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Meta-Analysis
. 2020 Jul 26;7(7):CD004345.
doi: 10.1002/14651858.CD004345.pub3.

Surgical techniques for the removal of mandibular wisdom teeth

Edmund Bailey  1 , Wafa Kashbour  2 , Neha Shah  1 , Helen V Worthington  3 , Tara F Renton  4 , Paul Coulthard  5
Affiliations
Meta-Analysis

Surgical techniques for the removal of mandibular wisdom teeth

Edmund Bailey et al. Cochrane Database Syst Rev. .

Abstract

Background: Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short-term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity.

Objectives: To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth.

Search methods: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication.

Selection criteria: Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth.

Data collection and analysis: Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel-group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross-over or split-mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split-mouth studies in our analyses, and combined parallel-group and split-mouth studies using the generic inverse-variance method. We used the fixed-effect model for three studies or fewer, and random-effects model for more than three studies.

Main results: We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low-certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low-certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low-certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low-certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand-piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low-certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low-certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low-certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low-certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low-certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported.

Authors' conclusions: In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future.

Trial registration: ClinicalTrials.gov NCT02831374 NCT02942108.

PubMed Disclaimer

Conflict of interest statement

Edmund Bailey: none known Wafa Kashbour: none known Neha Shah: none known Helen V Worthington: none known. Tara F Renton: I am an author of a study included in this review; however, I was not involved in 'Risk of bias' assessment of this study. Paul Coulthard: none known

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Study flow diagram.
1.1
1.1. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 1: Alveolar osteitis (7 days)
1.2
1.2. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 2: Wound infection (7 days)
1.3
1.3. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 3: Permanent altered tongue sensation (> 6 months)
1.4
1.4. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 4: Adverse effects ‐ wound dehiscence (up to 30 days)
1.5
1.5. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 5: Pain present at 24 hours (yes/no)
1.6
1.6. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 6: Mean pain at 24 hours (0 to 10 VAS)
1.7
1.7. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 7: Swelling present (after 1 week) (yes/no)
1.8
1.8. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 8: Mean swelling (after 1 week)
1.9
1.9. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 9: Trismus (after 1 week) (yes/no)
1.10
1.10. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 10: Maximum mouth opening (after 1 week) (SMD)
1.11
1.11. Analysis
Comparison 1: Surgical flap type (A versus B), Outcome 11: Maximum mouth opening (after 1 week) (MD)
2.1
2.1. Analysis
Comparison 2: Lingual nerve protection versus no protection, Outcome 1: Permanent altered sensation (up to 6 months)
2.2
2.2. Analysis
Comparison 2: Lingual nerve protection versus no protection, Outcome 2: Temporary altered sensation (up to 1 month)
3.1
3.1. Analysis
Comparison 3: Bone removal techniques, Outcome 1: Wound infection (7 days)
3.2
3.2. Analysis
Comparison 3: Bone removal techniques, Outcome 2: Temporary alteration of tongue sensation (< 1 month)
3.3
3.3. Analysis
Comparison 3: Bone removal techniques, Outcome 3: Temporary alteration of chin sensation (< 1 month)
3.4
3.4. Analysis
Comparison 3: Bone removal techniques, Outcome 4: Pain at 24 hours (0‐to‐10 VAS)
3.5
3.5. Analysis
Comparison 3: Bone removal techniques, Outcome 5: Mean pain at 24 hours (0‐to‐10 VAS)
3.6
3.6. Analysis
Comparison 3: Bone removal techniques, Outcome 6: Swelling (after 7 days)
3.7
3.7. Analysis
Comparison 3: Bone removal techniques, Outcome 7: Maximum mouth opening (after 7 days)
3.8
3.8. Analysis
Comparison 3: Bone removal techniques, Outcome 8: Maximum mouth opening (after 7 days)
4.1
4.1. Analysis
Comparison 4: Wound irrigation techniques (A versus B), Outcome 1: Alveolar osteitis (7 days)
4.2
4.2. Analysis
Comparison 4: Wound irrigation techniques (A versus B), Outcome 2: Wound infection (7 days)
5.1
5.1. Analysis
Comparison 5: Primary versus secondary wound closure, Outcome 1: Alveolar osteitis (7 days)
5.2
5.2. Analysis
Comparison 5: Primary versus secondary wound closure, Outcome 2: Wound infection (7 days)
5.3
5.3. Analysis
Comparison 5: Primary versus secondary wound closure, Outcome 3: Adverse effects ‐ reactionary bleeding
5.4
5.4. Analysis
Comparison 5: Primary versus secondary wound closure, Outcome 4: Pain at 24 hours (0‐to‐10 VAS)
5.5
5.5. Analysis
Comparison 5: Primary versus secondary wound closure, Outcome 5: Swelling (after 7 days)
5.6
5.6. Analysis
Comparison 5: Primary versus secondary wound closure, Outcome 6: Maximum mouth opening (after 7 days)
6.1
6.1. Analysis
Comparison 6: Suturing techniques, Outcome 1: Maximum mouth opening
7.1
7.1. Analysis
Comparison 7: Surgical drain versus no drain, Outcome 1: Pain at 24 hours (0‐to‐10 VAS)
7.2
7.2. Analysis
Comparison 7: Surgical drain versus no drain, Outcome 2: Swelling at 7 days
7.3
7.3. Analysis
Comparison 7: Surgical drain versus no drain, Outcome 3: Maximum mouth opening at 7 days
8.1
8.1. Analysis
Comparison 8: Wound closure with blood products versus none, Outcome 1: Alveolar osteitis (7 days) split‐ mouth studies (OR/BB)
8.2
8.2. Analysis
Comparison 8: Wound closure with blood products versus none, Outcome 2: Mean pain at 24 hours (0‐to‐10 VAS)
8.3
8.3. Analysis
Comparison 8: Wound closure with blood products versus none, Outcome 3: Swelling at 7 days
9.1
9.1. Analysis
Comparison 9: Coronectomy versus odontectomy, Outcome 1: Swelling at day 7
9.2
9.2. Analysis
Comparison 9: Coronectomy versus odontectomy, Outcome 2: Maximum mouth opening at day 7
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Xavier 2008 {published data only}
    1. Xavier RL, Vasconcelos BC, Caubi AF, Porto GG, Maurette MA. Passive drainage through the vestibular oblique incision in impacted inferior third molar surgery: a preliminary study. Acta Odontologica Latinoamericana 2008;21(1):57-63. - PubMed

References to studies excluded from this review

Abu‐Serriah 2004 {published data only}
    1. Abu-Serriah M, Critchlow H, Whitters CJ, Ayoub A. Removal of partially erupted third molars using an Erbium (Er):YAG laser: a randomised controlled clinical trial. British Journal of Oral and Maxillofacial Surgery 2004;42(3):203-8. - PubMed
Afat 2018 {published data only}
    1. Afat IM, Akdogan ET, Gonul O. Effects of leukocyte- and platelet-rich fibrin alone and combined with hyaluronic acid on pain, edema, and trismus after surgical extraction of impacted mandibular third molars. Journal of Oral and Maxillofacial Surgery 2018;76(5):926-32. - PubMed
Akota 1998 {published data only}
    1. Akota I, Alvsaker B, Bjørnland T. The effect of locally applied gauze drain impregnated with chlortetracycline ointment in mandibular third-molar surgery. Acta Odontologica Scandinavica 1998;56(1):25-9. - PubMed
Al‐Moraissi 2016 {published data only}
    1. Al-Moraissi EA, Elmansi YA, Al-Sharaee YA, Alrmali AE, Alkhutari AS. Does the piezoelectric surgical technique produce fewer postoperative sequelae after lower third molar surgery than conventional rotary instruments? A systematic review and meta analysis. International Journal of Oral and Maxillofacial Surgery 2016;45(3):383-91. - PubMed
Alqahtani 2017 {published data only}
    1. Alqahtani NA, Khaleelahmed S, Desai F. Evaluation of two flap designs on the mandibular second molar after third molar extractions. Journal of Oral and Maxillofacial Pathology 2017;21(2):317-8. - PMC - PubMed
Ayad 1995 {published data only}
    1. Ayad W, Jöhren P, Dieckmann J. Results of a comparative prospective randomized study of surgical removal of mandibular wisdom teeth with and without rubber drainage. Fortschritte der Kiefer- und Gesichts-chirurgie 1995;40:134-6. - PubMed
Bilginaylar 2016 {published and unpublished data}
    1. Bilginaylar K, Uyanik LO. Evaluation of the effects of platelet-rich fibrin and piezosurgery on surgical outcomes after removal of impacted mandibular third molars. British Journal of Oral & Maxillofacial Surgery 2016;54(10):e99. [DOI: 10.1016/j.bjoms.2016.03.016] - PubMed
Cetinkaya 2009 {published data only}
    1. Cetinkaya BO, Sumer M, Tutkun F, Sandikci EO, Misir F. Influence of different suturing techniques on periodontal health of the adjacent second molars after extraction of impacted mandibular third molars. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 2009;108(2):156-61. - PubMed
Chang 2015 {published data only}
    1. Chang HH, Lee MS, Hsu YC, Tsai SJ, Lin CP. Comparison of clinical parameters and environmental noise levels between regular surgery and piezosurgery for extraction of impacted third molars. Journal of the Formosan Medical Association 2015;114(10):929-35. - PubMed
Chen 2016 {published data only}
    1. Chen YW, Lee CT, Hum L, Chuang SK. Effect of flap design on periodontal healing after impacted third molar extraction: a systematic review and meta-analysis. International Journal of Oral and Maxillofacial Surgery 2016;46(3):363-72. - PubMed
Chossegros 2002 {published data only}
    1. Chossegros C, Guyot L, Cheynet F, Belloni D, Blanc JL. Is lingual nerve protection necessary for lower third molar germectomy? A prospective study of 300 procedures. International Journal of Oral and Maxillofacial Surgery 2002;31(6):620-4. - PubMed
    1. Thierry G, Chossegros C, Paris J, Guyot L, Cheynet F, Belloni D, et al. Should the lingual nerve be protected during germectomies? A prospective study of 300 procedures [Faut-il protéger le nerf lingual au cours des germectomies? Etude prospective à propos de 300 interventions]. Revue de Stomatologie et de Chirurgie Maxillo-Faciale 2001;102(6):299-303. - PubMed
Clauser 1994 {published data only}
    1. Clauser C, Barone R. Effect of incision and flap reflection on postoperative pain after the removal of partially impacted mandibular third molars. Quintessence International 1994;25(12):845-9. - PubMed
Cortell‐Ballester 2015 {published data only}
    1. Cortell-Ballester I, Figueiredo R, Valmaseda-Castellon E, Gay-Escoda C. Effects of collagen resorbable membrane placement after the surgical extraction of impacted lower third molars. Journal of Oral and Maxillofacial Surgery 2015;73(8):1457-64. - PubMed
de Carvalho 2015 {published data only}
    1. Carvalho RW, do Egito Vasconcelos BC. High weight standard and removal of third molars: a prospective randomised study. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology 2015;120(5):554-61. - PubMed
Desai 2014 {published data only}
    1. Desai A, Patel R, Desai K, Vachhani NB, Shah KA, Sureja R. Comparison of two incision designs for surgical removal of impacted mandibular third molar: a randomised comparative clinical study. Contemporary Clinical Dentistry 2014;5(2):170-4. - PMC - PubMed
Ding 2000 {published data only}
    1. Ding L, Lu Q. The comparative study of high-speed air turbine handpiece and traditional chisel applying in extraction of impacted mandibular third molars. Chinese Journal of Stomatology 2000;20(3):133-4.
Dubois 1982 {published data only}
    1. Dubois DD, 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(10):631-4. - PubMed
Dutta 2015 {published data only}
    1. Dutta SR, Singh P, Passi D, Patter P. Mandibular third molar extraction wound healing with and without platelet rich plasma: a comparative prospective study. Journal of Maxillofacial and Oral Surgery 2015;14(3):808-15. - PMC - PubMed
Egbor 2014 {published data only}
    1. Egbor PE, Saheeb BD. A prospective randomized clinical study of the influence of primary closure or dressing on post-operative morbidity after mandibular third molar surgery. Nigerian Journal of Surgery 2014;20(2):59-63. [www.ajol.info/index.php/njs/article/view/106844/96760] - PMC - PubMed
Elo 2016 {published data only}
    1. Elo JA, Sun HH, Dong F, Tandon R, Singh HM. Novel incision design and primary flap closure reduces the incidence of alveolar osteitis and infection in impacted mandibular third molar surgery. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology 2016;122(2):124-33. - PubMed
Eshghpour 2018 {published data only}
    1. Eshghpour M, Danaeifar N, Kermani H, Nejat AH. Does intra-alveolar application of chlorhexidine gel in combination with platelet-rich fibrin have an advantage over application of platelet-rich fibrin in decreasing alveolar osteitis after mandibular third molar surgery? A double-blinded randomized clinical trial. Journal of Oral and Maxillofacial Surgery 2018;76(5):939.e1-7. - PubMed
Finne 1981 {published data only}
    1. Finne K, Klamfeldt A. Removal of lower third molar germs by lateral trepanation and conventional technique. A comparative study. International Journal of Oral Surgery 1981;10(4):251-4. - PubMed
Gao 2011 {published data only}
    1. Gao Y, Jiang A, Li B, Yang L. Comparison of piezosurgery and chisel osteotomy in the extraction of mandibular impacted third molars. Huaxi Kongqiang Yixue Zazhi [West China Journal of Stomatology] 2011;29(4):372-4. - PubMed
Gawai 2015 {published data only}
    1. Gawai KT, Sobhana CR. Clinical evaluation of use of platelet rich plasma in bone healing. Journal of Maxillofacial and Oral Surgery 2015;14(1):67-80. - PMC - PubMed
Gay‐Escoda 2015 {published data only}
    1. Gay-Escoda C, Gomez-Santos L, Sanchez-Torres A, Herraez-Vilas JM. Effect of the suture technique on postoperative pain, swelling and trismus after removal of lower third molars: a randomized clinical trial. Medicina Oral, Patologia Oral y Cirugia Bucal 2015;20(3):e372-7. - PMC - PubMed
Gazivoda 2015 {published data only}
    1. Gazivoda D, Pelemis D, Vujaskovic G. A clinical study on the influence of suturing material on oral wound healing. Journal of Maxillofacial and Oral Surgery 2015;72(9):765-9. - PubMed
Genu 2008 {published data only}
    1. Genu PR, Vasconcelos BCE. Influence of the tooth section technique in alveolar nerve damage after surgery of impacted lower third molars. International Journal of Oral and Maxillofacial Surgery 2008;37(10):923-8. - PubMed
Gonzalez 2001 {published data only}
    1. Gonzalez MT, Medina AS, Mendoza AS, Milina RP, Sanchez FN, Canacho LS. Comparative study of surgery (scalpel vs electro surgery) of impacted inferior third molars (Abstract FDI World Dental Congress). International Dental Journal 2001;51(5):380.
Goyal 2012 {published data only}
    1. Goyal M, Marya K, Jhamb A, Chawla S, Sonoo PR, Singh V. Comparative evaluation of surgical outcome after removal of impacted mandibular third molars using a Piezotome or a conventional handpiece: a prospective study. British Journal of Oral and Maxillofacial Surgery 2012;50(6):556-61. - PubMed
Guo 2012 {published data only}
    1. Guo ZZ, Zhang H, Li Y, Li X, Liu Y, Wang Y, et al. Comparative study of complications among routine method, high speed turbine handpiece and piezosurgery device after extraction of impacted wisdom teeth. Shanghai Journal of Stomatology 2012;21(2):208-10. - PubMed
He 2015 {published data only}
    1. He JQ, Ouyang KX, Zhang QB, Zhou M, Yang ZN, Piao ZG. Comparison of two different flap designs in removal of impacted wisdom tooth. Shanghai Kou Qiang Yi Xue 2015;24(2):224-7. - PubMed
Holland 1984 {published data only}
    1. Holland CS, Hindle MO. The influence of closure or dressing of third molar sockets on post-operative swelling and pain. British Journal of Oral and Maxillofacial Surgery 1984;22(1):65-71. - PubMed
Jain 2016 {published data only}
    1. Jain N, Thomas S, Prabhu S, Jain S, Pathak AD, Pillai A, et al. Influence of tooth sectioning technique and various risk factors in reducing the IAN injury following surgical removal of an impacted mandibular third molar. Oral and Maxillofacial Surgery 2016;20(2):149-56. - PubMed
Jakse 2002 {published data only}
    1. Jakse N, Bankaoglu V, Eskici A, Pertl C. Wound healing without complications after removal of lower wisdom teeth using a modified incision. Deutsche Zahnarztliche Zeitschrift 2001;56 Suppl:S8-9.
    1. Jakse N, Bankaoglu V, Wimmer G, Eskici A, Pertl C. Primary wound healing after lower third molar surgery: evaluation of 2 different flap designs. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 2002;93(1):7-12. - PubMed
Jiang 2015 {published data only}
    1. Jiang Q, Qiu Y, Yang C, Yang J, Chen M, Zhang Z. Piezoelectric versus conventional rotary techniques for impacted third molar extraction: a meta-analysis of randomized controlled trials. Medicine 2015;94(41):e1685. - PMC - PubMed
Kerdvongbundit 1989 {published data only}
    1. Kerdvongbundit V, Sirirat M, Vechakarnvithaya A. The effect of two flap designs for the removal of the impacted mandibular third molar on the periodontal status of the mandibular second molar. Mahidol Dental Journal 1989;9(3):141-50.
Korkmaz 2015 {published data only}
    1. Korkmaz YT, Mollaoglu N, Ozmeric N. Does laterally rotated flap design influence the short-term periodontal status of second molars and postoperative discomfort after partially impacted third molar surgery? Journal of Oral and Maxillofacial Surgery 2015;73(6):1031-41. - PubMed
Li 2012 {published data only}
    1. Li S, Li C, Wu Y, Pan J, Zhao H, Li L. Drainage for the control of complications after extraction of impacted mandibular third molar: a systematic review. Huaxi Kongqiang Yixue Zazhi [West China Journal of Stomatology] 2012;30(6):615-9. - PubMed
Li 2014 {published data only}
    1. Li D, Wei Z, Zhang W, Li Z. Crown cutting mode selection in extracting the mandible third molar by dental drilling system. Chinese Journal of Stomatology 2014;49(9):521-4. - PubMed
Ma 2015 {published data only}
    1. Ma Z, Xu G, Yang C, Xie Q, Shen Y, Zhang S. Efficacy of the technique of piezoelectric corticotomy for orthodontic traction of impacted mandibular third molars. British Journal of Oral and Maxillofacial Surgery 2015;53(4):326-31. - PubMed
Martin 2015 {published data only}
    1. Martin A, Perinetti G, Costantinides F, Maglione M. Coronectomy as a surgical approach to impacted mandibular third molars: a systematic review. Head & Face Medicine 2015;11(1):9. - PMC - PubMed
Mavrodi 2015 {published data only}
    1. Mavrodi A, Ohanyan A, Kechagias N, Tsekos A, Vahtsevanos K. Influence of two different surgical techniques on the difficulty of impacted lower third molar extraction and their post-operative complications. Medicina Oral, Patologia Oral y Cirugia Bucal 2015;20(5):e640-4. - PMC - PubMed
Oyri 2016 {published data only}
    1. Oyri H, Bjornland T, Barkvoll P, Jensen JL. Mandibular third molar surgery in 396 patients at a Norwegian university clinic: morbidity recorded after 1 week utilizing an e-infrastructure for clinical research. Acta Odontologica Scandinavica 2016;74(2):148-54. - PubMed
Quee 1985 {published data only}
    1. Quee TA, Gosselin D, Millar EP, Stamm JW. Surgical removal of the fully impacted mandibular third molar. The influence of flap design and alveolar bone height on the periodontal status of the second molar. Journal of Periodontology 1985;56(10):625-30. - PubMed
Robinson 1996 {published data only}
    1. Robinson PP, Smith KG. Lingual nerve damage during lower third molar removal: a comparison of two surgical methods. British Dental Journal 1996;180(12):456-61. - PubMed
Rosa 2002 {published data only}
    1. Rosa AL, Carneiro MG, Lavrador MA, Novaes AB Jr. Influence of flap design on periodontal healing of second molars after extraction of impacted mandibular third molars. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 2002;93(4):404-7. - PubMed
Sala‐Perez 2016 {published data only}
    1. Sala-Perez S, Lopez-Ramirez M, Quinteros-Borgarello M, Valmaseda-Castellon E, Gay-Escoda C. Antibacterial suture vs silk for the surgical removal of impacted lower third molars. A randomized clinical study. Medicina Oral, Patologia Oral y Cirugia Bucal 2016;21(1):e95-102. - PMC - PubMed
Salentijn 2011 {published data only}
    1. Salentijn EG, Forouzanfar T. Effect of ice compression on pain after mandibular third molar surgery: a single blind randomized controlled trial. International Journal of Oral and Maxillofacial Surgery 2011;40(10):1100. - PubMed
Sener 2015 {published data only}
    1. Sener I, Metin M, Bereket C, Tek M, Arici S, Alkan A. Effects of different local haemostatic agents on facial swelling after the third molar surgery. Journal of Experimental and Clinical Medicine 2015;32(1):7-11.
Shevel 2001 {published data only}
    1. Shevel E, Koepp WG, Butow K-W. A subjective assessment of pain and swelling following the surgical removal of impacted third molar teeth using different surgical techniques. South African Dental Journal 2001;56(5):238-41. - PubMed
Sivolella 2011 {published data only}
    1. Sivolella S, Berengo M, Bressan E, Di Fiore A, Stellini E. Osteotomy for lower third molar germectomy: randomized prospective crossover clinical study comparing piezosurgery and conventional rotatory osteotomy. Journal of Oral and Maxillofacial Surgery 2011;69:e15-23. - PubMed
Smith 2000 {published data only}
    1. Smith K. Lingual nerve protection during the removal of lower third molars not necessary. Evidence-Based Dentistry 2000;2(4):92.
Sortino 2008 {published data only}
    1. Sortino F, Pedulla E, Masoli V. The piezoelectric and rotatory osteotomy technique in impacted third molar surgery: comparison of postoperative recovery. Journal of Oral and Maxillofacial Surgery 2008;66(12):2444-8. - PubMed
Strukmeier 1980 {published data only}
    1. Strukmeier A, Pape HD. Comparative studies on the vestibular and lingual osteotomy in the removal of lower wisdom teeth [Vergleichende untersuchungen zur vestibularen und lingualen osteotomie bei der entfernung unterer weisheitszahne]. Deutsche Zahnarztlische Zeitschrift 1980;35:124-7. - PubMed
Suarez‐Cunqueiro 2003 {published data only}
    1. Suarez-Cunqueiro MM, Gutwald R, Richman J, Otero-Cepeda XL, Schmelzeisen R. Marginal flap versus paramarginal flap in impacted third molar surgery: a prospective study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 2003;95(4):403-8. - PubMed
Suddhasthira 1991 {published data only}
    1. Suddhasthira T, Chaiwat S, Sattapongsda P. The comparative study of primary and secondary closure techniques after removal of impacted lower third molars. Thai Journal of Oral Maxillofacial Surgery 1991;5:67-73.
Sun 2009 {published data only}
    1. Sun G, Dang H, Zhao YG, Zhang YD, Qian J, Cui H. Comparative study of extraction of impacted wisdom teeth assisted by micro-dynamic systems and turbines. China Journal of Oral & Maxillofacial Surgery 2009;7(5):468-9.
Sweet 1978 {published data only}
    1. Sweet JB, Butler B. Predisposing and operative factors: effect on the incidence of localized osteitis in mandibular third-molar surgery. Oral Surgery 1978;46(2):206-15. - PubMed
Tabrizi 2014 {published data only}
    1. Tabrizi R, Khorshidi H, Shahidi S, Gholami M, Kalbasi S, Khayati A. Use of lincomycin-impregnated demineralized freeze-dried bone allograft in the periodontal defect after third molar surgery. Journal of Oral and Maxillofacial Surgery 2014;72(5):850-7. - PubMed
Tan 2015 {published data only}
    1. Tan S, Lynham A. Efficacy of cold saline irrigation on reducing post operative complications of third molar extraction. International Journal of Oral and Maxillofacial Surgery 2015;44:e150.
Torres‐Lagares 2006a {published data only}
    1. Torres-Lagares D, Infante-Cossio P, Gutierrez-Perez JL, Romero-Ruiz MM, Garcia-Calderon M, Serrera-Figallo MA. Intra-alveolar chlorhexidine gel for the prevention of dry socket in mandibular third molar surgery. A pilot study [Gel de Clorhexidina intra-alveolar en la prevención de la alveolitis tras la extracción de terceros molares inferiores. Estudio piloto]. Medicina Oral, Patología Oral y Cirugía Bucal 2006;11(2):113-8. - PubMed
Torres‐Lagares 2006b {published data only}
    1. Torres-Lagares D, Gutierrez-Perez JL, Infante-Cossio P, Garcia-Calderon M, Romero-Ruiz MM, Serrera-Figallo MA. Randomized, double-blind study on effectiveness of intra-alveolar chlorhexidine gel in reducing the incidence of alveolar osteitis in mandibular third molar surgery. International Journal of Oral and Maxillofacial Surgery 2006;35(4):348-51. - PubMed
Tuffin 1990 {published data only}
    1. Tuffin JR, Cunliffe DR, Begg R, Shaw SR. Does bupivacaine irrigation of third molar sockets reduce postoperative pain? A double blind controlled trial. British Journal of Oral and Maxillofacial Surgery 1990;28(2):96-8. - PubMed
Yang 2015 {published data only}
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Yolcu 2015 {published data only}
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Zhang 1997 {published data only}
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Zhou 2016 {published data only}
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References to studies awaiting assessment

Kumar 2013 {published data only}
    1. Kumar SB, Sarumathi T, Veerabahu M, Raman U. Study of comparison of flap designs - comma incision versus standard incision in impacted third molar surgery. Journal of Clinical and Diagnostic Research 2013;7(7):1514-8. [DOI: 10.7860/JCDR/2013/6200.3135] - DOI - PMC - PubMed
Ozveri Koyuncu 2013 {published data only}
    1. Özverí Koyuncu B, Zeytínoğlu M, Çetíngül E. Comparison of 2 different flap techniques in the surgical removal of bilateral impacted mandibular third molars. Turkish Journal of Medical Sciences 2013;43:891-8.

References to ongoing studies

ChiCTR‐ICR‐15006182 {published data only}
    1. ChiCTR-ICR-15006182. Posterior-triangle flap: a new flap design for impacted mandibular third molars. www.chictr.org.cn/showprojen.aspx?proj=10696.
IRCT2014052017781N1 {published data only}
    1. IRCT2014052017781N1. Compare of influence different two suture techniques on periodontal health of the mandibular second molars after extraction of impact third molar. Iranian Registry of Clinical Trials 2014.
IRCT2014052717863N2 {published data only}
    1. IRCT2014052717863N2. Evaluation of side effects of two types of flap after impacted mandibular third molar surgery. Iranian Registry of Clinical Trials 2014.
IRCT2015050722139N1 {published data only}
    1. IRCT2015050722139N1. Tissue adhesives for surgical wound closures. Iranian Registry of Clinical Trials 2015.
IRCT201506191760N42 {published data only}
    1. IRCT201506191760N42. The effect of releasing (relaxing) incision on the postoperative complication of mandibular third molar surgery. Iranian Registry of Clinical Trials 2015.
ISRCTN16849867 {published data only}
    1. ISRCTN16849867. Platelet rich fibrin effects on third molar surgery. IRCTN Registry. [DOI: 10.1186/ISRCTN16849867] - DOI
NCT02495207 {published data only}
    1. NCT02495207. A comparison between conventional surgery and piezosurgery. ClinicalTrials.gov 2016.
NCT02831374 {published data only}
    1. NCT02831374. Effectiveness of platelet rich plasma in wound healing. ClinicalTrials.gov 2016.
NCT02942108 {published data only}
    1. NCT02942108. Piezoelectric vibrations and tissue, cellular and molecular mechanisms of oral wound healing after third molar surgery. ClinicalTrials.gov 2016.

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References to other published versions of this review

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