Title Primary Wound Closure Versus Secondary Wound Closure Following Extraction of Mandibular Third Molars Causes a Statistically Significant Increase in Post-Operative Pain and Swelling
Clinical Question In a patient requiring surgical extraction of mandibular third molars, does primary wound closure in comparison to secondary wound closure result in more post-operative pain and swelling?
Clinical Bottom Line Primary closure in comparison to secondary closure following surgical extraction of mandibular third molars results in greater and more intense post-operative pain and swelling. This is reinforced by three comparative studies that implemented different surgical incisions but used the same suture material and techniques.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
20116700Danda/2010N=93 healthy patients; mean age 24.3 years; bilateral impacted mandibular third molars; randomly divided (primary and secondary closure)Comparative Split Mouth Study
Key resultsThis split mouth study allowed the 93 subjects to act as their own control, with one mandibular side receiving primary closure and the other side, secondary closure. The subjects used the visual analog scale (VAS) to define the degree of post-operative pain and swelling over 7 days. The scale is scored from 0 to 5. 0 equals no pain or swelling, and 5 equates to extremely severe pain and swelling. The average VAS swelling score associated with primary closure was 2.56, in comparison to 2.02 for secondary closure. The average VAS pain score associated with primary closure was 2.43, and the score for secondary closure was 2.16. These results showed that there is a statistically significant increase in post-operative swelling (P<.001) and pain (P<.05) when the subject received primary closure in comparison to secondary closure.
15617967Pasqualini/2005N=200 healthy patients; age range 19-27 years; complete or partially impacted mandibular third molars with mesial inclination; randomly divided (primary and secondary closure)Comparative Study
Key resultsUsing the VAS scale, the study determined that the intensity of post-operative pain and swelling (P<0.001) over 7 days was greater with primary closure versus secondary closure. However, there was no significant difference (P=0.081) in the decrease in pain over 7 days between the two groups.
23251051Chaudhary/2012N=12 healthy patients; younger than 30 years of age; partially erupted mandibular third molars with mesial inclination; randomly divided (primary and secondary closure)Prospective Comparative Study
Key resultsThis prospective study assessed the degree of pain and swelling in 12 subjects following extraction of partially erupted mandibular third molars. Patients used the VAS scale, starting 6 hours post-operatively and for 6 consecutive days after the surgery. At the 6-hour post-operative time mark, there was no statistically significant difference in pain (P=0.131) or swelling between the groups. Day 1 results showed that the mean pain and swelling scores were much greater in the group with primary closure (P=0.004 and 0.006). It was determined that there is a statistically significant increase in pain (p=0.015) and swelling (p=0.006) 2 days after the surgery with the primary closure group. Day 3 (pain p=0.070; swelling p=0.018) and day 4 (pain p=0.020; swelling p=0.021) showed similar results to day 2. There was no statistically significant difference in pain and swelling between the two groups on days 5 and 6. From these results, it was concluded that secondary closure is superior to primary closure with respect to pain and swelling for the first 4 post-operative days.
Evidence Search Therapy/Broad[filter] AND (primary[All Fields] AND closure[All Fields] AND ("secondary"[Subheading] OR "secondary"[All Fields] OR "neoplasm metastasis"[MeSH Terms] OR ("neoplasm"[All Fields] AND "metastasis"[All Fields]) OR "neoplasm metastasis"[All Fields]) AND closure[All Fields] AND ("mandible"[MeSH Terms] OR "mandible"[All Fields] OR "mandibular"[All Fields]) AND ("molar, third"[MeSH Terms] OR ("molar"[All Fields] AND "third"[All Fields]) OR "third molar"[All Fields] OR ("third"[All Fields] AND "molars"[All Fields]) OR "third molars"[All Fields]))
Comments on
The Evidence
Validity: Danda’s study design is different than the other two articles because it is a split comparative study. However, the three analyses are part of the same hierarchical level of evidence because they are all comparative studies. The studies were not double-blind in nature; there was adequate follow-up and compliance throughout the studies; and recall bias was unlikely. The groups were all similar at the start; however, the surgical incision designs were slightly different. Danda does not specify the type of incision used. Chaudhary’s study used the Ward’s incision and Pasqualini reflected a trapezoidal flap. Despite the differences in incision design, all three studies performed the primary and secondary closure techniques the same way and with the same suture material (3-0 silk). The study subjects recorded VAS scores for approximately 7 days following the surgery. All three studies determined that primary wound closure causes greater post-operative pain and swelling compared to secondary wound closure when extracting impacted mandibular third molars.
Applicability Extraction of impacted mandibular third molars is a common practice for many oral surgeons and general practitioners. The healing period following surgery is almost always associated with some degree of pain and swelling. Procedural decisions, including primary or secondary wound closure of the surgical site, can greatly affect the intensity of the post-operative symptoms.
Specialty (General Dentistry) (Oral Surgery)
Keywords Primary closure, secondary closure, impacted mandibular third molars, post-operative pain and swelling
ID# 2923
Date of submission 10/09/2015
E-mail casarezquint@livemail.uthscsa.edu
Author Alicia Casarez-Quintana, DDS
Co-author(s) e-mail
Faculty mentor William Pierpont, DDS
Faculty mentor e-mail Pierpont@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
None available
Comments and Evidence-Based Updates on the CAT
None available