of 30 each.

Group I (n=30): patients will be treated by primary wound closure technique.

Group II (n=30): patients will be treated by secondary wound closure technique.

CLASS AND LEVEL OF IMPACTION INCLUDED IN THE STUDY:

1. Based on the Nature of the Overlying Tissue

Soft Tissue Impaction.

Hard Tissue ('Bony') Impaction.

Partial Bony or completely bony.


Page 20

2. Winter's Classification: based on the inclination of the impacted wisdom tooth (3rd molar)

to the long axis of the 2nd molar.

Mesio-Angular.

Disto-Angular.

Horizontal.

Vertical.

Buccal / Lingual Obliquity.

Transverse.

3. Pell & Gregory's Classification: based on the relationship between the impacted lower wisdom

tooth (3rd molar) to the ramus of the mandible.

Class I

Class II

Class III

Position A

Position B

Position C

SURGICAL TECHNIQUE:-

The patient was asked to rinse his/her mouth with 0.2% Chlorhexidine before the start of the

procedure.

Anaesthesia: Inferior alveolar, lingual and long buccal nerve blocks were administered using 2%

Lignocaine with 1:200000 Adrenaline.

Surgical access was done by standard Ward’s incision.


Page 21

Bone guttering around the tooth was done using a straight fissure bur (No 702) under copious

irrigation with saline. The crown or roots were sectioned when necessary.

After complete extraction of tooth socket was inspected, irrigated copiously and flap was sutured

back with interrupted 3-0 silk sutures.

Primary haemostasis was achieved.

Post -operative instructions:

Regular post extraction instructions were given.

All patients were given Tab Amoxicillin 500mg 8th

hourly for five days and metronidazole

400mg and diclomol 8th

hourly for 3 days.

INCLUSION CRITERIA:

1. Patients of either sex between the age group of 18-40 years who require extraction of third

molar teeth and are willing to be included in this study.

2. Systemically healthy patients.

3. Mesioangular or horizontal impacted mandibular third molars.

EXCLUSION CRITERIA:

1. Patients suffering from systemic diseases such as bleeding and clotting disorders,

cardiovascular diseases, hypertension, uncontrolled diabetes mellitus.

2. Smokers.

3. Patients allergic to the drugs or anesthetic agents used in the surgical protocol.

4. Patients who do not give informed consent to the above study.

PROCEDURE:

All patients will be asked to take antibiotics prior to the day of surgery. All patients will be

instructed to rinse with 5-10 ml of 0.12% of chlorhexidine for 2 min preoperatively. The surgical


Page 22

removal of impacted mandibular third molars will be performed under local anesthesia, with 2%

lignocaine (1:200000 with adrenaline). The surgical steps will include incision, reflection of

mucoperiosteal flap, bone removal, tooth sectioning, tooth removal, irrigation with saline and

debridement of the socket. After achieving proper hemostasis the wound closure will be done. In

primary closure technique the flap will be repositioned and hermetically closed using black

braided silk sutures. In secondary wound closure technique a wedge of mucosa, with a width of

5-6 mm will be removed distal to second molar and the flap will be repositioned and sutured

using black braided silk, so as to form a triangular opening distal to second molar.

Postoperatively, all the patients will receive amoxicillin 500mg, three times a day for 5 days and

tablet diclofenac 50mg, three times a day for 3 days. If the patient is allergic to penicillin group

of drugs, erythromycin 500mg twice daily for 5 days can be given. Follow up will be done on 1,

3, and 7 postoperative days.

EVALUATION CRITERIA:

Assessment of pain will be done by two scales :

1. Visual analogue scale6: which consists of interval scale ranging from 0-10

where

0 indicates no pain

1-3 indicates mild pain,

4-6 indicates moderate pain

7-8 severe pain

10 indicates worst possible pain.

2. Verbal response scale6 :

which consists of 4 grades where,

0 indicates No pain

1 indicates mild relief

2 indicates moderate relief

3 indicates sufficient relief

4 indicates complete relief.


Page 23

Assessment of swelling7:

Swelling will be assessed using a measuring tape as described by Gabka and Matsumara.7 Here

five fixed points and four surgical base lines will be used in order to cover all possible directions

of extension of swelling where, S1 indicates distance between ala and outer corner of the mouth,

S2 indicates distance between tragus and the soft tissue pogonion, S3 indicates distance between

angle of the mandible and outer corner of the mouth, S4 indicates distance between angle of the

mandible and lateral corner of the eye.

FIG 4: Markings for measurement of facial swelling.

Assessment of mouth opening:

Mouth opening will be assessed with a vernier caliper instrument by measuring the inter incisal

distance.


Page 24

PICTURES:

Pre operative clinical picture of completely impacted mandibular 3rd

molar

Orthopantomagram showing the impacted tooth.


Page 25

After the guttering of bone

After the extraction of impacted tooth.


Page 26

The sectioned tooth.

Only two sutures in place after cutting the wedge of tissue.


Page 27

Sutures in Secondary wound closure technique

Sutures in Primary wound closure technique


Page 28

Follow up - opening noted which is left intentionally in secondary wound closure

technique.

Mouth opening measured using a vernier caliper


Page 29

SAMPLE SIZE ESTIMATION

Analysis: A priori: Compute required sample size

Input: Tail(s) = Two

Effect size d = 0.80

α err prob = 0.05

Power (1-β err prob) = 0.80

Allocation ratio N2/N1 = 1

Output: Noncentrality parameter δ = 2.8844410

Critical t = 2.0085591

Df = 50

Sample size group 1 = 26


Total sample size = 52

Actual power = 0.8074866

The sample size has been estimated using the software GPower v. 3.1.9.2

Considering the effect size to be measured (d) at 80%, power of the study at 80% and the margin

of the error at 5%, the total sample size needed is 52, rounding the sample size to 60.

So, each study group will comprise of 30 samples.

SAMPLE SIZE

SAMPLE SIZE ESTIMATION

Analysis: A priori: Compute required sample size

Input: Tail(s) = Two

Effect size d = 0.80

α err prob = 0.05

Power (1-β err prob) = 0.80

Allocation ratio N2/N1 = 1

Output: Noncentrality parameter δ = 2.8844410

Critical t = 2.0085591

Df = 50



Total sample size = 52

Actual power = 0.8074866

The sample size has been estimated using the software GPower v. 3.1.9.2

Considering the effect size to be measured (d) at 80%, power of the study at 80% and the margin

of the error at 5%, the total sample size needed is 52, rounding the sample size to 60.

So, each study group will comprise of 30 samples.

RESULTS

Page 30

Descriptive and inferential statistical analysis has been carried out in the present study. The

results were analysed by using SPSS version 18 (IBM Corporation, SPSS Inc., Chicago, IL,

USA). Microsoft word and Excel was used to generate graphs, tables etc. Results on continuous

measurements were presented on Mean SD (Min-Max) and results on categorical measurements

were presented in Number (%). Significance was assessed at 5 % level of significance.

Normality of data was checked using Shapiro-Wilk test. Mann-whitney U test, Friedman’s test,

Chi-square test with Yate’s Correction were used to find the significance of study parameters

between the two groups. Mann-Whitney test is used to find out the difference between the

groups. Friedman’s test is used to find out the difference in parameters over a period of time.

A total of 60 patients who visited the Department of Oral and Maxillofacial Surgery, The Oxford

Dental College and Hospital, Bangalore, for surgical extraction of lower third molars were

enrolled for the study. There were equal men and women (Table 1 and Graph 1) in the age range

of 18-40 years (Table 2 and Graph 2). Following completion of clinical study on the patients, the

measurements and data taken from all patients were tabulated for statistical studies.

The results of our study are described in brief as follows:

PAIN (Table 3 and Graph 3) - The mean postoperative pain was lower in the group 2(secondary

closure) when compared with the group 1(primary closure). The intensity of pain was not

significant at the 7th

day between the two groups. Friedman’s test, Chi-square test with Yate’s

Correction were used to find the significance of study parameters between the two groups

Mann-Whitney test is used to find out the difference between the groups. Friedman’s test is used

to find out the difference in parameters over a period of time. There is significant difference in

distribution of scores at 1 and 3 day post op but non-significant at 7th

day post-op.

MOUTH OPENING (Table 7 and Graph 7) - A comparison of measurement of mouth opening is

made between the test group and the control group. The significant reduction in trismus was seen

in group2 (secondary closure) on the 1st 3

rd post operative day.

FACIAL SWELLING – The facial measurements were taken preoperatively using 4 baselines

(S1, S2, S3, S4) (Table 10 and Graph 10) and was compared with facial swelling on 1st,

3rd

and

7th

postoperative day in both the groups. Day wise comparison of S1(Table 11 & 12), S2 (Table),

S3 (Table), S4 (Table) in both the groups. Mann-Whitney test has been used to find the

RESULTS

Page 31

significance of comparison of facial swelling between the test group and the control group based

on the facial measurements.

Table 1: Gender distribution of the study sample

Age and Gender Distribution among study Subjects in 02 groups

Variables Category

Group 1 Group 2

P-Value Mean SD Mean SD

Age (in

yrs)

Mean &

SD 28.5 3.2 27.9 3.7 0.48a

Range 22 - 33 22 - 33

Gender Males 16 53.3% 23 76.7% 0.06

b

Females 14 46.7% 7 23.3%

Note: a. Mann Whitney U test; b. Chi Square Test

Group 1 - Primary Wound Closure Technique, Group 2- Secondary Wound Closure

Technique

Inference: Since p value is greater than 0.05, it shows both groups are homogeneously

distributed.

Graph 1 : Gender wise distribution of study patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Group 1 Group 2

53.3%

76.7%

46.7%

23.3%

Pe

rce

nta

ge

Genderwise distribution of study patients

Females

Males

RESULTS

Page 32

There was significant reduction in swelling in the group2 (secondary closure) as compared to the

group1 (primary closure)

Graph 2: Age distribution of study patients

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Group 1 Group 2

28.5 27.9 M

ean

Age

(in

Yrs

)

Agewise distribution of study patients

RESULTS

Page 33

Table 2: Pain distribution in the two groups studied

Comparison of mean VAS scores for Pain between Group 1 & Group 2 at different time

intervals using Mann Whitney U Test

Time Group N Mean SD

Mean

Diff Z P-Value

Baseline Group 1 30 2.87 2.01 -0.63 -1.179 0.24

Group 2 30 3.50 2.30

Day 1 Group 1 30 5.37 1.81 3.97 -6.149 <0.001*

Group 2 30 1.40 1.33

Day 3 Group 1 30 4.53 1.70 3.60 -6.209 <0.001*

Group 2 30 0.93 1.20

Day 7 Group 1 30 2.60 1.52 2.30 -5.529 <0.001*

Group 2 30 0.30 0.65

Graph 3 : Comparison of pain scores between Group 1 and Group 2 patients.

Inference: There is overall statistically significant reduction in pain when compared

between Day 1, 2 & 3 separately in group 2.

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Baseline Day 1 Day 3 Day 7

2.87

5.37

4.53

2.60

3.50

1.40

0.93

0.30

Me

an V

AS

Sco

res

Comparison of mean VAS scores for Pain between Group 1 & Group 2 at different time intervals

Group 1 Group 2

RESULTS

Page 34

Table 3 : Comparison of mean Swelling size (in cm) at S1 Region between Group 1 &

Group 2 at different time intervals using Independent Student t Test

Comparison of mean Swelling size (in cm) at S1 Region between Group 1 &


Time Group N Mean SD Mean Diff t P-Value

Baseline Group 1 30 2.65 0.16 0.01 0.159 0.87

Group 2 30 2.64 0.17

Day 1 Group 1 30 15.30 0.32 0.00 0.000 1.00

Group 2 30 15.30 0.32

Day 3 Group 1 30 6.55 0.21 0.00 0.000 1.00

Group 2 30 6.55 0.21

Day 7 Group 1 30 8.33 0.20

0.00 0.000 1.00

Group 2 30 8.33 0.20

Comparison of mean Swelling size (in cm) at S1 Region between Group 1 & Group 2 at

different time intervals

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00


2.65

15.30

6.55

8.33

2.64

15.30

6.55

8.33

Me

an S

we

llin

g Si

ze (

in c

m)

Comparison of mean Swelling size (in cm) at S1 Region between Group 1 & Group 2 at different time intervals

Group 1 Group 2

RESULTS

Page 35

Table 4: Comparison of mean Swelling size (in cm) at S2 Region between Group 1 &





Baseline Group 1 30 2.66 0.17 0.00 0.075 0.94

Group 2 30 2.66 0.18

Day 1 Group 1 30 15.99 0.25 0.54 7.357 <0.001*

Group 2 30 15.45 0.31

Day 3 Group 1 30 8.34 0.22 1.58 29.511 <0.001*

Group 2 30 6.75 0.20

Day 7 Group 1 30 10.40 1.72 1.92 6.072 <0.001*

Group 2 30 8.48 0.19



0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00


2.66

15.99

8.34

10.40

2.66

15.45

6.75

8.48

Me

an S

we

llin

g Si

ze (

in c

m)


Group 1 Group 2

RESULTS

Page 36






Baseline Group 1 30 2.66 0.16 -0.01 -0.238 0.81

Group 2 30 2.67 0.17

Day 1 Group 1 30 15.55 0.40 0.22 2.362 0.02*

Group 2 30 15.33 0.31

Day 3 Group 1 30 6.60 0.20 0.03 0.481 0.63

Group 2 30 6.57 0.23

Day 7 Group 1 30 8.33 0.19 -0.01 -0.259 0.80

Group 2 30 8.35 0.21



0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00


2.66

15.55

6.60

8.33

2.67

15.33

6.57

8.35

Me

an S

we

llin

g Si

ze (

in c

m)


Group 1 Group 2

RESULTS

Page 37






Baseline Group 1 30 2.65 0.16 -0.01 -0.239 0.81

Group 2 30 2.66 0.16

Day 1 Group 1 30 15.39 0.31 0.06 0.727 0.47

Group 2 30 15.33 0.33

Day 3 Group 1 30 6.59 0.17 0.04 0.810 0.42

Group 2 30 6.55 0.21

Day 7 Group 1 30 8.35 0.16 0.02 0.351 0.73

Group 2 30 8.33 0.20



0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00


2.65

15.39

6.59

8.35

2.66

15.33

6.55

8.33

Me

an S

we

llin

g Si

ze (

in c

m)


Group 1 Group 2

RESULTS

Page 38

Table 7: Comparison of mean Mouth Opening (in mm) between Group 1 & Group 2 at

different time intervals using Independent Student t Test

Comparison of mean Mouth Opening (in mm) between Group 1 & Group 2 at

different time intervals using Independent Student t Test


Baseline Group 1 30 42.73 2.89 1.26 1.415 0.16

Group 2 30 41.47 3.96

Day 1 Group 1 30 28.53 4.08 -12.17 -11.596 <0.001*

Group 2 30 40.70 4.04

Day 3 Group 1 30 35.73 5.07 -5.54 -4.681 <0.001*

Group 2 30 41.27 4.03

Day 7 Group 1 30 39.73 3.10 -1.60 -1.739 0.09

Group 2 30 41.33 3.98

Comparison of mean Mouth Opening (in mm) between Group 1 & Group 2 at different

time intervals

Inference: There is overall statistically significant increase in mouth-opening when

compared between Day 1, 2 & 3 separately in group 2.

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00


42.73

28.53

35.73

39.73 41.47

40.70 41.27 41.33

Me

an M

ou

th O

pe

nin

g (i

n m

m)

Comparison of mean Mouth Opening (in mm) between Group 1 & Group 2 at different time intervals

Group 1 Group 2

RESULTS

Page 39

Table 8: Comparison of mean VAS scores between different time intervals in Group 1 &

Group 2 using Friedman's Test

Comparison of mean VAS scores between different time intervals in

Group 1 & Group 2 using Friedman's Test

Group Time N Mean SD 2 P-Value

Group 1 Baseline 30 2.87 2.01

46.012 <0.001* Day 1 30 5.37 1.81

Day 3 30 4.53 1.70

Day 7 30 2.60 1.52


59.172 <0.001* Day 1 30 1.40 1.33

Day 3 30 0.93 1.20

Day 7 30 0.30 0.65

Table 9: Comparison of mean Swelling Size (in cm) at S1 region between different time

intervals in Group 1 & Group 2 using Repeated measures of ANOVA Test

Comparison of mean Swelling Size (in cm) at S1 region between

different time intervals in Group 1 & Group 2 using Repeated measures

of ANOVA Test

Group Time N Mean SD F P-Value


0.056 0.98 Day 1 30 2.66 0.17

Day 3 30 2.66 0.16

Day 7 30 2.65 0.16


0.358 0.59 Day 1 30 2.66 0.18

Day 3 30 2.67 0.17

Day 7 30 2.66 0.16

RESULTS

Page 40

Table 10: Multiple comparison of mean VAS scores for pain b/w diff. time intervals in G1

& G2 using Wilcoxon Signed Rank Test as post hoc test

Multiple comparison of mean VAS scores for pain b/w diff. time intervals

in G1 & G2 using Wilcoxon Signed Rank Test as post hoc test

Groups

BL Vs

D1

BL Vs

D3

BL Vs

D7

D1 Vs

D3

D1 Vs

D7

D3 Vs

D7

Group 1 <0.001* 0.003* 0.65 0.002* <0.001* <0.001*

Group 2 <0.001* <0.001* <0.001* 0.01* <0.001* 0.003*

Table 11: Comparison of mean Swelling Size (in cm) at S2 region between different time

intervals in Group 1 & Group 2 using Repeated measures of ANOVA Test



of ANOVA Test



34.167 <0.001* Day 1 30 15.99 0.25

Day 3 30 15.55 0.40

Day 7 30 15.39 0.31


19.389 <0.001* Day 1 30 15.45 0.31

Day 3 30 15.33 0.31

Day 7 30 15.33 0.33

Comparison of mean Swelling Size (in cm) at S3 region between different time intervals in

Group 1 & Group 2 using Repeated measures of ANOVA Test



of ANOVA Test



559.149 <0.001* Day 1 30 8.34 0.22

Day 3 30 6.60 0.20

Day 7 30 6.59 0.17


127.191 <0.001* Day 1 30 6.75 0.20

Day 3 30 6.57 0.23

Day 7 30 6.55 0.21

RESULTS

Page 41

Multiple comparison of swelling size at S2 region b/w diff. time intervals in G1 & G2 using

Bonferroni's post hoc analysis

Multiple comparison of swelling size at S2 region b/w diff. time intervals

in G1 & G2 using Bonferroni's post hoc analysis

Groups

BL Vs

D1

BL Vs

D3

BL Vs

D7

D1 Vs

D3

D1 Vs

D7

D3 Vs

D7

Group 1 <0.001* 0.04* 1.00 <0.001* <0.001* 0.27

Group 2 <0.001* 0.06 0.10 0.001* 0.001* 1.00



Multiple comparison of swelling size at S3 region b/w diff. time intervals

in G1 & G2 using Bonferroni's post hoc analysis

Groups

BL Vs

D1

BL Vs

D3

BL Vs

D7

D1 Vs

D3

D1 Vs

D7

D3 Vs

D7

Group 1 <0.001* 1.00 1.00 <0.001* <0.001* 1.00

Group 2 <0.001* 0.04* 1.00 <0.001* <0.001* 0.04*

Comparison of mean Swelling Size (in cm) at S4 region between different time intervals in




of ANOVA Test



42.195 <0.001* Day 1 30 10.40 1.72

Day 3 30 8.33 0.19

Day 7 30 8.35 0.16


120.952 <0.001* Day 1 30 8.48 0.19

Day 3 30 8.35 0.21

Day 7 30 8.33 0.20

RESULTS

Page 42

Table 12: Comparison of mean Mouth Opening (in mm) between different time intervals in


Comparison of mean Mouth Opening (in mm) between different time

intervals in Group 1 & Group 2 using Repeated measures of ANOVA

Test



113.806 <0.001* Day 1 30 28.53 4.08

Day 3 30 35.73 5.07

Day 7 30 39.73 3.10


17.600 <0.001* Day 1 30 40.70 4.04

Day 3 30 41.27 4.03

Day 7 30 41.33 3.98



Multiple comparison of swelling size at S3 region b/w diff. time intervals in

G1 & G2 using Bonferroni's post hoc analysis

Groups

BL Vs

D1

BL Vs

D3

BL Vs

D7

D1 Vs

D3

D1 Vs

D7

D3 Vs

D7

Group 1 <0.001* 1.00 1.00 <0.001* <0.001* 1.00

Group 2 <0.001* 0.26 1.00 <0.001* <0.001* 0.26

Multiple comparison of Mouth Opening (in mm) b/w diff. time intervals in G1 & G2 using


Multiple comparison of Mouth Opening (in mm) b/w diff. time intervals in

G1 & G2 using Bonferroni's post hoc analysis

Groups

BL Vs

D1

BL Vs

D3

BL Vs

D7

D1 Vs

D3

D1 Vs

D7

D3 Vs

D7

Group 1 <0.001* <0.001* <0.001* <0.001* <0.001* <0.001*

Group 2 <0.001* 0.34 0.26 0.002* 0.001* 0.97

RESULTS

Page 43

Comparison of mean VAS scores between different time intervals in Group 1 & Group 2



2.87

5.37

4.53

2.60

3.50

1.40 0.93

0.30 0.00

1.00

2.00

3.00

4.00

5.00

6.00


Me

an V

AS

Sco

res

Comparison of mean VAS scores between different time intervals in Group 1 & Group 2

Group 1

2.65

15.30

6.55 8.33

2.64

15.30

6.55

8.33

0.00

10.00

20.00


Me

an S

we

llin

g si

ze (

in c

m)

Comparison of mean Swelling size (in cm) at S1 Region between Group 1 & Group 2 at different time

intervals

Group 1 Group 2

RESULTS

Page 44





2.66

15.55

6.60 8.33

2.67

15.33

6.57

8.35

0.00

5.00

10.00

15.00

20.00


Me

an S

we

llin

g si

ze (

in c

m)

Comparison of mean Swelling size (in cm) at S3 Region between Group 1 & Group 2 at different time

intervals

Group 1 Group 2

2.66

15.99

8.34 10.40

2.66

15.45

6.75

8.48

0.00

5.00

10.00

15.00

20.00


Me

an S

we

llin

g si

ze (

in c

m)


Group 1 Group 2

RESULTS

Page 45

Comparison of mean Mouth Opening (in mm) between different time intervals in Group 1

& Group 2

42.73

28.53

35.73

39.73

41.47

40.70 41.27

41.33

20.00

25.00

30.00

35.00

40.00

45.00


Me

an M

ou

th O

pe

nin

g (i

n m

m)

Comparison of mean Mouth Opening (in mm) between different time intervals in Group 1 & Group 2

Group 1 Group 2

DISCUSSION

Page 46

Impacted third molars, which are probably a result of both genetic and environmental factors,

causes a variety of complications, such as pericoronitis, root resorption of the adjacent tooth,

cystic and orthodontic problems, prosthetic and even temperomandibular symptoms1. Surgical

removal of third molars is a very common procedure and is associated with post operative

complications which include pain, swelling, trismus and alveolar osteitis7. Over the years, there

have been numerous studies conducted to evaluate the influence of primary and secondary

healing after third molar surgery.Some authors are in the favour of closed healing, however other

authors, ealing by secondary intention , where wound drainage is facilitated, causes less patient

discomfort3,6,14,24

.

In a prospective study, Pasqualini et al evaluated the efficacy of primary and secondary closure

in third molar surgery reported significant reduction in post-operative pain, swelling and trismus

in the secondary closure group compared to the primary closure5.

Comparitive studies where investigators limited their work to the influence of closure techniques

on post-operative pain, swelling alone, without considering the effects on trismus.

Our study addresses the influence of secondary closure technique on mouth opening limitations

after the third molar surgery as well.

The passively repositioned closure involved no complex improvisation or invasive techniques

compared to conventional techniques and was less time consuming for the operator since for

additional sutures was negated.14

A significant difference was found in the extent of trismus on the 3rd

post-operative day between

the two groups and the extent of pain, swelling also had significant difference respectively. A

lower value for all parameters was found in the passively repositioned closure technique and the

reason can be because of difference in retention of inflammatory exudates. In the passively

repositioned closure, the retention of the exudates is less because more room is present for the

release of inflammatory exudates compared with onventional closure technique. Post-operative

pain was less at days 1,3 and 7 in passively repositioned closure technique.

DISCUSSION

Page 47

The hermetic edge to edge closure secured in conventional closure technique resulted in early

healing and reduction in periodontal pocket depth distal to the mandibular second molar. The

single anchor suture used in our study did not seem to promote early healing as the flap was

positioned passively without edge to edge.

Further studies should be conducted to compare the passively repositioned closure and other

modified secondary closure techniques to achieve a ideal closure technique in the third molar

surgery.

CONCLUSION

Page 48

Within the parameters of this study to assess and compare the passively repositioned closure

with conventional closure on the post operative complications after third molar surgery by

clinical assessment methods the following conclusion were drawn

There was no significant difference in post operative pain in passively repositioned closure

group and conventional closure group, however there was approximately 7% more pain on 1th

post-op day,11% more pain 3rd

post-op day and 9% more pain on 7th

post-op day in

conventional closure group when compared to passively repositioned closure.

There was no significant difference in post operative swelling in passively repositioned

closure group and conventional closure group. The swelling gradually reduced from 1st post–

op day to the 15th

post op day. Hence we can conclude that the effect of both passively

repositioned closure and conventional closure on soft tissue swelling in the present study was

almost similar.

There was significant difference in post operative trismus between passively repositioned

closure and conventional closure groups. Inter incisal opening was seem to be 1.78% more on

1st post op day and 2.32%more on 3

rd post op day in passively repositioned closure group

when compared to conventional closure groups. On 7th

day and 14th

post-op days the trismus

in both the groups was found to be same.

There was no significant difference in the post-operative periodontal health of second molar

in passively repositioned closure group and conventional closure group.

Healing by passively repositioned closure of the surgical wound after the removal of third

molars showed a significant difference in post-operative trismus on the third post-operative

day compared to the healing which occurred by the primary closure and also slight

improvement in the post-operative pain, swelling and trismus was seen in the passively

repositioned closure technique compared to the healing occurred by primary closure.

SUMMARY

Page 49

Third molars are the most frequently impacted teeth in all human populations. The post-operative

period following surgical removal of third molars is frequently characterized by swelling, pain

and trismus. One of the factors closely responsible for the intensity of complications is the type

of healing of the surgical wound. In secondary healing, the socket remains in communication

with oral cavity, and in primary healing the socket is closed hermetically by a mucosal flap.

Conflicting opinions which has been expressed in literature concerning these two types of

healing.

The present study aimed to determine the efficacy of passively repositioned closure and

conventional closure in reducing the post-operative complication after the third molar surgery in

60 patients who reported to The Oxford Dental College and Hospital, requiring surgical removal

of impacted mandibular third molars. The study was approved by the ethical committee of the

college.

The two closure techniques were secured and evaluated post operatively for pain, swelling and

trismus on 1st post–op day, 3

rd post-op day,7

th post-op day and 14

th post-op day. Periodontal

health in relation to the mandibular second molar was evaluated on the 1st post-operative week,

1st post-operative month and 3

rd post operative month.

A significant difference was found in the extend of trismus on the 3rd

post operative day between

the passively repositioned closure group and conventional closure group. The measurement of

trismus on the third post operative day was 2.32% less in passively repositioned group. It was

found that there was no significant difference in the extend of pain and swelling in the 1st ,3

rd and

7th

post operative day between the passively repositioned closure group and conventional closure

group. Post operative pain was less at days 1, 3 and 7 in patients who underwent passively

repositioned closure. In the present study, the pain level had peaked at 24 hours post operatively

and then steadily decreased in a linear fashion in both passively repositioned closure and

conventional closure, although the peak in the earlier group was lower.

SUMMARY

Page 50

The periodontal pocket depth measurement in both groups steadily decreased from first post

operative week to third post operative month. On first week, first month and third month, the

periodontal pocket depth were 1.38%, 1.15% and 0.99% higher in the passively repositioned

group compared to the conventional closure group.

The periodontal pocket depth measurements were seen to be maximum at the first post operative

week, however there was no significant difference in periodontal depth in both the groups. A

lower value for all parameters were observed for passively repositioned closure technique when

compared to the conventional closure technique although significant difference were not present

except for the trismus on the third post operative day.

BIBLIOGRAPHY

Page 51

1. Juodzbalys G, Daugela P. Mandibular Third Molar Impaction: Review of Literature

and a Proposal of a Classification. J Oral Maxillofac Res 2013 Apr-Jun; 4(2).

2. Kasapoglu C, Brkic A, Koseoglu BG, Berberoglu HK. A Textbook of Advanced Oral

andMaxillofacialSurgery:In Tech;2013.p. 4-25. Available from: URL:

http://www.intechopen.com/books/a-textbook-of-advanced-oral-and-maxillofacial-

surgery/complications-following-surgery-of-impacted-teeth-and-their-management.

3. Management of inflammatory complications in third molar surgery: A review of the

literature. African Health Sciences 2011;11(3):530-537.

4. Anighoro EO, Gbotolorun OM, Adewole RA, Arotiba GT, Effiom OA. Assessment of

the effect of wound closure technique on postoperative sequelae and complications after

impacted mandibular third molar extraction. Open J Stom 2013;3:527-32.

5. Lekholm U and Grondahl HG. Influence of mandibular third molars on related

supporting tissues. Int J Oral surg.1973;2:137-142.

6. Dubois D, Pizer ME, Chinnis RJ. Comparison of primary and secondary closure

techniques after removal of impacted mandibular third molars. Journal of Oral and

Maxillofacial Surgery 1982;40:631-634.

7. Stephen RJ, George R, Foreman DW. Periodontal evaluation of two mucoperiosteal flaps

in removing impacted mandibular third molars. J Oral Max. Surg.1983;4:719-724.

8. Chin Quess TA, Denis gosselin, Millar EP, Stamm JW. Surgical removal of the fully

mandibular third molar. Periodontology 1985;56:625-630.

9. Kugelberg CE. Periodontal healing two and four years after impacted lower third molar

surgery. Int J OralMaxillofac Surg. 1990; 19: 341-345.

10. Rakprasitkul S and Pariuehvej V. Mandibular third molar surgery with primary closure

and tube drain. Int. J. Oral Maxillofac. Sur. 1997;26:187-190.

BIBLIOGRAPHY

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11. Conrad SM, Blakey GH, Shugars DA, Marciano RD, Phillips C, White RP. Patient’s

perception of recovery after third molar surgery. J Oral Maxillofac Surg 1999: 57: 1288-

1294.

12. Garcia AG, Sampedro FG, Rey JG, Vila PG, Martin MS. Pell- Gregory classification is

unreliable as a predictor of difficulty in extracting impacted lower third molars. British

Journal of Oral and Maxillofacial Surgery 2000;38:585-587.

13. Kan KW, Liu JKS and Lo ECM. Residual periodontal defects distal to the mandibular

second molar 6-36 months after impacted third molar extraction. J Clin Periodontol

2002;29:1004-1011.

14. Mercedes M, Cunqueiro S, Gutwald R, Reichman J, Cepeda XLO and Schmelzeisen R. A

Marginally flap versus paramarginal flap in impacted third molar surgery: A prospective

study .Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2003;95:403-8.

15. Halmos DR, Ellis E, Dodson TB. Mandibular third molars and angle fractures. J Oral

Maxillofac Surg 2004;62:1076-81.

16. Poeshcl PW, Eckel D, and Poeschl E Postoperative Prophylactic Antibiotic Treatment in

Third molar surgery- A necessity? J Oral MaxillofacSurg, 2004;63:3-8.

17. Yuasa H and Sugiura M. Clinical postoperative findings after removal of impacted

mandibular third molars: prediction of postoperative facial swelling and pain based on

preoperative variables. British journal of Oral and Maxillofacial Surgery 2004;42:209-

214.

18. 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;34:52-57.

19. Susarla SM and Dodson TB. Estimating third molar extraction difficulty: A Comparison

of subjective and objective factors. J Oral Maxillofacsurg 2005;63:427-34.

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20. Filho JRL, Silva ED and Camargo IB. The influence of cryotherapy on reduction of

swelling, pain and trismus after third molar extraction. JADA 2005;136:774-8.

21. Kim JC, Choi SS, Wang SJ, Kim SC. Minor complications after mandibular third molar

surgery: type, incidence and possible prevention. Oral Surg Oral Med Oral Pathol Oral

Radiol Endod. 2006:102;e4-e11.

22. Polat HB, Ozdemir H Sinan A. Effect of different mouth rinses on third molar surgery-

related oral malodour. Oral Surg Oral Med Oral Pathol Oral RadiolEndod . 2008;

105:e1-e8.

23. Bielsa JSM, Bazan SH, Diago MP Flap repositioning versus conventional suturing in

third molar surgery Med Oral Pathol Oral Cir Buccal 2008;13:E138-42.

24. Danda KA, Tatiparthi MK, Narayanan V and Siddareddi A. Influence of Primary and

Secondary Closure of Surgical Wound After Impacted Mandibular Third Molar Removal

on Postoperative Pain and Swelling – A Comparative and Split Mouth Study.

OralMaxillofacSurg 2010;68:309-312.

25. Dicus C, Blakey GH, Eggleston JF, Hoverstad E, Offenbacher S, Phillips C, White RP.

Second Molar Periodontal Inflammatory Disease After Third Molar Removal in Young

Adults. Journal of Oral and Maxillofacial Surgery 2010;68:3000-3006.

26. Osunde OD, Saheeb BD, Adebola RA. Comparative study of Effect of single and

multiple suture Techniques on inflammatory complications after third molar surgery.

Journal of Oral and maxillofacial Surgery 2011;69:971-76.

27. Khande K, Saluja H, Mahindra U. Primary and Secondary closure of the surgical wound

after removal of impacted mandibular third molars. J Maxillofac Oral Surg 2011 Apr-

Jun;10(2):112-7.

28. Hashemi HM, Beshkar M, Aghajani R. The effect of sutureless wound closure on

postoperative pain and swelling after impacted mandibular third molar surgery. British

Journal of Oral and Maxillofacial Surgery 2012;50:256-258.

BIBLIOGRAPHY

Page 54

29. Goldsmith SM, De Silva RK, Tong DC, Love RM. Influence of a pedicle flap design on

acute postoperative sequelae after lower third molar removal. International Journal of

Oral and Maxillofacial surgery 2012;41:371-375.

30. Anighoro EO, Gbotolorun OM, Adewole RA, Arotiba GT, Effiom OA. Assessment of

the effect of wound closure technique on postoperative sequelae and complications after

impacted mandibular third molar extraction. Open J Stom 2013;3:527-32.

CONSENT FORM

P a g e 55

Patient consent form

Title of the study :. COMPARISON OF POST OPERATIVE SEQUELAE IN PRIMARY AND

SECONDARY WOUND CLOSURE FOLLOWING IMPACTED MANDIBULAR THIRD

MOLAR SURGERY

Name of the participant:

Name of the Investigator: Dr. PARTHIBAN PRABAKARAN

Name of the Institution: THE OXFORD DENTAL COLLEGE, BENGALURU

Documenation of the informed consent.

I,…………………………………… have read the information in this form (or it has been read to

me). I was free to ask any questions and they have been answered and I hereby give my willful

consent to be included as a participant in “COMPARISON OF POST OPERATIVE SEQUELAE

IN PRIMARY AND SECONDARY WOUND CLOSURE FOLLOWING IMPACTED

MANDIBULAR THIRD MOLAR SURGERY.” I have read and understood this consent form and

the information provided to me.

(1) I have had the consent document explained to me.

(2) I have been explained about the nature of the study.

(3) My rights and responsibilities have been explained to me by my investigator.

(4) I have been advised about the risks associated with my participation in the study.

(5) I have informed the investigator about all the treatments I am taking or have taken in the

past months including any alternative treatments.

(6) I agree to cooperate with the study.

(7) I am aware of the fact that I can opt out of the study at any time without having to give any

reason and this will not affect my future treatment in the hospital.

(8) I am also aware that the investigators may terminate my participation in the study at any

time, for any reason, without my consent.

CONSENT FORM

P a g e 56

(9) I hereby give permission to the investigators to release the information obtained from me

as a result of my participation in the study to the sponsors, regulatory authorities, Government

agencies, and ethics committee. I understand that they may inspect my records.

(10) My identity will be kept confidential if my data is publicly presented.

(11) I have had my questions answered to my satisfaction.

(12) I have decided to be in the research study.

I am aware that if I have any questions during this study, I should contact at one of the addresses

listed above. By signing this consent form, I attest that the information given in this document has

been clearly explained to me and apparently understood by me. I will be given a copy of this

consent document

Name and signature/ left thumb impression of the participant

(Name) (Signature)

Date : Time :

Name and signature of impartial witness (required if participant illiterate):

(Name) (Signature)

Date: Time:

Name and Signature of Investigator or her representative obtaining consent:

(Name) (Signature)

Date:

CONSENT FORM

P a g e 57

CONSENT FORM

P a g e 58

CONSENT FORM

P a g e 59

CONSENT FORM

P a g e 60

CONSENT FORM

P a g e 61

Investigator Certificate

I certify that all the elements including the nature, purpose and possible risks of the above study

as described in this consent document have been fully explained to the subject. In my judgement,

the participant possesses the legal capacity to give informed consent to participate in this research

and is voluntarily and knowingly giving informed consent to the above trial.

Information to participants

Investigator: Dr Parthiban Prabakaran

Name: of Participant:

Title: COMPARISON OF POST OPERATIVE SEQUELAE IN PRIMARY AND SECONDARY

WOUND CLOSURE FOLLOWING IMPACTED MANDIBULAR THIRD MOLAR SURGERY

You are invited to take part in this research study. The information in this document is meant to

help you decide whether or not to take part. Please feel free to ask if you have any queries or

concerns.

What is the purpose of this research?

The purpose is to find out the efficiency of one drug alone over combination of two different

drugs in reducing pain, swelling and difficulty in mouth opening after third molar removal.

Study Procedures:

After the removal of third molar teeth, pain killers will be prescribed for three days. Follow up

will be done on 1, 3 and 7 postoperative days.

CONSENT FORM

P a g e 62

Possible risks:

Belching, bloating, nausea, vomiting, abdominal pain.

Possible benefits to you: Manifests reduced pain and swelling.

Who is paying for this research?

The investigator will bear the cost of medications to be taken after third molar removal.

Confidentiality of the information obtained from you will be maintained and no disclosure

of the identity will be done.

Can you decide to stop participating in the study once you start?

Yes , you can opt out of the study once you start without giving any reason and this decision will

not affect your future treatments in any manner.

Can the investigator take you off the study?

Yes, you can be dropped out of the study without giving any reason and this shall not affect your

further treatments in the hospital.

Right to new information

Yes you will be provided with any new information that is obtained during the study or after the

study.

Contact persons

For further information / questions, you can contact us at the following address:

Dr Parthiban Prabakaran

Dept. of Oral and Maxillofacial Surgery,

The Oxford Dental College,

Bommanahalli,

CONSENT FORM

P a g e 63

Bangalore.

Mobile No: 9626916872

In case of conflicts, you can contact the Member Secretary of our Institutional Ethics Committee

at the following address:

Dr Bipin C Reddy

Reader,

Department of Oral and Maxillofacial Surgery,

Contact no.9845198582

Dr.Priya Subramaniam,

Principal,

The Oxford Dental College,

Bommanahalli,

Bangalore

CLEARANCE FORM

Page 64

PROFORMA

P a g e 65

CASE HISTORY PROFORMA FOR THIRD MOLAR SURGERY

Name of the patient: - O.P. No. :-

Age:-

Sex:-

Address:-

Contact no:-

Chief complaint:-

History of presenting illness:-

Past medical/dental history:-

History of allergy:-

Personal history:-

PROFORMA

P a g e 66

General physical examination:-

Blood pressure -

Pulse -

Temperature -

Pallor -

Icterus –

Extra oral examination:-

Swelling-

TMJ-

Lymph node-

Intra oral examination:-

Occlusion:

Soft tissue examination:

Hard tissue examination:

Oral hygiene - good/fair/poor

Pericoronal status - good/fair/poor

Eruption status of impaction - partially erupted/unerupted/erupted

Any other findings –

Provisional diagnosis:-

PROFORMA

P a g e 67

Investigations -

Final diagnosis -

PEDERSON’S DIFFICULTY INDEX FOR REMOVAL OF IMPACTED LOWER THIRD

MOLAR

Class I 1

Class II 2

Class III 3

Mesioangular 1

Horizontal 2

Vertical 3

Distoangular 4

Position A 1

Position B 2

Position C 3

Total score:

INTERPRETATION:

Relatively difficulty: 3-4

Moderately difficulty: 5-7

Very difficult: 7-10

Radiographic assessment of relationship of the root to the canal

PROFORMA

P a g e 68

1 - Related but not involving the canal:

(a) Separated

(b) Adjacent

(c) Super imposed

2 - Related to changes in the roots:

(a) Darkening of the roots

(b) Dark and bifid root

(c) Narrowing of the roots

(d) Deflected root

3 - Related to changes in the canal:

(a) Interruption of lines(lines)

(b) Covering canals(narrowing)

(c) Diverted canal

Treatment plan -

Treatment done -

Post op instructions -

Recalled on -

PROFORMA

P a g e 69

Informed consent:

I the undersigned give my full consent to operate on me /or my wife /child and to do any

investigation as necessary and required under any anaesthesia

SIGNATURE:

EVALUATION SHEET

1. PAIN

VISUAL ANALOGUE SCALE

PRE OPERATIVE 1ST POST

OPERATIVE DAY

3RD POST

OPERATIVE DAY

7TH POST

OPERATIVE DAY

VERBAL RESPONSE SCALE


OPERATIVE DAY

3RD POST

OPERATIVE DAY

7TH POST

OPERATIVE DAY

2. SWELLING


OPERATIVE DAY

3RD POST

OPERATIVE DAY

7TH POST

OPERATIVE DAY

PROFORMA

P a g e 70

3. MOUTH OPENING

INTER INCISAL DISTANCE


OPERATIVE DAY

3RD POST

OPERATIVE DAY

7TH POST

OPERATIVE DAY

MASTER CHART

P a g e 71

PRIMARY WOUND CLOSURE – PAIN (VAS SCALE)

patient age/sex pre op post 1 post 3 post 7

1 27/f 0 4 3 2

2 22/f 6 7 3 2

3 27/m 0 4 3 1

4 27/m 6 3 3 1

5 24/f 5 7 7 4

6 28/f 4 7 7 4

7 33/m 3 7 7 4

8 32/m 6 4 4 2

9 32/f 0 7 5 4

10 32/m 3 6 4 3

11 27/m 2 7 5 2

12 28/f 4 2 2 0

13 27/m 4 4 4 4

14 29/f 4 4 4 4

15 33/m 3 7 7 4

16 27/f 0 4 3 0

17 22/f 7 7 3 0

18 27/m 3 4 3 1

19 27/m 3 3 3 1

20 24/f 1 7 7 4

21 28/f 4 7 7 4

MASTER CHART

P a g e 72

22 33/m 3 7 7 4

23 32/m 0 4 4 2

24 32/f 2 8 5 4

25 32/m 3 6 4 3

26 27/m 2 7 5 2

27 28/f 4 2 2 0

28 27/m 0 4 4 4

29 29/f 1 4 4 4

30 33/m 3 7 7 4

PRIMARY WOUND CLOSURE – SWELLING MEASUREMENT

patient age/sex

pre op

S1

Pre op

S2

Pre op

S3

pre op

S4

post 1

S1

post

1S2

post1

S3

1 2.5cm 15.3 6.2 8.1 2.9cm 16.2 8.2

2 2.6cm 15.2 6.3 8.2 2.6cm 16.1 8.7

3 2.7cm 15.3 6.8 8.3 2.7cm 16.3 8.3

4 2.9cm 15.4 6.5 8.6 2.9cm 15.8 8.2

5 2.6cm 15.7 6.4 8.4 2.6cm 15.9 8.4

6 2.8cm 15.8 6.5 8.3 2.8cm 16.1 8.7

7 2.7cm 15.7 6.7 8.1 2.7cm 16.2 8.2

8 2.5cm 14.8 6.8 8.2 2.5cm 16.3 8.3

9 2.3cm 14.8 6.5 8.7 2.3cm 16.4 8.2

10 2.7cm 14.9 6.2 8.3 2.7cm 16.4 8.4

11 2.8cm 15.2 6.3 8.2 2.8cm 16.5 8.2

MASTER CHART

P a g e 73

12 2.5cm 15.2 6.8 8.4 2.6cm 15.9 8.6

13 2.6cm 15.3 6.5 8.7 2.8cm 15.9 8.4

14 2.7cm 15.2 6.4 8.2 2.7cm 15.8 8.7

15 2.9cm 15.3 6.5 8.3 2.5cm 15.8 8.2

16 2.6cm 15.4 6.7 8.2 2.3cm 16.1 8.1

17 2.8cm 15.7 6.8 8.4 2.7cm 16.1 8.1

18 2.7cm 15.8 6.5 8.2 2.8cm 15.9 8.4

19 2.5cm 15.7 6.2 8.6 2.5cm 15.8 8.7

20 2.3cm 14.8 6.3 8.4 2.6cm 15.3 8

21 2.7cm 14.8 6.8 8.7 2.7cm 15.8 8.4

22 2.8cm 14.9 6.5 8.2 2.9cm 15.7 8.4

23 2.5cm 15.2 6.4 8.1 2.6cm 15.9 8.2

24 2.6cm 15.2 6.5 8.1 2.8cm 15.7 8.1

25 2.7cm 15.3 6.7 8.4 2.7cm 15.9 8.1

26 2.9cm 15.2 6.8 8.7 2.5cm 15.9 8.4

27 2.6cm 15.2 6.5 8 2.3cm 15.9 8.7

28 2.8cm 15.3 6.8 8.4 2.7cm 15.9 8

29 2.7cm 15.7 6.8 8.4 2.8cm 16 8.4

30 2.5cm 15.8 6.8 8.2 2.8cm 16.1 8.4

MASTER CHART

P a g e 74

post 1

S4 post3 1

post3

S2

post 3

S3 post3 S4

post7

S1 post7S2 post 7 S3

post 7

S4

10.1 2.9cm 15.4 6.8 8.4 2.6cm 15.2 6.8 8.3

10.2 2.6cm 15.4 6.5 8.3 2.7cm 15.3 6.5 8.6

1.5 2.8cm 15.3 6.2 8.1 2.9cm 15.4 6.4 8.4

11 2.7cm 15.2 6.3 8.2 2.6cm 15.7 6.5 8.3

11.1 2.5cm 15.8 6.8 8.7 2.8cm 15.8 6.7 8.5

11.2 2.3cm 16 6.5 8.3 2.7cm 15.7 6.8 8.3

10.8 2.7cm 16.2 6.4 8.2 2.5cm 14.8 6.5 8.3

10.9 2.8cm 16.3 6.5 8.4 2.3cm 15.8 6.2 8.3

11.2 2.5cm 15.4 6.7 8.7 2.7cm 14.9 6.3 8.6

10.8 2.6cm 15.7 6.8 8.2 2.8cm 15.2 6.8 8.4

10.7 2.7cm 16.4 6.5 8.3 2.5cm 15.2 6.5 8.3

10.5 2.9cm 15.7 6.2 8.2 2.6cm 15.5 6.4 8.2

10.2 2.6cm 14.8 6.3 8.4 2.7cm 15.2 6.5 8.3

10.4 2.8cm 15.7 6.8 8.2 2.9cm 15.3 6.7 8.2

10.7 2.7cm 14.9 6.5 8.6 2.6cm 15.4 6.8 8.6

10.3 2.5cm 15.2 6.4 8.4 2.8cm 15.2 6.5 8.4

10.1 2.3cm 16 6.5 8.7 2.7cm 15.8 6.5 8.6

10.2 2.7cm 15.3 6.7 8.2 2.5cm 15.7 6.7 8.4

11.2 2.8cm 15.2 6.8 8.1 2.3cm 14.8 6.8 8.2

11 2.5cm 15.2 6.5 8.1 2.7cm 15.3 6.5 8.2

11.1 2.6cm 15.3 6.8 8.2 2.8cm 14.9 6.7 8.1

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11.2 2.7cm 15.7 6.8 8.1 2.5cm 15.2 6.5 8.1

10.8 2.9cm 15.8 6.8 8.1 2.6cm 15.7 6.7 8.4

10.9 2.6cm 15.3 6.5 8.4 2.7cm 15.3 6.8 8.7

11.2 2.8cm 15.2 6.7 8.7 2.9cm 15.5 6.5 8

10.8 2.7cm 15.3 6.8 8.4 2.6cm 15.3 6.8 8.4

10.7 2.5cm 15.4 6.5 8.4 2.8cm 15.3 6.6 8.4

10.5 2.6cm 15.7 6.8 8.4 2.7cm 15.7 6.8 8.3

10.2 2.8cm 15.8 6.8 8.2 2.5cm 15.8 6.4 8.4

10.4 2.7cm 15.9 6.8 8.4 2.4cm 15.7 6.5 8.3

PRIMARY CLOSURE – MOUTH OPENING

Patient Pre op Post 1 Post 3 Post 7

1 45mm 25mm 30mm 35mm

2 45mm 28mm 32mm 38mm

3 38mm 24mm 30mm 34mm

4 40mm 23mm 30mm 38mm

5 45mm 26mm 43mm 45mm

6 45mm 25mm 32mm 39mm

7 45mm 28mm 32mm 40mm

8 40mm 38mm 40mm 40mm

9 40mm 33mm 40mm 40mm

10 40mm 30mm 40mm 40mm

11 38mm 28mm 35mm 38mm

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12 45mm 25mm 42mm 44mm

13 45mm 32mm 34mm 40mm

14 45mm 33mm 44mm 45mm

15 45mm 30mm 32mm 40mm

16 45mm 25mm 30mm 35mm

17 45mm 28mm 32mm 38mm

18 38mm 24mm 30mm 34mm

19 40mm 23mm 30mm 38mm

20 45mm 26mm 43mm 45mm

21 45mm 25mm 32mm 39mm

22 45mm 28mm 32mm 40mm

23 40mm 38mm 40mm 40mm

24 40mm 33mm 40mm 40mm

25 40mm 30mm 40mm 40mm

26 38mm 28mm 35mm 38mm

27 45mm 25mm 42mm 44mm

28 45mm 32mm 34mm 40mm

29 45mm 33mm 44mm 45mm

30 45mm 30mm 32mm 40mm

SECONDARY WOUND CLOSURE - PAIN (VAS SCALE)

patient age/sex pre op post 1 post 3 post 7

1 23/f 1 0 0 0

2 27/m 0 2 1 0

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3 22/m 6 0 0 0

4 27/m 2 2 0 0

5 32/m 3 0 0 1

6 28/f 0 0 0 0

7 33/m 6 1 1 1

8 32/m 4 1 1 0

9 27/m 6 4 1 1

10 29/f 4 1 0 0

11 22/m 4 0 0 0

12 24/m 0 0 0 0

13 27/m 6 3 3 0

14 31/m 4 3 3 2

15 32/f 3 2 2 0

16 32/m 3 0 0 0

17 28/f 7 4 0 0

18 33/m 1 1 0 0

19 32/m 7 1 0 0

20 27/m 4 0 1 0

21 29/f 1 1 0 0

22 22/m 4 1 1 0

23 24/m 1 1 0 0

24 27/m 7 3 3 0

25 31/m 4 3 3 2

26 32/f 3 2 2 0

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27 22/m 0 0 0 0

28 24/m 3 0 0 0

29 27/m 7 3 3 0

30 31/m 4 3 3 2

SECONDARY WOUND CLOSURE – SWELLING MEASUREMENT

Patient pre op S1 pre op S2 Pre op S3 pre op S4 post 1 S1 post 1 S2 post 1 S3

1 2.3cm 14.8 6.5 8.2 2.3cm 14.9 6.6

2 2.7cm 14.9 6.2 8.7 2.8cm 15 6.3

3 2.8cm 15.2 6.3 8.3 2.8cm 15.3 6.4

4 2.5cm 15.2 6.8 8.2 2.5cm 15.3 7

5 2.6cm 15.3 6.5 8.4 2.6cm 15.4 6.8

6 2.7cm 15.2 6.4 8.7 2.7cm 15.4 6.8

7 2.9cm 15.3 6.5 8.2 2.9cm 15.5 6.7

8 2.6cm 15.4 6.7 8.3 2.7cm 15.5 6.8

9 2.8cm 15.7 6.8 8.2 2.8cm 15.8 7

10 2.7cm 15.8 6.5 8.4 2.7cm 15.9 6.8

11 2.5cm 15.7 6.2 8.2 2.5cm 15.8 6.5

12 2.3cm 14.8 6.3 8.6 2.3cm 15 6.5

13 2.7cm 14.8 6.8 8.4 2.7cm 15 7

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14 2.8cm 14.9 6.5 8.7 2.6cm 15 6.8

15 2.5cm 15.2 6.4 8.2 2.8cm 15.3 6.8

16 2.6cm 15.2 6.5 8.1 2.8cm 15.4 6.7

17 2.7cm 15.3 6.7 8.1 2.5cm 15.5 6.8

18 2.9cm 15.2 6.8 8.4 2.3cm 15.5 6.9

19 2.6cm 15.2 6.5 8.7 2.7cm 15.5 6.7

20 2.5cm 15.3 6.8 8 2.8cm 15.5 6.9

21 2.6cm 15.7 6.8 8.4 2.5cm 15.9 7

22 2.7cm 15.8 6.8 8.4 2.6cm 15.9 7

23 2.9cm 15.3 6.2 8.2 2.7cm 15.5 6.4

24 2.6cm 15.2 6.3 8.1 2.9cm 15.5 6.5

25 2.8cm 15.3 6.8 8.2 2.6cm 15.3 7

26 2.7cm 15.4 6.5 8.3 2.5cm 15.8 6.7

27 2.5cm 15.7 6.4 8.6 2.6cm 15.9 6.7

28 2.3cm 15.8 6.5 8.4 2.7cm 15.9 6.7

29 2.7cm 15.7 6.7 8.3 2.9cm 15.2 6.9

30 2.8cm 14.8 6.8 8.1 2.9cm 15.1 6.9

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post 1

S4

post 3

S1

post 3

S2

post 3

S3

post 3

S4

post 7

S1

post

7 S2

post 7

S3

post7

S4

8.3 2.4cm 14.9 6.6 8.2 2.4cm 14.8 6.5 8.2

8.9 2.8cm 14.9 6.2 8.8 2.7cm 14.9 6.2 8.7

8.5 2.8cm 15.2 6.3 8.3 2.8cm 15.2 6.3 8.3

8.3 2.5cm 15.2 6.9 8.2 2.5cm 15.2 6.8 8.2

8.6 2.6cm 15.3 6.6 8.4 2.6cm 15.3 6.5 8.4

8.8 2.7cm 15.3 6.4 8.7 2.7cm 15.2 6.4 8.7

8.3 2.9cm 15.4 6.5 8.2 2.9cm 15.3 6.5 8.2

8.4 2.8cm 15.4 6.7 8.3 2.6cm 15.4 6.7 8.3

8.4 2.9cm 15.7 6.8 8.3 2.9cm 15.8 6.8 8.2

8.5 2.7cm 15.8 6.6 8.4 2.7cm 15.9 6.5 8.4

8.3 2.5cm 15.7 6.2 8.2 2.5cm 15.7 6.2 8.2

8.7 2.3cm 14.8 6.3 8.6 2.3cm 14.8 6.3 8.6

8.5 2.7cm 14.8 6.8 8.4 2.7cm 14.8 6.8 8.4

8.8 2.8cm 14.9 6.5 8.7 2.8cm 14.9 6.5 8.7

8.3 2.5cm 15.3 6.4 8.2 2.5cm 15.2 6.4 8.2

8.3 2.8cm 15.2 6.5 8.1 2.7cm 15.2 6.5 8.1

8.2 2.7cm 15.5 6.7 8.1 2.7cm 15.4 6.7 8.1

8.5 2.9cm 15.2 6.8 8.4 2.9cm 15.2 6.8 8.4

8.8 2.6cm 15.2 6.5 8.7 2.6cm 15.2 6.5 8.7

8.2 2.6cm 15.3 6.8 8 2.6cm 15.5 6.8 8

8.5 2.6cm 15.7 6.9 8.4 2.6cm 15.7 6.8 8.4

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8.6 2.7cm 15.8 6.9 8.5 2.7cm 15.9 6.8 8.4

8.5 2.9cm 15.3 6.2 8.2 2.9cm 15.3 6.2 8.2

8.4 2.6cm 15.4 6.3 8.1 2.6cm 15.2 6.3 8.1

8.4 2.8cm 15.3 6.8 8.2 2.8cm 15.3 6.8 8.2

8.4 2.7cm 15.4 6.5 8.3 2.7cm 15.4 6.5 8.3

8.7 2.5cm 15.7 6.4 8.6 2.5cm 15.7 6.4 8.6

8.6 2.3cm 15.8 6.5 8.4 2.3cm 15.8 6.5 8.4

8.4 2.7cm 15.7 6.7 8.3 2.7cm 15.7 6.7 8.3

8.2 2.8cm 14.9 6.9 8.2 2.8cm 14.9 6.8 8.1

SECONDARY WOUND CLOSURE – MOUTH OPENING

Patient Pre op Post 1 Post 3 Post 7

1 45mm 44mm 45mm 45mm

2 45mm 43mm 45mm 45mm

3 45mm 44mm 45mm 45mm

4 40mm 38mm 38mm 39mm

5 45mm 45mm 45mm 45mm

6 39mm 39mm 39mm 39mm

7 45mm 45mm 45mm 45mm

8 43mm 42mm 42mm 42mm

9 45mm 44mm 45mm 45mm

10 40mm 39mm 40mm 40mm

11 40mm 40mm 40mm 40mm

12 45mm 45mm 45mm 45mm

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13 35mm 34mm 35mm 35mm

14 35mm 35mm 35mm 35mm

15 35mm 35mm 35mm 35mm

16 45mm 44mm 45mm 45mm

17 45mm 45mm 45mm 45mm

18 45mm 45mm 45mm 45mm

19 40mm 38mm 38mm 39mm

20 45mm 45mm 45mm 45mm

21 39mm 37mm 39mm 39mm

22 45mm 42mm 45mm 45mm

23 43mm 42mm 42mm 42mm

24 45mm 45mm 45mm 45mm

25 40mm 39mm 40mm 40mm

26 40mm 39mm 40mm 40mm

27 45mm 45mm 45mm 45mm

28 35mm 35mm 35mm 35mm

29 35mm 34mm 35mm 35mm

30 35mm 34mm 35mm 35mm

ANNEXURE

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Fig – 1 showing diagnostic instruments.

Fig - 2 Armamentarium for Extraction of third molar

ANNEXURE

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Fig – 3 702 STRAIGHT BUR AND STRAIGHT HANDPIECE

FIG 4: Markings for measurement of facial swelling.

S1 S2

S3

S4

ANNEXURE

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PICTURES:

Pre operative clinical picture of completely impacted mandibular 3rd molar

Orthopantomagram showing the impacted tooth.

ANNEXURE

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After the guttering of bone

After the extraction of impacted tooth.

ANNEXURE

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The sectioned tooth.

Only two sutures in place after cutting the wedge of tissue.

ANNEXURE

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Sutures in Secondary wound closure technique

Sutures in Primary wound closure technique

ANNEXURE

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Follow up - opening noted which is left intentionally in secondary wound closure

technique.

Mouth opening measured using a vernier caliper

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