The assessment of need for suturing following maxillary third molar extractions

Maxillary third molar extractions (MTME) are one of the most common procedures done in maxillofacial surgery. Nevertheless, there are general complications that arise with every surgery. In our study, we have aimed to understand why suturing had been done following MTME and to observe a predilection in age and gender. By attempting to do so, we may establish when suturing is required and if age and gender have a role to play. A retrospective cross-sectional study was conducted after reviewing and analysing the data from 86,000 patient records between June 2019 and March 2020. Patients with an established record of MTME were selected from the age group of (20-60) years. The females of the study population had a larger frequency for having undergone MTME (52.7%) compared to the males (47.3%) and lastly trans-genders (0.1%). The highest incidence of MTME was found in the age group of (31-40) years with 30.6% followed by (20-30) and (41-50) years with 26.9% each. (51-60) years had the least MTME done (15.6%). There was a higher incidence of extracted 28’s than 18’s (52.1% > 47.9%). Sutures were placed only in 1.6% of the total cases due to tuberosity fractures that had occurred as a complication of MTME. The placement of a suture following exodontia is not always mandatory, but when a complication such as a maxillary tuberosity fracture arises, suturing must be done. It is imperative to be equipped with the knowledge on how to manage possible complications, because even simple exodontias can prove to have fatal outcomes. Thus, further studies must be done to con(cid:977)irm our (cid:977)indings and to test other geographical locations and ethnicities.


INTRODUCTION
Exodontia is the removal of a tooth from the dental alveolus in the alveolar bone. A tooth may be removed from the oral cavity for a variety of reasons such as tooth decay, infection, periodontitis, pericoronitis, prosthetics, cosmetics and in the past for prophylaxis (Nice, 2000;APHA, 2008;Zadik et al., 2008;Hollins, 2019). Molar teeth are the most frequently extracted teeth (Mosha and Lema, 1991) and the third molar is the most com-mon molar extracted (Reich and Hiller, 1993) followed by premolars in recent years (Alesia et al., 2013). Thus, third molar surgery is one of the most commonly performed procedures in maxillofacial surgery units (Patturaja and Pradeep, 2016). Nevertheless, accurate planning and sound surgical skills are required as complications arise in general following any surgery (Packiri et al., 2017;Jain et al., 2019). The incidence of complications following third molar surgery ranges between 2.6% to 30.9% (Bui et al., 2003;Brauer et al., 2013). The spectrum of complications that could possibly occur range from expected post-operative pain and swelling to permanent nerve damage, mandibular fractures, maxillary tuberosity fractures, maxillofacial trauma, alveolar osteitis, life threatening infections and abscess formation (Jerjes et al., 2006;Kim et al., 2006;Christabel et al., 2016).
A suture is placed to hold body tissues together after an injury or a surgery and several studies have hinted that placing sutures increases post-operative pain (Rao and Kumar, 2018;Sweta et al., 2019) and swelling when opposed to leaving the extraction site sutureless (Hashemi et al., 2012). But sutures must be placed following surgical complications such as maxillary tuberosity fractures and mandibular fractures (Bertram et al., 2011). Third molar extractions are one of the most dif icult teeth to extract, thus our study aims to highlight when and where suturing is needed and to pinpoint the age and gender in which maxillary third molar extractions are common in, such that we may better excel in our prophylactic, pre-operative anxiety (Kumar, 2017b), waste (Rahman and  and complication management standards (Patil et al., 2017;Kumar, 2017a).

Study Design and Setting
This retrospective study examined the records of 86,000 patients who underwent treatment at Saveetha Dental College, Chennai during June 2019 to March 2020. Ethical approval was obtained from the Institutional Ethics Committee. The study population included patients who had undergone maxillary third molar extractions from the age of 20 years to 60 years. They were separated according to their sex, age and tooth number extracted and were checked for suture placements and complications. Mentally or physically disabled individuals were excluded from the study due to the dif iculties in obtaining reviews.

Data Collection
The patient records of 86,000 patients who vis-ited Saveetha Dental College from June 2019 to March 2020 were analysed and were used to identify 1836 patients in the hospital database who had undergone maxillary third molar extractions. Relevant data such as patient age, sex, tooth number extracted, complications and suture placement were recorded. Repeated patient records, incomplete entries and extractions with no history of reviews were excluded. The data obtained was then veri ied by an external reviewer.

Statistical Analysis
Data was recorded in Microsoft Excel 2016 (Microsoft Of ice 10) and was later exported to the Statistical Package for the Social Sciences for Windows. (Version 20.0, SPSS, Inc., Chicago, USA) and was subjected to statistical analysis.

RESULTS AND DISCUSSION
The inal dataset consisted of 1836 patients, predominantly of South Indian origin who had undergone left, right or both maxillary third molar extractions. There was a clear female predilection with the females having undergone 52.7% of the extractions, followed by males (47.3%) and inally 0.1% of transgenders as inferred from Figure 2. The most number of maxillary third molar extractions was seen in the age group of (31-40) years with 30.6% of all the total extractions, followed by the age groups of (20-30) years and (41-50) years with 26.9% of the extractions each and lastly, 15.6% of the extractions in the age group of (51-60) years. There was also a predominance of tooth number where upper left third molars (28) were more commonly extracted than upper right third molars (18) 52.1% > 47.9%. Sutures were placed only in 1.6% of the total cases to contain the complication of maxillary tuberosity fractures (1.6%).
The data for this retrospective study was based on residents of South Indian cities seeking treatment at Saveetha Dental College, Chennai, India. Currently there are no studies directly seeking to identify the same -to assess the need for suturing following maxillary third molar extractions. (Kumar and Snena, 2016;Abhinav et al., 2019;Jesudasan et al., 2015) Since there was no iltration process involved, this study mostly remains free of bias in regard to the selection of patients -except for the exclusion of patients below the age of 20 years and above the age of 60 years, those with mental and physical disabilities and extractions left unreviewed which was classi ied as incomplete data. According to most studies, females are reported to have a higher inci-  (Quek et al., 2003;Alsadat-Hashemipour et al., 2013;Nejat et al., 2014). This is in accordance to our indings, where 52.7% of the total study population undergoing maxillary third molar extractions were females, followed by 47.3% of males and 0.1% of transgenders.

Figure 2: Gender distribution
In a study conducted by Marimuthu et al. (2018). They found a subject incidence of 57.3% of the study population to be females (Susarla and Dodson, 2005), which is comparable to our result of 52.7%. To identify the incidence of the highest number of maxillary third molar extractions with respect to age, the patients of our study population aged (20-60) years were divided into four smaller age subsets: (20-30) years, (31-40) years, (41-50) years and (51-60) years. As inferred from Figure 1, the highest incidence of maxillary third molar extractions was seen in the age group of (31-40) years with 30.6% of the total extractions, followed by the age groups of both (20-30) years and (41-50) years with 26.9% each and lastly by the age group of (51-60) years with 15.6% of the total extractions. This data suggests that maxillary third molar extractions are commonly undergone between the age of 31 years and 40 years.

Figure 3: Frequency of distribution of the samples according to Tooth Number
This is inconsistent with a study performed by Sayed et al. (2019) where they concluded that (20-29) years is the most common age for third molar extractions. This contrast could be an attribute to the difference in number of individuals in each group in both the studies. But in this same study, they have suggested that the incidence of tuberosity fracture as a complication was 1.2% (Sayed et al., 2019), which is in line with our inding of 1.6% for the same.

Figure 4: Frequency of distribution of samples requiring sutures placement
In another study by Kandasamy et al. (2009), they suggest that the incidence of fracture during third molar removal alone is 0.6% (Kandasamy et al., 2009), which is also in line with our results. The fracture of the maxillary tuberosity, an important retentive area for maxillary complete dentures  (Venkateshwar et al., 2011), can even result -on rare occasions -in torrential haemorrhage due to its close proximity with signi icant blood vessels and other life-threatening complications (Bertram et al., 2011).

Figure 5: Distribution of samples based on Complications involved
In our study population, 1.6% of the total extractions were sutured because the same 1.6% of the cases had maxillary tuberosity fractures as complications of exodontia. The remaining 98.4% were left unsutured because of the absence of complications. When comparing the incidence of extractions between the right (18) and left (28) maxillary third molars, 28 seemed to be more frequently extracted (52.1%) when compared to 18 (47.9%). Thus, our results pointed to a female predilection with a commonly affected age group of (31-40) years with 28 being more frequently extracted than 18 and maxillary tuberosity fractures (complications) caused the need for suturing following maxillary third molar extractions. (Marimuthu et al., 2018;Kumar and Rahman, 2017) Figure 1, Bar chart showing the frequency of extraction distribution among different age groups where the statistically signi icant incidence of maxillary third molar extractions is the highest in the age of (31-40) years and lowest in the age of (51-60) years across the scale of percentage study population in the 'y' axis and age in the 'x' axis. (Chi Square Test, p<0.05)     Table 1 showing the cross tabulation between suture placement and complications statistically signi icant with p=0.000 (Chi Square Test, p<0.05)

CONCLUSIONS
Within the limits of our study, there is a need for suturing only when complications such as maxillary tuberosity fractures are present, otherwise it is acceptable for it to even remain suture less, with better prognosis, in fact. This is assuming that the individual undergoing the exodontia is not systemically compromised or prone to secondary health problems. Since the study does pose with certain limitations such as geographical barriers that lower the study's generalizability, further research must be done while actively trying to nullify said limitations.