British Journal of Oral and Maxillofacial Surgery (1984) 22, 65-71

@ 1984 The British Association of Oral and Maxillofacial Surgeons

THE INFLUENCE

OF CLOSURE OR DRESSING OF THIRD MOLAR SOCKETS

ON POST-OPERATIVE

SWELLING

C.S.HOLLAND,B.D.S.,M.D.S.,F.D.S.R.C.S.*

AND PAIN

~~~M.O.~IINDLE,T.D.,B.D.S.,M.D.S.,
F.D.S.R.C.S.

Department

of Dental Surgery, 30 The Ropewalk, Nottingham,

Dental Surgery, University of Shefield

Department

of

Summary.
This study compares
the influence of complete closure as opposed to partial closure and
dressing of lower third molar sockets on post-operative
pain and swelling, and on healing. These closure
techniques were used on opposite sides of the mouths of each of 70 patients undergoing
bilateral third
molar surgery. The comparison of the two techniques within each individual patient showed that complete
closure resulted in more pain and swelling post-operatively
in a significant number of patients, but that the
use of a dressing delayed satisfactory
healing in a few patients.

Introduction
Numerous studies have been carried out to assess the influence of various factors on
the post-operative
course following the removal of third molar teeth. In the main,
investigators
have been concerned with pain experience,
swelling and the influence
of various drug regimes on these parameters.
Fewer studies have been concerned
with the influence
of operative
technique
on the post-operative
course. Holland
(1979) discussed critically the methods of measuring swelling use.d in these studies
and found none were entirely satisfactory. He developed a more satisfactory method
in order to produce valid information
about factors influencing
swelling following
third molar surgery. Using this method, a study of the influence of complete closure
of third molar sockets by sutures as compared with partial closure with sutures and
the insertion of a B.I.P.P. ribbon gauze dressing on post-operative
swelling, and the
patients subjective assessment of post-operative
pain has been carried out. Hellem
and Nordenram
(1973) had shown that a socket protected by a dressing impregnated
with Whiteheads
varnish had reduced post-operative
pain and swelling following
third molar removal as judged by subjective assessment.

Method
Patients who were admitted to either the Northern General Hospital, Sheffield or
the University Hospital, Nottingham
for the removal of bilateral lower third molar
teeth under general anaesthesia
were included in the trial provided the two teeth
were symetrically positioned.
Clinical examination
anckorthopantolmographic
radiographs were used to assess the similarity of depth and angulation
of the teeth. If
upper third molar teeth were to be removed at the same time they had to be bilateral
and not require a transalveolar
approach for their removal. The state of eruption of
the lower third molar teeth was recorded for each tooth as either being in communication with, or not in communication
with the oral cavity. Any history of
(Received 4 August
*Requests
Present

1982; accepted 1 September

1982)

for reprints.

address:

Department

of Oral Surgery,

Prince Charles

65

Hospital,

Merthyr

Tydfil, Mid

Glamorgan.

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pericoronitis was noted for each side as a single or multiple episodes as was the timing
of the most recent episode for each side. Any treatment of previous pericoronitis was
recorded.
Operative

Technique

The operative procedure was performed by the same surgeon and assistant on each
patient using a standardised approach to the surgery as follows:A buccal flap was reflected with the anterior limb running from the distal aspect
of the second molar to the buccal sulcus and the posterior limb over the external
oblique$dge
of the mandible. A lingual flap was reflected with a Howarth
periosteal elevator which was retained for protection of the lingual nerve.
Bone was removed with burs in a conventional speed handpiece.
The delivery of the tooth was accomplished in the same way if at all possible, so
that if tooth division were used, it would be used bilaterally.
Closure techniques.
(a) Suturing of the distal incision over the external oblique ridge only and the
suturing of a small B.I.P.P.* dressing to the apex of the flap and inserting it
lightly into the socket so as to tuck the flap into the socket.
(b) Suturing of both anterior and distal incisions so as completely to close the
socket.
Both closure techniques were used on every patient and the side on which each was
used was allocated randomly. In addition the side which was operated on first was
selected on a random basis. The time of operation for each side from incision to the
last suture was recorded.
Observations

helling.
Measurement of the cheeks were made using the facebow apparatus
developed by Holland (1979) in order to calculate the facial swelling at 24 hours and
seven days post-operatively for all patients, and in addition at 48 hours for the 59
patients treated in Sheffield.
Post-Operative Pain. At 20.00 hours on each post-operative day the patients were
asked to record which was the more painful side of their mouth or if both were
equally painful. In addition they were asked to record when a side had become free of
pain and recording was continued until both sides were pain-free.
Healing. At review seven days post-operatively, the healing of each socket was
assesse,d after the dressing and sutures had been removed by another operator. The
socket was assessed as healing either by primary intention if a blunt probe could not
be passed into the socket through a defect in the mucosa or by secondary intention if
such a defect existed.
The number of days to achieve satisfactory healing as defined by the following
criteria was recorded for each socket:(1) Socket should be pain-free.
(2) Healed by primary intention or if healing by secondary intention the socket
should be self-cleansing and not require an occlusive dressing.
*Bismuth

Iodoform

paraffin

paste

POST-OPERATIVE

SWELLING

Further Treatment. If any additional

for regular
recorded.

irrigation

with saline,

treatment
or antibiotics

AND

PAIN

67

such as a socket dressing, syringing

was needed, the details of tnis were

Results
Seventy patients were entered into the trial (22 males, 48 females) with the
majority between
20 and 35 years of age. An even distribution
of the patients
between the treatment
groups was achieved by the random allocation (Table I).
The state of eruption of the third molar teeth differed between the two sides in 14
patients but there was no statistically
significant
bias towards either method of
treatment.
Similarly, a history of pericoronitis
was evenly distributed.
The mean,
median and the range of operating times (Table II) were similar for both treatment
methods. In 38 patients the operating time differed between sides by more than three
minutes but again there was no bias toward either method of treatment.

Table I
Distribution

of the treatment

methods

in the 70 patients

Side operated
on first
Procedure
Left closed/right
Right closed/left
Total

dressed
dressed

Left

Right

Total

18
18
36

17
17
34

35
35
70

Table II
Operating

times for each treatment

Operating

method

time (mins)

Treatment
method

Mean

Median

Range

Closed
Dressed

12.8
13.8

12
14

5-3 1
5-30

Swelling
The overall mean swelling for both methods of treatment was 17.9 C.C. (s.d. 13.5)
24 hours post-operatively
and 18.8 C.C. (s.d. 17.6) 48 hours post-operatively.
By the
time seven days had elapsed virtually all swelling had resolved with a mean value of
4.7 C.C. (s.d. 9.6). However, it is important
to consider the differences between the
two treatment
methods in each individual
patient. These results are recorded in
Table III with only differences greater than 3 C.C.S. being considered for this purpose.
The test for statistical significance
was based on binomial
distribution
(Diem &
Lentner, 1970) to see whether the true proportion
of patients with less swelling.on
the dressed side could be 0.5.

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Table III
Differences in swelling between closed and dressed treatment
No. of patients

24 hours
n=70
48 hours
n=.59
7 days
n=70
n=No.

with:
Closed side
less

Less than
3 C.C.

Statistical
significance

37

1.5

18

p<O.Ol

30

19

10

p==o.os

30

15

25

p=o.o5

Dressed
less

Time
post-op

methods

side

of patients

Pain Experience

During the first week post-operatively, except for the first and seventh day, more
than half the patients experienced a difference between the severity of pain from
each side of their mouths. Of these patients with differing pain experience the greater
proportion had less pain from the dressed side of their mouths (Fig. 1). The proportion differed statistically significantly (based on binomial distribution, Diem &
Lentner, 1970) from the value of 0.5, expected if there was really no difference, on
the third day (pCO.05) and on the fourth day (pCO.01). In 27 patients the dressed
side became pain-free before the closed side did. The reverse occurred in only 18
patients. Twenty three patients showed no difference between the two treatment
methods. Table IV shows a profile of the time taken to achieve freedom from pain for
each of the methods of treatment.

n-41

0.8 Proportion of
patients with
less pain on the
dressed side

Days post-operative
n = No. of patients with a difference
Day 3 p<O.O5

in pain between sides

Day 4 p < 0.01

Fig. 1

Figure

l-Histogram

showing

the proportion
dressed

of patients, experiencing
method less painful.

different

pain levels, with the

POST-OPERATIVE

Table IV
The time to achieve

Treatment

freedom

3
7
Two patients

AND

PAIN

69

from pain

Cumulative no. of sides free of pain at daily intervals

5
6
7
8
9
10
12
1
2
3
4

method

Closed
Dressed
n=68.

SWELLING

9
11

failed to return

10
17

a completed

17
28

12
21

29
39

52
55

61
60

series of pain record

63
63

64
6h!

67
66

13

14

18

67
67

68
67

68
68

cards and have been excluded.

Healing
Twenty seven of the closed sides were healing by primary intention at seven days.
The remaining
43 closed sides together with all the dressed sides were healing by
secondary intention.
In 46 patients both sides reached the criteria for satisfactory
healing at the same time. The closed side was first in 18 patients whereas it was the
dressed side in six patients. A profile of the time to reach satisfactory healing for each
of the methods of treatment
is given in Table V.

Table V
The time to achieve

satisfactorily

healing

Cumulative No. of sides satisfactorily

healing at 7-day intervals
Treatment
method
Closed
Dressed

Additional

14

21

28

35

42

34
26

53
49

63
63

67
68

69
70

70
70

Treatment

The local treatment which was prescribed at review, seven days post-operatively,
is
summarised
in Table VI.
Further local treatment was required after the fourteenth post-operative
day on six
closed sides (irrigation with saline) and six dressed sides (five irrigation with saline,
one dressing). Antibiotics were not routinely prescribed during this trial but their use
in ten patients is summarised
in Table VII.

Table VI
Local treatment

prescribed
Additional

7 days post-operatively
local treatment

Treatment
method

Dressing

Regular irrigation
with saline

None

Closed
Dressed

4
5

9
28

57
37

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Table VII
Indication
Prophylaxis
Frank

for antibiotic
against

infection

endocarditis

of dressed

sides

Frank infection of closed side

Phargyngeal
trauma during intubation
Prescribed by general medical practitioner,
indication unknown

Drug

Number

Benzylpenicillin
+ Penicillin V
Penicillin V
Erthromycin
Penicillin V
Amoxycillin

2
1
1
1
1

Penicillin

of operations

Discussion

The clinical trial was designed so that both the methods of treatment under
investigation were used in the same patient at the same time. The use of such internal
control within each patient is essential when investigating a parameter, such as
post-operative swelling, which varies so markedly between different patients undergoing similar surgery. Without such internal control, undoubtedly the inter-patient
variation would have obscured the influence of the methods of treatment on postoperative swelling, and invalidated conclusions derived regarding them.
Following this concept of comparison within an individual patient, this clinical trial
has shown that 24 hours post:operatively there were more patients who exhibited
less swelling associated with sockets maintained partially open with a dressing. The
data collected in this trial does not allow any conclusions to be drawn as to the
mechanism of the reduction in swelling. However, the radio-isotope studies on
animals reported by Perriman et al. (1978) does offer a method by which it may be
possible to determine if the reduction is in the traumatic exudate or the haemorrhagic
component of post surgical swelling, or both.
The reduced pain experience associated with the dressed technique re-emphasises
the positive correlation between post-operative pain and swelling shown previously
by McGregor and Hart (1969). This reduction was only evident in the first postoperative week, with the contrast most marked between the third and sixth day.
By the seventh day almost 80 per cent of the operation sites were pain-free with
little difference between the two methods of treatment. Two thirds of the patients
showed no difference in the time to achieve satisfactory healing between the two
methods of treatment. However, some dressed sockets did take longer to achieve the
criteria for satisfactory healing. As the two methods showed little difference in the
number of patients who were pain-free after the first post-operative week this delay
is due to the dressed sides, which all healed by secondary intention, taking longer to
become self cleansing. The implication of this is that more patients were obliged to
use an irrigation syringe on their dressed side. It is interesting to note that just under
two thirds of the closed sockets had broken down within the first week and healed by
secondary intention negating the effort taken to achieve primary closure at operation. Antibiotics were not routinely prescribed as prophylaxis against wound infection in this trial. Only ten patients received antibiotics and in only three instances
could the indication be confidently ascribed to wound infection. In the majority of
instances minor complications of healing such as clot lysis and food stagnation were
effectively managed by local therapy.

POST-OPERATIVE

SWELLING

AND

71

PAIN

Conclusions
The complete closure of third molar sockets leads to increased
post-operative
swelling and pain experience
for the patients as compared
w-ith maintaining
the
sockets partially open with a dressing. However, this dressed method did require a
few patients
to maintain
home care of these sockets for a longer period and,
therefore, delays the satisfactory healing of sockets managed in this way.
Acknowledgement
We wish to acknowledge
the assistance given by Dr R. A. Dixon, Department
University of Sheffield, who carried out the statistical analysis of the results.

of Community

Medicine,

References
Diem, K. & Lentner, C. (1970). Documenta Geigy Scientific Tables 7th Edn, pp. 105. Geigy Pharmaceuticals, Macclesfield.
Hellem, S. & Nordenram,
A. (1973). Prevention
of post-operative
symptoms
by general antibiotic
treatment
and local bandage in removal of mandibular
third molars. International Journal ofOral
Surgery, 2, 273.
Holland, C. S. (1979). The development
of a method assessing swelling following third molar surgery.
British Journal of Oral Surgery, 17, 104.
MacGregor,
A. J. & Hart, P. (1969). Effect of bacteria and other factors on pain and swelling after
removal of ectopic mandibular
third molars. Journal of Oral Surgery, 27, 174.
Perriman,
A., Bramley, P. A., Holroyd,
A. M. & Segasby, C. A. (1978). A preliminary
study of the
dynamics of resolution of experimental
haematomas:
radioisotope
studies in animals. British Journal
of Oral Surgery, 15, 240.