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ORIGINAL RESEARCH Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 1  |  Page : 15-18
Comparison of morbidity following the removal of mandibular third molar by lingual split, surgical bur and simplified split bone technique


Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College, Alapakkam Main Road, Maduravoyal, Chennai - 95, India

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Date of Submission01-Apr-2006
Date of Decision08-Sep-2006
Date of Acceptance18-Sep-2006
 

   Abstract 

Background: The methods frequently used for surgical removal of impacted third molars are bur technique, lingual split and simplified split bone technique. The morbidity rates following the use of these different surgical techniques are not completely resolved. The use of a surgical method with minimum postoperative complication is needed. Aim: This study was conducted to compare the morbidity rates of the three different surgical techniques and their efficacy with regard to postoperative pain, swelling, labial and lingual sensation. Materials and Methods: Ninety patients with a symptomatic impacted mandibular third molar with the age range of 14-62 years were divided into three groups of 30 patients each for surgical bur technique, lingual split technique and simplified split bone technique. All patients were operated by the same surgeon under local anesthesia (2% lignocaine) in the dental chair. The severity of pain and swelling was recorded on a visual analogue scale and the presence or absence of sensory disturbance at 6, 24, 48 hours and seven days after operation. The pain was scored according to a visual analogue 4-point scale. Patients were asked to indicate which side was more swollen and to record this assessment on the swelling scale. Results: Lingual split technique was more painful than the other two techniques. Surgical bur technique had more swelling than the other two techniques. Labial and lingual sensations were not altered in all the techniques. Conclusion: The simplified split bone technique had the least morbidity than the lingual split and surgical bur technique.

Keywords: Lingual split technique, mandibular third molar, simplified split bone technique, surgical bur technique

How to cite this article:
Praveen G, Rajesh P, Neelakandan R S, Nandagopal C M. Comparison of morbidity following the removal of mandibular third molar by lingual split, surgical bur and simplified split bone technique. Indian J Dent Res 2007;18:15-8

How to cite this URL:
Praveen G, Rajesh P, Neelakandan R S, Nandagopal C M. Comparison of morbidity following the removal of mandibular third molar by lingual split, surgical bur and simplified split bone technique. Indian J Dent Res [serial online] 2007 [cited 2014 Apr 21];18:15-8. Available from: http://www.ijdr.in/text.asp?2007/18/1/15/30916

   Introduction Top


The incidence of complication after surgical removal of impacted third molar needs to be as low as possible, particularly as this is a high volume procedure both in hospital practice and general dental practice. The surgical method should be one with minimum complication; however many past studies have not been controlled internally by many, using different techniques for the same procedure, randomized to eliminate bias in relation to each technique (or) have not been performed by the same operator. Not surprisingly the arguments about morbidity rates following the use of three different surgical techniques for removal of third molar either by bur technique, lingual split and simplified split open technique, is not resolved, although all methods are frequently used. Previous studies of the effects of bone removal have been performed on animals[1] and on humans[2] and include comparison between morbidity rates in different centers in nonrandomized studies in which surgery was performed by several surgeons. All past studies have been of a parallel group design with comparison made between patients but by different operators; but this is a single operator study for postoperative morbidity.


   Materials and Methods Top


Ninety consecutive healthy patients with a symptomatic impacted mandibular third molar, who had been scheduled for surgery were entered into the trial with the age range of 14-62 yrs (mean 38) and were divided into three groups of 30 patients each for surgical bur technique, lingual split technique and simplified split bone technique.

All patients were operated by the same surgeon under local anesthesia (2% lignocaine) in the dental chair. The methods for a particular patient were selected randomly and the time taken for each procedure was noted.

Surgical procedures

Standardized surgical procedure was performed for all the three techniques. A bayonet shaped incision is made and a buccal mucoperiosteal flap was reflected onto the external oblique ridge, joined at a point distal to the crown of the second molar by a vertical incision, which extended downwards approximately at 60 degrees, 1.5 cm towards the muco-buccal fold. Buccal bone removal and tooth division were performed with 702 bur with electrically powered motor at a speed of 15,000 rpm. The lingual nerve was protected by a Howarth's periosteal elevator in all cases. Sterile isotonic saline was used as coolant and the surgical field and the cutting edges of the bur were sprayed constantly by the same assistant. When the bone was removed by the chisel, a lingual split method was employed, with a 5 mm mono-beveled instrument. A vertical cut was made in the buccal bone, distal to second the molar. Second horizontal cut was joined to the first posteriorly; the bone removed allowed access to the mesio-buccal aspect of the impacted tooth and permitted a point of application for the elevator. The bevel of the chisel was turned lingually and lingual split was made which allowed the tooth to be elevated. This method is well-described by Lewis in 1980. The socket was irrigated with saline and the wound closed with two sutures. One placed immediately distal to second molar and one placed midway between the second molar and the distal incision over the external oblique ridge.

Collection of data and assessment

The angulations of the tooth and the state of eruption were recorded, together with the operating time to evaluate efficiency of surgery. A questionnaire was given to each patient for recording pain, scores, facial swelling and sensory disturbances of lip or tongue for each side of the face. The patients were asked to record the severity of pain and swelling on a visual analogue scale and the presence or absence of sensory disturbance at 6, 24, 48h and seven days after the operation. The pain was scored according to a visual analogue 4-point scale: 0-absent, 1-slight, 2-moderate and 3-severe. Patients were asked to indicate which side was more swollen and to record this assessment on the swelling scale. The assessment of pain, swelling and sensory disturbance of the lip and tongue was deliberately designed to take in to account patient's perceptions and not to include independent assessment. The justification for this was that patient's perceptions of these applications are of overriding importance and those reliable, objective methods of assessing swelling are yet to be developed. On the seventh day postoperatively, the questionnaires were collected, the sutures removed and the wounds were examined by an independent observer. The clinical criteria for satisfactory wound healing by Holland and Hindle were adopted.[3] They were the following:

  1. The patient should be free from pain.[4]
  2. The healing should be by primary intention or if healing is by secondary intention the socket should be self-cleansing and not require an occlusive dressing.



   Results Top


The statistical analysis by Kruskal-Wallis one-way ANOVA was used to calculate the p-value. Mann Whitney u-test was used to identify the significant groups at 5% level by way of adjusting P -value for Bonferroui correlation.

Pain and swelling [Table - 1],[Table - 2]

Lingual split technique was more painful than other techniques at all intervals. It was noted that the surgical bur technique produced more swelling than other technique at all intervals.

Incidence of sensory disturbance [Table - 3],[Table - 4]

No statistically significant difference in magnitude and loss of labial and lingual sensation noted at all intervals.


   Discussion Top


The investigation was designed as a split unit trial so that three different surgical techniques could be compared under local anesthesia. This is an internal control study as factors relating to postoperative swelling and pain are compared. The surgical procedure is also standardized. The trial was single blind to patients as far as the surgical technique was concerned.

In this study the method of bone removal influenced the intensity and duration of pain. There was a significant difference in quantum and the duration of pain between surgical bur, lingual split and the simplified spilt bone techniques. The cases that were operated by lingual split technique had more pain (pain score 2.5±1.0, 1.9 ± 0.4, 1.1 ± 0.3) in the postoperative period after 24 h, 48 h and the seventh day, when compared to the other two techniques. There was also a significant difference in the swelling amongst the three techniques, the maximum being with the surgical bur technique. These results were consistent with previous reports[3],[5] and are in co-relation to a study where different techniques were compared but in different centers, with different patients and involving several surgeons.

In this study it was found that the techniques using chisel i.e. simplified split bone technique and lingual split technique were associated with less external swelling than the surgical bur technique. Amongst the chisel techniques the simplified split bone technique had comparatively less swelling than lingual split technique. This was corelating to the results revealed by other authors.[6],[7]

On the seventh postoperative day, with regard to the pain, there was no significant difference between surgical bur technique and the simplified split bone technique where as with lingual split bone technique of pain was more with regard to other two techniques.

On the seventh postoperative day, none complained of altered labial sensation with any of these techniques. However two patients operated by lingual split bone technique had altered lingual sensation out of which one regained sensation after the seventh postoperative day.

In simplified split bone technique there is an apprehension about the potential damage to lingual nerve, excessive hemorrhage from lingual soft tissue, introduction of infection into the sublingual spaces and the edema in proximity to the airway. However, we did not come across any of these complication excepting in one case who had altered lingual sensation and that resolved on the 14th day. This finding corroborated with a similar study conducted by Absi et al.[7] Previous research has suggested that more permanent damage to the lingual nerve is associated with surgical bur technique[8] although no account was taken of different complication rates associated with multiple operators and the fact that damage may be caused by the lingual retractors.[4]

In our study all the patients irrespective of the technique had good primary healing except in two patients who underwent surgery by lingual split technique using chisel had delayed secondary wound healing probably due to wound infection. The depth of distal pockets were measured after a period of four weeks postoperatively and the mean depth of the pocket did not show any significant difference in all techniques. Dubois et al[9] studied primary and secondary wound closure for impacted mandibular third molars surgery and his results showed that primary wound closure gave rise to most postoperative problems than secondary wound closure. Suddhasthira et al[10] did a similar study in which he did not report any difference in the two groups. Holland and Hindle[3] showed that wound healing in primary closure was better than the secondary wound closure using a drain.

The operative time was calculated to find out the efficacy of the surgery and statistical comparison did not reveal any significant difference between the three techniques. However, the simplified split bone technique (17.7 min) was less time consuming than, lingual split technique (19.6 min) and surgical bur technique (18.53 min)

Lingual split technique was the most painful than the other two techniques, this was consistent with the results of Rood.[8] The surgical bur technique had more swelling than the other two technique, this was comparable to the study by Holland and Hindle.[3] The simplified split bone technique was least morbid compared to the other two techniques at all intervals, this was consistent with the results of Absi[7] and Yeh.[5]


   Conclusion Top


The simplified split bone technique had the least morbidity than the lingual split and surgical bur technique.

 
   References Top

1.Horton JE, Tarpley TM Jr, Wood LD. The healing of surgical defects in alveolar bone produced with ultrasonic instruments, chisel and rotary bur. J Oral Surg 1975;39:536-46.  Back to cited text no. 1  [PUBMED]  
2.Ten Bosch JJ, van Gool AV. The interrelationship of post­operative compliance following removal of the mandibular third molar. Int J Oral Surg 1977;6:22-8.  Back to cited text no. 2  [PUBMED]  
3.Holland CS, Hindle MO. The influence of closure or dressing of third molar socket on post operative swelling and pain. Br J Oral Maxillofac Surg 1984;22:65-71.  Back to cited text no. 3  [PUBMED]  
4.Blackburn CW, Bramley PA. Lingual nerve damage associated with the removal of lower third molar. Br Dent J 1989;167:103-7.  Back to cited text no. 4  [PUBMED]  
5.Yeh CJ. Simplified split-bone technique for removal of impacted mandibular third molars. Int J Oral Maxillofac Surg1995;24:348-50.  Back to cited text no. 5  [PUBMED]  
6.Yates C, Rood JP, Guralinck W. Swelling and trismus after third molar removal - A comparison of two techniques. Int J Oral Surg 1979;8:347-8.  Back to cited text no. 6    
7.Absi JP, Shepherd. A comparison of morbidity following the removal of lower third molar by the lingual split and surgical bur methods. J Oral Maxillofac Surg 1993;153.   Back to cited text no. 7    
8.Rood JP. Permanent damage to inferior alveolar and lingual nerves during the removal of impacted third molar: Comparison of two methods of bone removal. Br Dent J 1992;172:108-10.  Back to cited text no. 8  [PUBMED]  
9.Dubois DD, Pizer ME, Chinnis RJ. Comparison of primary and secondary closure techniques after removal of impacted mandibular third molars. J Oral Maxillofac Surg 1982;40:631-4.  Back to cited text no. 9  [PUBMED]  
10.Suddasthira T, Chaiwat S, Sattapogdsa P. The comparison of primary and secondary closure technique after removal of impacted mandibular third molars. Thai J Oral Surg 1991;5:67-73.  Back to cited text no. 10    

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Correspondence Address:
P Rajesh
Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College, Alapakkam Main Road, Maduravoyal, Chennai - 95
India
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DOI: 10.4103/0970-9290.30916

PMID: 17347539

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    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4]

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