Cochrane · intervention · CD004345
Surgical techniques for the removal of mandibular wisdom teeth
Bailey, E, Kashbour, W, Shah, N, et al. · Cochrane Database of Systematic Reviews · 2020 · Cochrane Library
Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.
Questions
68
current version
GRADE rated
13
No studies
33
Included studies
62
as reported
No studies 33 · 48.5%Ungraded 22 · 32.4%Very low 9 · 13.2%Low 4 · 5.9%Moderate 0 · 0%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | People requiring surgical removal of mandibular wisdom teeth (flap raised) | Adults requiring surgical removal of mandibular third molars (n=4643; 62 RCTs) |
| Intervention | Surgical flap design; lingual nerve protection; root retention; bone removal technique; wound irrigation; suturing techniques; wound closure; surgical drains; platelet rich plasma/fibrin (PRP/PRF) | As PUB2 plus piezoelectric bone removal; horizontal mattress/fibrin sealant suturing; platelet rich plasma/fibrin (PRP/PRF) |
| Comparison | Alternative surgical technique within each domain | Envelope flap; no retractor; bur; manual/low-volume irrigation; secondary closure; conventional suturing; no drain; no blood product; complete extraction (odontectomy) |
| Outcomes | Primary: alveolar osteitis (7d); infection (7d); permanent altered tongue/chin/lip sensation (>6mo); adverse effects (reactionary bleeding or mandible fracture, up to 30d). Secondary: temporary altered tongue sensation; temporary altered chin/lip sensation; postoperative pain (24h); swelling (1 week); trismus (1 week) | Alveolar osteitis; wound infection; permanent altered sensation; adverse effects (wound dehiscence/bleeding); temporary altered sensation; postoperative pain 24h; swelling 7d; trismus 7d (mandible fracture: n=0) |
| Study designs | RCT | RCT (n=62; 33 high risk of bias, 29 unclear) |
| Timing | 24 hours; 7 days; ~1 month; >6 months; up to 30 days (adverse) | 24 hours; 7 days; ~1 month; >6 months; up to 30 days |
Search date: 2019-07. Databases: Cochrane Oral Health Trials Register; CENTRAL; MEDLINE (Ovid); Embase (Ovid); ClinicalTrials.gov; WHO ICTRP
Questions and results
Current version onlyTriangular flap vs Envelope flap
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Postoperative pain (mean) 24 hours · short triangular vs envelope | MD -0.84 [-1.65, -0.03] | 4 studies · 161 participants | Ungraded |
Wound infection 1 week | OR 0.29 [0.04, 2.06] 46 per 1000 vs 14 per 1000 | 2 studies · 65 participants | Low Downgraded: risk of bias, imprecision |
Alveolar osteitis 1 week | OR 0.33 [0.09, 1.23] 132 per 1000 vs 48 per 1000 | 5 studies · 187 participants | Low Downgraded: risk of bias, imprecision, inconsistency |
Adverse effects (wound dehiscence) up to 30 days | no estimate extracted | 2 studies · 39 participants | Ungraded |
Swelling (mean) 7 days · short triangular vs envelope | MD 0.60 [0.25, 0.95] | 2 studies · 99 participants | Ungraded |
Permanent altered tongue, chin, or lip sensation >6 months | Peto OR 4.48 [0.07, 286.49] 20 per 1000 vs 90 per 1000 | 1 study · 45 participants | Very low Downgraded: risk of bias, imprecision |
Temporary altered tongue, chin, or lip sensation ~1 month | no estimate extracted | NR | No studies |
Maximum mouth opening 7 days · short triangular vs envelope | SMD -0.67 [-1.04, -0.30] | 2 studies · 158 participants | Ungraded |
Lingual nerve retractor (subperiosteal or Free's) vs No retractor
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Maximum mouth opening 7 days | no estimate extracted | NR | No studies |
Temporary altered tongue, chin, or lip sensation ~1 month · retractor type A vs B | OR 12.96 [2.26, 74.46] | 1 study · 150 participants | Ungraded |
Temporary altered tongue, chin, or lip sensation ~1 month · retractor vs no retractor | OR 4.18 [1.75, 9.98] | 3 studies · 735 participants | Ungraded |
Wound infection 1 week | no estimate extracted | NR | No studies |
Swelling 7 days | no estimate extracted | NR | No studies |
Adverse effects (reactionary bleeding) up to 30 days | no estimate extracted | NR | No studies |
Alveolar osteitis 1 week | no estimate extracted | NR | No studies |
Permanent altered tongue, chin, or lip sensation >6 months | Peto OR 0.14 [0.00, 6.82] 5 per 1000 vs 1 per 1000 | 1 study · 380 participants | Very low Downgraded: risk of bias, imprecision |
Postoperative pain 24 hours | no estimate extracted | NR | No studies |
Lingual split with chisel vs Lingual split with bur
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Temporary altered tongue sensation <1 month · chisel vs bur | OR 3.06 [0.27, 34.48] | 1 study · 52 participants | Ungraded |
Adverse effects up to 30 days | no estimate extracted | NR | No studies |
Alveolar osteitis 1 week | no estimate extracted | NR | No studies |
Swelling (mean) 7 days · ultrasound vs bur | MD 0.37 [0.20, 0.54] | 1 study · 26 participants | Ungraded |
Postoperative pain (mean) 24 hours · piezoelectric vs conventional | MD -1.93 [-3.08, -0.77] | 5 studies · 111 participants | Ungraded |
Temporary altered chin sensation <1 month · chisel vs bur | OR 0.24 [0.04, 1.31] | 1 study · 52 participants | Ungraded |
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Wound infection 1 week · chisel vs bur | OR 1.00 [0.31, 3.21] 58 per 1000 vs 58 per 1000 | 1 study · 52 participants | Very low Downgraded: risk of bias, imprecision |
Trismus / maximum mouth opening (mean) 7 days · piezoelectric vs conventional | MD 2.68 [0.54, 4.81] | 4 studies · 110 participants | Ungraded |
High-volume irrigation (~175 mL) vs Low-volume irrigation (~25 mL)
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Wound infection 1 week · high vs low volume | RR 0.17 [0.02, 1.37] 28 per 1000 vs 5 per 1000 | 1 study · 211 participants | Very low Downgraded: risk of bias, imprecision |
Adverse effects up to 30 days | no estimate extracted | NR | No studies |
Alveolar osteitis 1 week · high vs low volume | RR 0.52 [0.27, 1.02] 10 per 1000 vs 5 per 1000 | 1 study · 211 participants | Very low Downgraded: risk of bias, imprecision |
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Wound infection 1 week · mechanical vs manual | RR 0.50 [0.05, 5.43] 20 per 1000 vs 10 per 1000 | 1 study · 99 participants | Very low Downgraded: risk of bias, imprecision |
Alveolar osteitis 1 week · mechanical vs manual | RR 0.33 [0.01, 8.09] 10 per 1000 vs 3 per 1000 | 1 study · 99 participants | Very low Downgraded: risk of bias, imprecision |
Primary (complete) wound closure vs Secondary (partial) wound closure
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Adverse effects (reactionary bleeding) up to 30 days | RR 0.41 [0.11, 1.47] 175 per 1000 vs 72 per 1000 | 1 study · 82 participants | Very low Downgraded: risk of bias, imprecision |
Swelling (mean) 7 days | MD 0.33 [0.09, 0.57] | 7 studies · 557 participants | Ungraded |
Temporary altered tongue, chin, or lip sensation ~1 month | no estimate extracted | NR | No studies |
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Wound infection 1 week | RR 4.77 [0.24, 96.34] 50 per 1000 vs 13 per 1000 | 1 study · 82 participants | Very low Downgraded: risk of bias, imprecision |
Postoperative pain (mean) 24 hours | MD 0.94 [0.50, 1.38] | 5 studies · 474 participants | Ungraded |
Maximum mouth opening (mean) 7 days | MD -0.29 [-0.90, 0.32] | 4 studies · 274 participants | Ungraded |
Alveolar osteitis 1 week | RR 0.99 [0.41, 2.40] 43 per 1000 vs 43 per 1000 | 3 studies · 375 participants | Low Downgraded: risk of bias, imprecision |
Surgical drain (tube or gauze) vs No drain
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Maximum mouth opening (mean) 7 days | MD 3.11 [2.20, 4.02] | 4 studies · 234 participants | Ungraded |
Swelling (mean) 7 days | MD -0.90 [-1.62, -0.19] | 5 studies · 203 participants | Ungraded |
Wound infection 1 week | no estimate extracted | NR | No studies |
Postoperative pain (mean) 24 hours | MD -0.19 [-0.49, 0.12] | 2 studies · 180 participants | Ungraded |
Adverse effects (reactionary bleeding) up to 30 days | no estimate extracted | NR | No studies |
Alveolar osteitis 1 week | no estimate extracted | NR | No studies |
Temporary altered tongue, chin, or lip sensation ~1 month | no estimate extracted | NR | No studies |
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Coronectomy vs Complete extraction (odontectomy)
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Adverse effects (root migration / fracture) up to 30 days | no estimate extracted | NR | No studies |
Swelling (mean) 7 days | MD -0.18 [-0.63, 0.27] | 1 study · 30 participants | Ungraded |
Permanent altered sensation (inferior alveolar nerve damage) >6 months | no estimate extracted | NR | No studies |
Postoperative pain 24 hours | no estimate extracted | NR | No studies |
Alveolar osteitis 1 week | no estimate extracted | NR | No studies |
Wound infection 1 week | no estimate extracted | NR | No studies |
Maximum mouth opening (mean) 7 days | MD -2.94 [-8.20, 2.32] | 1 study · 30 participants | Ungraded |
Horizontal mattress / fibrin sealant suturing vs Conventional (simple interrupted) suturing
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Alveolar osteitis 1 week | no estimate extracted | NR | No studies |
Wound infection 1 week | no estimate extracted | NR | No studies |
Swelling 7 days | no estimate extracted | NR | No studies |
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Trismus / maximum mouth opening (mean) 7 days · fibrin sealant vs conventional | MD 3.50 [2.69, 4.31] | 1 study · 30 participants | Ungraded |
Postoperative pain 24 hours | no estimate extracted | NR | No studies |
Adverse effects up to 30 days | no estimate extracted | NR | No studies |
Autologous platelet concentrate (PRP/PRF) in socket vs No blood product (conventional)
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Wound infection 1 week | no estimate extracted | NR | No studies |
Swelling (mean) 7 days · PRF vs none | MD 0.11 [-0.12, 0.35] | 2 studies · 86 participants | Ungraded |
Adverse effects up to 30 days | no estimate extracted | NR | No studies |
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Alveolar osteitis 1 week · PRF vs none | OR 0.39 [0.22, 0.67] 205 per 1000 vs 91 per 1000 | 2 studies · 128 participants | Low Downgraded: risk of bias, imprecision |
Postoperative pain (mean) 24 hours · PRF vs none | MD -0.13 [-0.59, 0.34] | 3 studies · 116 participants | Ungraded |
Triangular flap vs Envelope flap
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Adverse effects (wound dehiscence) up to 30 days | no estimate extracted | 2 studies · 39 participants | Ungraded |
Wound infection 1 week | RR 1.55 [0.07, 35.89] 30 per 1000 vs 47 per 1000 | 1 study · 45 participants | Low Downgraded: risk of bias, imprecision |
Permanent altered tongue, chin, or lip sensation >6 months | Peto OR 4.48 [0.07, 286.49] 20 per 1000 vs 90 per 1000 | 1 study · 45 participants | Very low Downgraded: risk of bias, imprecision |
Postoperative pain (mean) 24 hours | MD -0.21 [-0.32, -0.10] -0.21 [-0.32, -0.10] points (0 to 10 VAS) | 2 studies · 102 participants | Moderate Downgraded: risk of bias |
Temporary altered tongue, chin, or lip sensation ~1 month | no estimate extracted | NR | No studies |
Alveolar osteitis 1 week | RR 0.29 [0.11, 0.78] 100 per 1000 vs 29 per 1000 | 3 studies · 94 participants | Moderate Downgraded: risk of bias |
Maximum mouth opening (mean) 7 days | MD 0.81 [-3.32, 4.94] 0.81 [-3.32, 4.94] mm | 2 studies · 39 participants | Low Downgraded: risk of bias, imprecision |
Swelling (mean) 7 days | MD 0.66 [0.26, 1.07] 0.66 [0.26, 1.07] mm | 2 studies · 39 participants | Low Downgraded: risk of bias, imprecision |
Lingual nerve retractor (subperiosteal or Free's) vs No retractor
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Postoperative pain 24 hours | no estimate extracted | NR | No studies |
Wound infection 1 week | no estimate extracted | NR | No studies |
Temporary altered tongue, chin, or lip sensation up to 1 month | Peto OR 5.19 [1.38, 19.49] 4 per 1000 vs 21 per 1000 | 2 studies · 355 participants | Low Downgraded: risk of bias, imprecision |
Maximum mouth opening 7 days | no estimate extracted | NR | No studies |
Alveolar osteitis 1 week | no estimate extracted | NR | No studies |
Temporary altered tongue, chin, or lip sensation up to 1 month · retractor type A vs B | Peto OR 5.83 [1.92, 17.69] | 1 study · 150 participants | Ungraded |
Swelling 7 days | no estimate extracted | NR | No studies |
Lingual split with chisel vs Lingual split with bur
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Wound infection 1 week · chisel vs bur | no estimate extracted | 1 study | Ungraded |
Postoperative pain (mean) 24 hours · chisel vs bur (also ultrasound vs bur; lingual split vs simplified) | MD 0.50 [0.08, 0.92] | 1 study · 60 participants | Ungraded |
Adverse effects up to 30 days | no estimate extracted | NR | No studies |
Temporary altered tongue sensation <1 month · chisel vs bur | RR 3.00 [0.13, 71.99] | 1 study · 104 participants | Ungraded |
Temporary altered chin sensation <1 month · chisel vs bur | RR 0.25 [0.03, 2.16] | 1 study · 104 participants | Ungraded |
Alveolar osteitis 1 week | no estimate extracted | NR | No studies |
Maximum mouth opening (mean) 7 days · ultrasound vs bur | MD 2.90 [-0.27, 6.07] | 1 study · 26 participants | Ungraded |
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Swelling (mean) 7 days · ultrasound vs bur (also chisel vs bur; lingual split vs simplified) | MD 0.37 [0.20, 0.54] | 1 study · 26 participants | Ungraded |
High-volume irrigation (~175 mL) vs Low-volume irrigation (~25 mL)
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Alveolar osteitis 1 week · high vs low volume | RR 0.52 [0.27, 1.02] 103 per 1000 vs 5 per 1000 | 1 study · 211 participants | Very low Downgraded: risk of bias, imprecision |
Maximum mouth opening 7 days | no estimate extracted | NR | No studies |
Postoperative pain 24 hours | no estimate extracted | NR | No studies |
Swelling 7 days | no estimate extracted | NR | No studies |
Wound infection 1 week · mechanical vs manual | RR 0.50 [0.05, 5.43] 203 per 1000 vs 10 per 1000 | 1 study · 103 participants | Very low Downgraded: risk of bias, imprecision |
Alveolar osteitis 1 week · mechanical vs manual | RR 0.33 [0.01, 8.09] 103 per 1000 vs 3 per 1000 | 1 study · 103 participants | Very low Downgraded: risk of bias, imprecision |
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Wound infection 1 week · high vs low volume | RR 0.17 [0.02, 1.37] 283 per 1000 vs 5 per 1000 | 1 study · 211 participants | Very low Downgraded: risk of bias, imprecision |
Temporary altered tongue, chin, or lip sensation ~1 month | no estimate extracted | NR | No studies |
Primary (complete) wound closure vs Secondary (partial) wound closure
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Maximum mouth opening 7 days | SMD -0.14 [-0.41, 0.13] -0.14 [-0.41, 0.13] standard deviations | 3 studies · 214 participants | Low Downgraded: risk of bias, imprecision |
Alveolar osteitis 1 week | RR 0.99 [0.41, 2.40] 43 per 1000 vs 43 per 1000 | 3 studies · 374 participants | Low Downgraded: risk of bias, imprecision |
Postoperative pain (mean) 24 hours | MD 0.79 [0.35, 1.24] 0.79 [0.35, 1.24] points (0 to 10 VAS) | 4 studies · 414 participants | Moderate Downgraded: risk of bias |
Adverse effects (reactionary bleeding) up to 30 days | RR 0.41 [0.11, 1.47] 175 per 1000 vs 72 per 1000 | 1 study · 82 participants | Very low Downgraded: risk of bias, imprecision |
Swelling (mean) 7 days | MD 0.33 [0.09, 0.57] 0.33 [0.09, 0.57] mm | 7 studies · 555 participants | Moderate Downgraded: risk of bias |
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Wound infection 1 week | RR 4.77 [0.24, 96.34] | 1 study · 82 participants | Very low Downgraded: risk of bias, imprecision |
Temporary altered tongue, chin, or lip sensation ~1 month | no estimate extracted | NR | No studies |
Surgical drain (tube or gauze) vs No drain
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Permanent altered tongue, chin, or lip sensation >6 months | no estimate extracted | NR | No studies |
Alveolar osteitis 1 week | no estimate extracted | NR | No studies |
Maximum mouth opening (mean) 7 days | MD 3.72 [2.84, 4.59] 3.72 [2.84, 4.59] mm | 2 studies · 123 participants | Moderate Downgraded: risk of bias |
Swelling (mean) 7 days | MD -0.90 [-1.62, -0.19] -0.90 [-1.62, -0.19] mm | 5 studies · 201 participants | Moderate Downgraded: risk of bias |
Postoperative pain (mean) 24 hours | MD 0 [-0.34, 0.34] 0 [-0.34, 0.34] points (0 to 10 VAS) | 1 study · 100 participants | Low Downgraded: risk of bias, imprecision |
Wound infection 1 week | no estimate extracted | NR | No studies |
Temporary altered tongue, chin, or lip sensation ~1 month | no estimate extracted | NR | No studies |
Coronectomy vs Complete extraction (odontectomy)
Population: Adults with mandibular third molars requiring removal
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Wound infection 1 week | No reliable data on any of these outcomes | 359 participants (2 studies) | GRADE low | 2 studies · 359 participants | Low Downgraded: risk of bias, imprecision |
Maximum mouth opening 7 days | No reliable data on any of these outcomes | 359 participants (2 studies) | GRADE low | 2 studies · 359 participants | Low Downgraded: risk of bias, imprecision |
Permanent altered sensation (inferior alveolar nerve damage) >6 months | No reliable data on any of these outcomes | 359 participants (2 studies) | GRADE low | 2 studies · 359 participants | Low Downgraded: risk of bias, imprecision |
Postoperative pain 24 hours | No reliable data on any of these outcomes | 359 participants (2 studies) | GRADE low | 2 studies · 359 participants | Low Downgraded: risk of bias, imprecision |
Swelling 7 days | No reliable data on any of these outcomes | 359 participants (2 studies) | GRADE low | 2 studies · 359 participants | Low Downgraded: risk of bias, imprecision |
Alveolar osteitis 1 week | No reliable data on any of these outcomes | 359 participants (2 studies) | GRADE low | 2 studies · 359 participants | Low Downgraded: risk of bias, imprecision |
Different surgical technique (any) vs Different surgical technique (any)
Population: Patients requiring removal of mandibular wisdom teeth
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Proportion of wounds becoming infected | no estimate extracted | NR | No studies |
Altered tongue sensation (binary) up to 1 year | no estimate extracted | NR | No studies |
Swelling (continuous) not specified | no estimate extracted | NR | No studies |
Restricted mouth opening (continuous) not specified | no estimate extracted | NR | No studies |
Altered chin or lower lip skin sensation (binary) up to 1 year | no estimate extracted | NR | No studies |
Postoperative pain (continuous) not specified | no estimate extracted | NR | No studies |
Other adverse events such as fracture of the mandible (binary) | no estimate extracted | NR | No studies |