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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 207-213

Comparison of modified lingual split technique and conventional buccal bone cutting technique for the surgical extraction of impacted mandibular third molar


Department of Oral and Maxillofacial Surgery, Maharishi Markandeshwar College of Dental Sciences and Research, Ambala, Haryana, India

Date of Submission07-Aug-2019
Date of Decision05-Sep-2019
Date of Acceptance05-Sep-2019
Date of Web Publication1-Oct-2019

Correspondence Address:
Atul Sharma
Department of Oral and Maxillofacial Surgery, Maharishi Markandeshwar College of Dental Sciences and Research, Mullana, Ambala, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_93_19

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  Abstract 


Objectives: The main objective of the study is to compare the modified lingual split technique and conventional buccal bone cutting technique for the surgical extraction of impacted mandibular third molar. Materials and Methods: Ten patients with bilaterally impacted third molars were randomly selected for the study. Technique selection for side will be done by coin tossing method for randomization. One side of each patient will be operated by conventional buccal bone cutting technique and other side will be operated by modified lingual split technique by Davis modification. Washout period will be of 2 weeks between the two surgical extractions. Various parameters were recorded intraoperatively and postoperatively. Results: Conventional buccal bone cutting technique took more time than modified lingual split technique, whereas no significant difference was found between the two techniques on comparing postoperative parameters such as trismus, dry socket, inflammation, and nerve paresthesia. Clinically, pain felt and swelling observed were less in modified lingual split technique as compared to conventional buccal bone cutting technique. Conclusion: It is been conclude that modified lingual split technique was less time-consuming, less painful, and less swelling was observed in comparison with conventional buccal bone cutting technique.

Keywords: Lingual split technique, pain, paresthesia, swelling, time duration, trismus


How to cite this article:
Singh KI, Sharma A, Bali A, Malhotra A, Patidar DC, Tanwar K. Comparison of modified lingual split technique and conventional buccal bone cutting technique for the surgical extraction of impacted mandibular third molar. Indian J Dent Sci 2019;11:207-13

How to cite this URL:
Singh KI, Sharma A, Bali A, Malhotra A, Patidar DC, Tanwar K. Comparison of modified lingual split technique and conventional buccal bone cutting technique for the surgical extraction of impacted mandibular third molar. Indian J Dent Sci [serial online] 2019 [cited 2019 Nov 15];11:207-13. Available from: http://www.ijds.in/text.asp?2019/11/4/207/268427




  Introduction Top


A tooth, which is completely or partially unerupted and is positioned against another tooth, bone, or soft tissue so that its further eruption is unlikely, is called an impacted tooth.[1] The word impaction is derived from the Latin word – impactus. In 1997, Anderson defined impaction as a cessation of eruption of the tooth caused by a clinically or radiographically detectable physical barrier in the path of eruption or by ectopic position of the tooth.[2]

Third molar eruption and continuous positional changes after eruption can be related not only with race but also with nature of the diet, the intensity of the use of the masticatory apparatus, and possibly due to genetic background.[3] Many theories were proposed for impaction such as Phylogenetic theory, Mendelian's theory, Nodine's theory, Pathological theory, Endocrinal theory, and Orthodontic theory.[4]

The etiological factors of impaction can be classified as local and systemic factors. Local factors are micrognathia, crowding of teeth, condensing osteitis, cyst, tumor, and thick fibrous bands beneath the mucosa. Systemic factors include the prenatal cause, i.e., hereditary and postnatal causes such as rickets, anemia, tuberculosis, congenital syphilis, malnutrition, and endocrinal disorders of the thyroid, parathyroid, and pituitary gland such as hypothyroidism, and achondroplasia.[5]

Many factors govern the decision of extraction of the impacted mandibular third molar which includes caries, recurrent pericoronitis, periodontal disease, obscure facial pain, prosthetic considerations, orthodontic reasons, and any pathological lesion.[5]

Surgical extraction of impacted third molar is difficult due to its anatomical position, poor accessibility, and potential injuries to the surrounding vessels, nerves, soft tissues, and adjacent teeth during surgery.[6]

Mandibular third molar is situated at the distal end of the body of the mandible where relatively thin ramus is present. This is the region of weakness and fracture can occur if excessive force is applied during impacted wisdom tooth elevation without preliminary and adequate removal of surrounding bone.[3] The buccal alveolar bone in this region is thicker than the lingual bone when viewed from superior aspect. The external oblique ridge forms the buttress that reinforces the buccal plate. The lingual nerve often lies close to the lingual cortical plate.[6] There is a high risk of lingual nerve damage using lingual split technique or elevating third molar flap medially to the distoangular recess. In some cases, third molar roots can contact or penetrate into mandibular canal, or they can be deflected. Close relationship of the canal with the roots can evoke inferior alveolar nerve damage during the surgery.[3]

Third molar surgery may give rise to morbidities such as pain, trismus, swelling inflammatory complications like alveolar osteitis (dry socket), and surgical site infections that may be severe enough to interfere with normal activities. Surgical complications may require additional management beyond what is originally planned.[7]

There are different techniques for surgical extraction of impacted mandibular third molar like buccal conventional technique using burs, chisel and mallet, and lingual split technique and its modifications. The present study was carried out to assess the two techniques, i.e., modified lingual split technique and conventional buccal bone cutting technique using burs for the surgical extraction of impacted mandibular third molar.


  Materials and Methods Top


Ten patients with bilaterally impacted third molars which were indicated for surgical extraction were randomly selected from the outpatient department of oral and maxillofacial surgery. Technique selection for side was done by coin tossing method for randomization. One side of each patient was operated by conventional buccal bone cutting technique and other side was operated by modified lingual split technique (Davis modification) at the washout period of 2 weeks.

Investigations

  1. Orthopantomogram (OPG), intraoral periapical radiograph (IOPA) (OPG for WHARFE assessments and Pederson scale and IOPA for WAR lines)
  2. Hemoglobin, total leukocyte count, differential leukocyte count, bleeding time, clotting time, blood glucose, and other investigations as deemed necessary.


Surgical procedure

Two techniques performed in the study are

  1. Modified lingual split technique
  2. Conventional buccal bone technique.


Modified lingual split technique

Lingual split technique was given by Sir William Kelsey Fry in 1933 was popularized by Ward in 1956.[8] In 1983, Davis et al. modified the procedure by not elevating lingual soft tissue or separating the lingual bone attached to the periosteum. This was accompanied by some osteotomy modifications, i.e., fragmentation of the bone rather than one-piece separation of bone.[9]

Technique

Patient was painted and Draped with drape sheets under all aseptic condition. Inferior alveolar nerve block, long buccal nerve block, and lingual nerve block were given with 2% lidocaine hydrochloride with 1:200,000 adrenaline. Ward's incision was given and flap was raised. Vertical stop cut was made at the distal aspect of the second molar exposing the most anterior portion of the crown of the third molar. The horizontal cut was made backward from the point above the lower border of the vertical stop to the distobuccal aspect of the tooth exposing the crown. Then, the distolingual bone was fractured by placing chisel pointing in the direction of mandibular second molar of contra lateral side parallel to the external oblique ridge. The tooth was removed in toto and the bone not attached to the periosteum was removed to prevent necrosis, then the suturing was done with 30 silk suture reverse cutting and pressure pack was given [Figure 1]a, [Figure 1]b, [Figure 1]c.[10]
Figure 1: (a) Vertical and horizontal osteotomy with chisel and mallet. (b) Fracturing the lingual bone and elevation of tooth. (c) Fractured lingual plate

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Conventional buccal bone technique

Patient was painted and draped under all aseptic condition. Inferior alveolar nerve block, long buccal nerve block, and lingual nerve block were given with 2% lidocane hydrochloride with 1:200,000 adrenaline. Wards incision was given and flap was raised. Guttering was done on the buccal side using straight fissure (No 703). Carbide burs extending toward the distal aspect of the tooth and on lingual side while protecting the lingual soft tissue. Sectioning of the tooth was done, where required. The elevator was applied after sufficient guttering and the tooth was elevated. The bony margins were smoothened and socket was irrigated with normal saline. Suturing was done with 30 silk suture and pressure pack was given [Figure 2].[11]
Figure 2: Buccal conventional bone cutting

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Evaluation of parameters

Difficulty index

Pederson scale used for difficulty index [12] [Table 1]a.


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Intraoperative assessments

It includes operative time taken, breakage of root, injuries to adjacent teeth, displacement of tooth in sublingual space, and injury to soft tissue and tongue.

Postoperative assessments

Postoperative parameters were evaluated at different time intervals, i.e., at 24 h, 4th day, and 7th day.

Haemorrhage

Bleeding was observed at the interval of 30 min, 60 min, and after 24 h. This will be done through visual inspection done after surgery and expressed in terms of Yes or No.

Swelling

Postoperative swelling was recorded by Breytenbach method of measurement, i.e., from tragus to pogonion (ear to chin) and from lateral canthus of eye to the angle of the mandible.[13] Comparison will be done between pre and postoperative measurement [Figure 3].
Figure 3: (a) Measurement of Swelling (Horizontally - from tragus to pogonion) (b) Measurement of Swelling (Vertically - lateral canthus of eye to the angle of the mandible)

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Pain [14] assessed by visual analog scale.

Numerical scale

  • 0: No pain – The patient feels well
  • 1: Slight pain – If the patient is distracted, he does not feel pain
  • 2: Mild pain – The patient feels pain even if concentrating on some activity
  • 3: Moderate – The patient is very disturbed but nevertheless can continue with normal activities
  • 4: Severe pain – The patient is forced to abandon normal activities
  • 5: Extreme pain – The patient must abandon every type of activity and feels the need to lie down.


Mouth opening (trismus)

Trismus was measured by measuring interincisal distance preoperatively and postoperatively.

Inflammation

It was noted as present or absent.

Nerve discrepancy

  • 0 = No sensational impairment
  • 1 = Mild loss of sensation
  • 2 = Moderate loss of sensation
  • 3 = Severe loss of sensation.[15]


Dry socket

Dry socket is noted as absent or present at different time intervals.


  Results Top


The present study compared two techniques, i.e., modified lingual split technique and conventional buccal bone cutting technique using burs for the surgical extraction of impacted mandibular third molar. The study involved ten eligible patients, among them five patients were male and five were female.

The Pederson scale comparison for difficulty index between the two groups showed that the mean score in modified lingual split group was 5.3 ± 0.483 and buccal conventional group was 5 ± 0.943, the mean difference was 0.300 and was found to be statistically nonsignificant using t-test with P = 0.382 [Table 1]b.

On intraoperative assessment, the comparison of time duration of the surgical procedure between the two techniques, the mean of modified lingual split group was 24.0 ± 5.164 and buccal conventional group was 33.5 ± 10.014 min. The mean difference was −9.5, and this showed modified lingual split technique took lesser time, and it was statistically significant using t-test with P = 0.016 [Table 2].
Table 2: Comparison of time duration of the procedure between the two technique groups

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The comparison of mouth opening at postoperative period between the two techniques at different time intervals, i.e., after 24 h, 4th day, and 7th day were done. At the first visit (after 24 h), the mean difference between the two techniques was 2.0, and it was statistically not significant using Mann–Whitney U test with P = 0.519. At the second visit (4th day), the mean difference was 4.4, and the difference was not statistically significant using Mann–Whitney U-test with P = 0.098. At the third visit (7th day), the mouth opening, the mean difference was 3.400 and the difference was statistically nonsignificant using Mann–Whitney U-test with P = 0.239 [Table 3].
Table 3: Comparison of postoperative mouth opening between the two technique groups

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In comparison of swelling postoperative between the two techniques at different time intervals at the first visit, the mean difference was 0.669, and the difference was not statistically significant using Mann–Whitney U test with P = 0.213. At the second visit (4th day), the mean difference was − 0.184, and the difference was not statistically significant using Mann–Whitney U-test with P = 0.636, and on the third visit (7th day), the mean difference was −0.174 and the difference was statistically not significant using Mann–Whitney U-test with P = 0.195 [Table 4].
Table 4: Comparison of swelling between the two technique groups

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The comparison of the presence of inflammation between the two technique groups at different time intervals. At the first and second visit, inflammation was present in only one subject in buccal conventional group as compared to 0 in modified lingual split group. This difference was statistically not significant using Fisher's exact test with P = 0.500. At the third visit, there was no inflammation in both the techniques [Table 5].
Table 5: Comparison of the presence of inflammation between the two technique groups

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In comparison of dry socket, the statistical analysis was not done because none of the techniques have dry socket in all the three visits [Table 6].
Table 6: Comparison of the presence of dry socket between the two technique groups

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In comparison of nerve paresthesia, the statistical analysis was not done because none of the techniques have nerve damage [Table 7].
Table 7: Comparison of the presence of nerve damage between the two technique groups

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The comparison of pain scores between two techniques, at the first visit, two patients had no pain, four had mild pain, and four had moderate pain in modified lingual split technique group, whereas none had no pain, none had slight pain, five had mild pain, and five had moderate pain in buccal conventional group. There was no statistically significant difference was observed with Chi-square test, P = 0.329 [Table 8].
Table 8: Comparison of pain scale at different time interval between the two technique groups

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In the second visit, two patients had no pain, two had slight pain, three had mild pain, and three had moderate pain in modified lingual split, whereas none had no pain, one had slight pain, three had mild pain, and six had moderate pain in buccal conventional group. The comparison between the groups showed statistically significant difference with Chi-square test, P = 0.048. In the third visit, four patients had no pain, three had slight pain, three had mild pain, and none had moderate pain in modified lingual split, while three had no pain, two had slight pain, three had mild pain, and two had moderate pain in buccal conventional group. The comparison between the groups showed no statistically significant difference with Chi-square test P = 0.504.

In comparison of the presence of hemorrhage between the two technique groups at different time intervals, hemorrhage was present in two patients in modified lingual split group as compared to 0 in buccal conventional group after 30 min of the procedure. No statistically significant difference was observed using Fisher's exact test with P = 0.125. There was no hemorrhage at 60 min and 24 h in both the techniques [Table 9].
Table 9: Comparison of the presence of hemorrhage between the two technique groups

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  Discussion Top


An impacted tooth is one which fails to erupt in the oral cavity due to obstruction to its path of the eruption. Obstruction may be due to adjacent tooth, thick bone, and fibrous tissue or due to any cyst or tumor. There are different techniques for surgical extraction of impacted mandibular third molars like buccal conventional technique using chisel and mallet or burs and lingual split technique and its modifications.

The present study was performed in the department of oral and maxillofacial surgery with an aim to compare the modified lingual split technique and buccal conventional technique for surgical extraction of impacted mandibular teeth. The study included the patients having bilateral impacted mandibular third molars and was indicated for surgical extraction. The study comprised ten eligible patients, of which five were male and five were female. The age group of patients was 19–34 years with the mean age of 25.60 ± 5.016 years. The mean ages of patients included were 25.60 ± 5.016 years, which indicate that the impaction occurs in younger age group, which is in accordance with the study conducted by Moan et al.,[15] In their study, twenty patients were taken, of which 14 were female and 6 were male with a mean age of 21.5 years.

Side selection was done by coin tossing method. The parameters noted were difficulty index (Pederson scale), time taken to complete the procedure, hemorrahge, trismus, nerve paresthesia, swelling, pain, and dry socket at postoperative on three visits, i.e., at 24 h, 4th day, and 7th day. The results were statistically significant for one parameters, i.e., time taken and were not statistically significant for other six parameters, i.e., hemorrhage, trismus, swelling, inflammation, and dry socket and pain.

In the present study, Pederson scale was used for assessing difficulty index concluding that the difficulty level of the impactions done by both the techniques was almost same. Time duration to complete the surgical procedure, modified lingual split technique required less time than buccal conventional technique, the analysis was done using t-test, and it was found statistically significant with P = 0.016 (P < 0.005). Similar studies were done by Rud and Dr Odont in 1984,[16] Hindy, Singh et al. in 2013,[14] and Vivek et al. in 2014,[17] which also yielded the same results.

The present study showed that postoperative trismus in patients done with lingual split technique was comparatively less, although their results were not statistically significant. The result of our study was similar with a study conducted by Moan et al., in 1996[15] and Steel in the year 2012.[18]

Postoperative swelling between the two techniques, less swelling as observed in patients treated with lingual split technique; however, statistically no significant difference was observed which was similar to the study done by Steel in 2012[18] and Moan et al. in 1996.[15]

Dry socket was not present in both the groups at all visits. A similar study was done Coulthard et al. in the year 2014[19] which states that there was incidence of dry socket were absent in both techniques.

On comparing the presence of nerve discrepancy between the two technique groups at different time intervals, the nerve damage was not present in both the groups at all visits. Similar results were seen in a study done by Steel in the year 2012[18] and Blackburn and Bramley in the year 1989.[20]

The comparison of pain scale scores between two techniques, less pain experienced by the patients in lingual split technique; however, no statistically significant difference was observed, the results are in accordance with the study done by Rud and Dr Odont in the year 1984[16] and Middlehurst et al. in the year 1988[21] stated that lingual split technique was less painful than buccal conventional technique.

The presence of haemorrhage at different time intervals for two techniques were noted and compared. After 30 min of the procedure, hemorrhage was present in two patients in modified lingual split group as compared to 0 in buccal conventional group. This difference was statistically nonsignificant. There was no hemorrhage at 60 min and 24 h in both the techniques. A similar study was done by Singh et al. in the year 2013.[14]


  Conclusion Top


The present study concluded that modified lingual split technique was less time-consuming, clinically less swelling, and less pain were observed in patients treated with this technique. Although studies with more sample size are required in future to further show the advantages of modified lingual split technique over buccal conventional technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Joshi M, Kasat V. Variations in impacted mandibular permanent molars: Report of three rare cases. Contemp Clin Dent 2011;2:124-6.  Back to cited text no. 1
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2.
Peterson LJ. Principles of management of impacted teeth. In: Peterson LJ, Ellis E 3rd, Hupp JR, Tuker MR, editors. Contemporary Oral and Maxillofacial Surgery. 3rd ed. St. Louis: Mosby; 1998. p. 215-48.  Back to cited text no. 2
    
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Juodzbalys G, Daugela P. Mandibular third molar impaction: Review of literature and a proposal of a classification. J Oral Maxillofac Res 2013;4:e1.  Back to cited text no. 3
    
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Bjork A, Jensen E, Palling M. Scandinav mandibular growth and third molar impaction. Acta Odontol Scand 1956;14:231-72.  Back to cited text no. 4
    
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Borley RM. Textbook of Oral and Maxillofacial Surgery. 1st ed. Jaypee Brothers Medical Publishers(P)Ltd, New Delhi, India; 2014. p. 222.  Back to cited text no. 5
    
6.
Carvalho RW, do Egito Vasconcelos BC. Assessment of factors associated with surgical difficulty during removal of impacted lower third molars. J Oral Maxillofac Surg 2011;69:2714-21.  Back to cited text no. 6
    
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Ghosh PK. Synopsis of Oral and Maxillofacial Surgery. Jaypee Brothers Medical Publishers (P)Ltd, New Delhi, India; 2006. p. 202.  Back to cited text no. 7
    
8.
Ward TG. The split bone technique for removal of third molars. Br Dent J 1956;101:297-304.  Back to cited text no. 8
    
9.
Davis WH, Hochwald DA, Kaminishi RM. Modified distolingual splitting technique for removal of impacted mandibular third molars: Technique. Oral Surg Oral Med Oral Pathol 1983;56:2-8.  Back to cited text no. 9
    
10.
Varghese KG. A Practical Guide to the Management of Impacted Teeth. 1st ed. Jaypee Brothers Medical Publishers (P)Ltd, New Delhi, India;2010. p. 8990.  Back to cited text no. 10
    
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Geoffrey L. Howe Minor Oral Surgery. 3rd ed. Butterworth-Heinemann Ltd;1985. p. 139-141.  Back to cited text no. 11
    
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Amin MM, Laskin DM. Prophylactic use of indomethacin for prevention of postsurgical complications after removal of impacted third molars. Oral Surg Oral Med Oral Pathol 1983;55:448-51.  Back to cited text no. 12
    
13.
Mansuri S, Mujeeb A, Hussain SA, Hussain MA. Mandibular third molar impactions in male adults: Relationship of operative time and types of impaction on inflammatory complications. J Int Oral Health 2014;6:9-15.  Back to cited text no. 13
    
14.
Singh V, Alex K, Pradhan R, Mohammad S, Singh N. Techniques in removal of impacted mandibular third molar. Eur J Gen Dent 2013;25-30.  Back to cited text no. 14
    
15.
Moan A, Kişnişci R, Uçok C. Stereophotogrammetric and clinical evaluation of morbidity after removal of lower third molars by two different surgical techniques. J Oral Maxillofac Surg 1996;54:171-5.  Back to cited text no. 15
    
16.
Rud J. Reevaluation of the lingual split-bone technique for removal of impacted mandibular third molars. J Oral Maxillofac Surg 1984;42:114-7.  Back to cited text no. 16
    
17.
Vivek M, Ebenezer V, Balakrishnan R. Technique and chisel mallet technique in impacted 3rd molar. Biomed Pharmacol 2014;7:281-4.  Back to cited text no. 17
    
18.
Steel B. Lingual split versus surgical bur technique in the extraction of impacted mandibular third molars: A systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:294-302.  Back to cited text no. 18
    
19.
Coulthard P, Bailey E, Esposito M, Furness S, Renton TF, Worthington HV. Surgical techniques of impacted wisdom teeth. Biomed Pharmacol J 2014;7:281-4.  Back to cited text no. 19
    
20.
Blackburn CW, Bramley PA. Lingual nerve damage associated with the removal of lower third molars. Br Dent J 1989;167:103-7.  Back to cited text no. 20
    
21.
Middlehurst RJ, Barker GR, Rood JP. Postoperative morbidity with mandibular third molar surgery: A comparison of two techniques. J Oral Maxillofac Surg 1988;46:474-6.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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