Effect of suture and sutureless techniques in the pain, edema, trismus and bleeding in third molar extractions: systematic review

revisão sistemática

Abstract

Introduction
Third molar extractions can cause discomfort to the patient after surgery due to the inflammatory reaction caused by local tissue damage. These procedures are notably relevant in dentistry, as they are one of the most commonly performed minor oral surgeries worldwide. Despite being part of the daily routine of dentists, the aforementioned inflammatory process causes complications such as bleeding, pain, edema, and trismus. Clinical trials have been developed in search of new methods to reduce these postoperative complications and consequently provide a better quality of life to patients. 1
Suturing is the synthesis procedure that aims to immediately co-opt the edges of the wound in which the healing process occurs by first intention. The use of sutures in third molar surgeries has been researched mainly in relation to the type of material and technique used. 2,3 However, with the low rate of postoperative bleeding and, on the other hand, the increase in postoperative inflammatory complications with primary closure using sutures, the real need and benefit of using sutures in third molar surgeries is questioned. 4
Objectives
The present study aims to analyze the effects of techniques with and without sutures in the analysis of pain, edema, trismus and bleeding in third molar surgeries.
Methodology
The guiding question of this review was “Does the omission of sutures in third molar surgeries present better results in postoperative complications of bleeding, pain, edema and trismus when compared to surgeries with sutures?” The studies were selected using the PICOS strategy (P) healthy patients with indication for surgical removal of third molars (I) surgery with omission of sutures; (C) surgery with sutures; (O) postoperative complications of pain, edema and trismus; (S) randomized clinical trials.
The exclusion criteria for articles were studies in which the initial condition was not the extraction of a third molar, which did not compare the use with the omission of sutures, or which did not analyze the effects on any of the described outcomes.

The search was conducted in the MEDLINE (PubMed), Embase, and Cochrane Central Registry of Controlled Trials (CENTRAL) databases without data or language restrictions using the descriptors: “third molars,” “suture,” “no suture,” and “sutureless” combined with the Boolean operators OR and AND.

The risk of bias assessment of the studies was performed using the Cochrane tool (RoB 2). The RevMan program was used for meta-analyses, and the quality of evidence was assessed using GRADE.

Results
The search resulted in 667 articles; after removing duplicates, a total of 470 articles were obtained. After the screening process and application of the eligibility criteria, 7 articles were selected and included in this review. 5
A total of 396 patients underwent third molar extractions, resulting in 758 tooth extractions in the study. The patients were between 14 and 52 years old, most were female, and underwent extractions of mandibular third molars. Most of the studies included in this review presented some concerns in the analysis of the risk of bias for the outcomes analyzed.
Bleeding was analyzed quantitatively in only one study and did not generate a significant difference between the groups. In another study, the occurrence of continuous bleeding was observed, which was present in 4 of the 52 patients in the group with no suture and in none of the patients in the group that received sutures. In the others, this variable was not analyzed.
Regarding the analysis of pain, all studies evaluated this parameter on the first, second, third, and seventh postoperative days. On the first and second days, postoperative pain was lower in the group that did not receive sutures and on the other days, there were no significant differences. Among these studies, only four provided data with a reduced risk of bias.
Edema was also assessed in the 7 studies, but only presented methodological quality in three of them, in which less edema was observed on the first and second day in the non-sutured group and there were no relevant changes on the third and seventh day.
Trismus was examined in five of the seven studies, demonstrating that patients who received sutures presented worse mouth opening on the first postoperative day and with no evidence on the other days; of these five, four presented care related to bias.
Conclusion
The omission of sutures in third molar extraction procedures showed evidence of reduced postoperative pain, edema and trismus in the first days, with low certainty of evidence. Despite the small number of studies analyzed and high heterogeneity, this review attracts interest regarding