Tissue adhesive and suturing for closure of the surgical wound

after removal of impacted mandibular third molars:

A comparative study
Mehdi Ghoreishian, DDS, MSc,a Rasoul Gheisari, DMD,b and Maasoumeh Fayazi, DDS,c
Isfahan, Iran
ISFAHAN UNIVERSITY OF MEDICAL SCIENCES

Objective. The most common method of wound closure in oral surgery is suturing. The efficacy of cyanoacrylate in
postoperative pain and bleeding was evaluated and compared with suturing.
Materials and methods. Sixteen patients with similar bone impaction and inclination of mandibular third molars on
the right and left sides were studied in this controlled clinical trial. The third molar surgery was carried out in 2 stages,
4 weeks apart, under local anesthesia. After bone removal and tooth resection, the right flap was closed with 3-0 silk
sutures and the left flap with cyanoacrylate. A visual analogical scale was used to evaluate the severity of pain and
bleeding on postoperative days.
Results. The data analysis showed that postoperative bleeding with cyanoacrylate method was less significant than
with suturing on the first and second days after surgery (P .05). There was no significant difference in the severity of
pain between the 2 methods (P .05).
Conclusion. This study suggested that the efficacies of cyanoacrylate and suturing in wound closure were similar in
the severity of pain, but use of cyanoacrylate resulted in better hemostasis. (Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2009;108:e14-e16)

Removal of the third molars is the most common surgical procedure in dentistry.1 Most surgeons agree that
surgical time, trauma, and difficulty are important factors in postoperative complications.2,3 The postoperative period following surgical removal of the third
molars is frequently characterized by swelling, bleeding, and pain.4 The most common method of wound
closure in oral surgery is suturing. The difficulty with
suturing and need for suture removal arise as major
problems; therefore, research has focused on more effective wound closure methods with better efficiency
and fewer complications.
A suggested method is using cyanoacrylate. The
adhesive property of cyanoacrylate was described in
1959 and submitted to the Food and Drug Administration (FDA) in 1964.5 These agents are adhesive coma

Assistant Professor, Department of Oral and Maxillofacial Surgery,

Torabi Nnejad Dental Research Center, School of Dentistry, Alzahra
Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.
b
Resident of Oral and Maxillofacial Surgery, Department of Oral and
Maxillofacial Surgery, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.
c
Dentist, Department of Oral and Maxillofacial Surgery, Dental
school, Isfahan University of Medical Sciences, Isfahan, Iran.
Received for publication Nov 27, 2008; returned for revision Jan 26,
2009; accepted for publication Mar 3, 2009.
1079-2104/$ - see front matter
2009 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2009.03.001

e14

pounds characterized by their polymerization, in the

presence of water, into glue with high tensile and
adhesive strengths. They are characterized according to
the length of the carbon chain (for example: methyl-,
ethyl-, butyl-, and octyl-) conjugated to the cyanoacrylate component.5 These materials are not absorbable
and are sloughed from the surface of the skin and
mucosa 7 to 10 days after adhesive application. These
agents are approved for external application only and
are not to be used as internal tissue adhesive because of
the reactions, toxicity, and carcinogenicity.6,7 In many
studies, the efficacy of cyanoacrylate as a sclerosing
agent in childrens wound closure, craniofacial fixation,
and so forth, has been supported by reports.8-11 In the
maxillofacial field, it has been used for wound closure,
skin graft, face lifts, blepharoplasty, brow lifts, and
other cosmetic surgeries12-16; but there has been no
indication in the literature supporting the efficacy of
cyanoacrylate for wound closure after the removal of
mandibular impacted third molars.
This study compares silk with cyanoacrylate for
wound closure after the removal of mandibular impacted third molars, evaluating the incidence of postoperative sequellae of bleeding and pain.
MATERIALS AND METHODS
Sixteen patients (9 women and 7 men; age range 18
to 24 years) with similar bone impaction and inclination
of mandibular third molars on the right and left sides

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Ghoreishian et al. e15

Table I. Visual analog scale to evaluate pain: reference values given to patients
0
1
2
3
4
5

No Pain
Slight Pain
Mild Pain
Severe Pain
Very Severe Pain
Extremely Severe Pain

The patient feels well

If the patient is distracted he or she does not feel the pain
The patient feels the pain even if concentrating on some activity
The patient is very disturbed but nevertheless can continue with normal activities
The patient is forced to abandon normal activities
The patient must abandon every type of activity

were studied in this controlled clinical trial. Panoramic

radiographs were taken to assess the third molar situation. All patients needed ostectomy and odontotomy
bilaterally. All the cases had good general health (ASA
I) and good oral hygiene, were nonsmokers, and were
cooperative with the study and with postoperative follow-up. They had no contraindication to the drugs or
anesthetic in the surgical protocol. The surgical procedures were performed by one operator in the oral and
maxillofacial surgery department. Patients rinsed with
0.12% chlorhexidine for 1 minute, and were given no
preoperative drugs. Local anesthesia was applied by
blocking the inferior alveolar nerve together with vestibular infiltration with 2% lidocaine hydrochloride
with epinephrine 1:100,000. A full-thickness incision
was made to prepare an envelope flap. The flap was
reflected and ostectomy was performed with a rounded
bur and the tooth crown sectioned with a fissure bur
under abundant irrigation, then all parts of the tooth
removed. Once the extraction was completed, curettage
of the socket was performed along with irrigation with
20 mL of sterile saline solution. The flap was next
repositioned and closed with 3-0 silk in an interrupted
fashion on the right side of all patients. The sutures
were removed after 7 days. This procedure was done on
the left side 28 days later and the flap repositioned and
closed by using 2 thin layers of ethyl-cyanoacrylate
(epiglu; Meyer-Haake, Wehrheim, Germany).
All the patients received postoperative instructions
(ice packs for 6 hours after surgery, alternating 20
minutes of application with a 20-minute pause, soft diet
for the first 24 hours, and normal oral hygiene from the
day after surgery and mouthwash with 0.12% chlorhexidine twice daily). Patients were given antibiotics
(amoxicillin, 500 mg every 8 hours for 5 days) and
analgesic drugs (acetaminophen, 325 mg every 6 hours
for 3 days). They were also given a pain and bleeding
recording form to be completed during the following
days. The patients entered the degree of pain (for 5
days) and bleeding (for 3 days) on a daily basis on the
form, making reference to predefined values (visual
analogical scale [VAS]). The pain scale was 5 cm long,
subdivided into 5 equal parts, one end corresponding to
no pain, the other to extremely severe pain. Table I
shows the reference values given to patients for pain,
and the corresponding clinical situations. The patients

Table II. Visual analog scale to evaluate bleeding:

reference values given to patients
0

No Bleeding

Oozing

Accidental Low
Bleeding
Continues Low
Bleeding
Massive Bleeding

3
4

The patient does not detect any blood in

saliva
The patient detects a slight blood but it
is not very noticeable
The patient has low bleeding sometimes
The patient has low bleeding often
Continues high bleeding

Table III. Pain: statistical analysis of data (no significant differences were found)
Day

Method

Mean

SE

Maximum

Minimum

Glue
Suture
Glue
Suture
Glue
Suture
Glue
Suture
Glue
Suture

16
16
16
16
16
16
16
16
16
16

4.19
4.38
3.09
3.63
2.47
2.47
1.34
0.71
1.31
0.59

0.32
0.35
0.38
0.33
0.51
0.39
0.40
0.28
0.39
0.24

4.48
4.12
3.90
4.33
3.55
3.31
2.20
1.31
2.14
1.10

3.50
3.62
2.28
2.92
1.38
1.62
0.48
0.11
0.47
0.86

2
3
4
5

also indicated their subjective perception of bleeding on

the VAS in a similar fashion. Table II shows the reference values given to patients for bleeding, and the
corresponding clinical situations.
Statistical analysis of the information obtained was
performed, using SPSS software (version 11.5; SPSS
Inc., Chicago, IL, USA) and Wilcoxon test for the VAS
of bleeding. Despite VAS of pain on the ordinal scale,
the distribution of VAS of pain has behavioral quantitative data. Hence, we used the paired t test in statistical
analysis. The differences with a P .05 were found to
be statistically significant.
RESULTS
There was no significant difference in the severity of
pain between the 2 methods on the right and left sides
of the mandible at all times recorded (P .05). The
data analysis showed that postoperative bleeding with
the cyanoacrylate adhesive method was less significant
than with suturing on the first and second days after
surgery (P .05); however, the bleeding index showed

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Ghoreishian et al.

Table IV. Bleeding: statistical analysis of data

Day

Method

Median

Interquartile range

Glue
Suture
Glue
Suture
Glue
Suture

16
16
16
16
16
16

2.00*
3.00*
1.00*
1.50*
0.00
0.00

2.00
2.00
1.00
1.75
0.00
1.00

2
3

*Significant difference.

no significant difference (P .05) between the 2 methods on the third day (Tables III and IV).
DISCUSSION
The severity of pain and bleeding are indicators of a
patients comfort during the postoperative period after
third molar removal. Minimizing postoperative pain
and bleeding allows patients having undergone the surgical procedure for removal of the third molars to return
to normal work-related and social activities in a shorter
time. Cyanoacrylate can be used for mucosal closure.
This adhesive can eliminate the need for suture placement and suture removal. Pasqualini and Cocero4 found
the pain was less severe with secondary healing than
with primary healing after third molar surgery. They
used the VAS, which is considered to be an efficacious
tool to evaluate clinical parameters, such as pain. In
2006, Waite and Cherala17 demonstrated good results
and fewer complications after third molar surgery with
the sutureless method. These studies examined open
wound or small foramens with the suturing method
resulting in better drainage and reduced pain, although
in our study there are no significant differences between
the 2 methods. In 1993, Ellis18 showed, unlike the
present study, reduced pain after wound closure using
cyanoacrylate adhesive. Al-Belasy and Amer19 in 2003
described the hemostatic effect of cyanoacrylate glue
on warfarin-treated patients undergoing oral surgery, in
agreement with our results.
The data analysis showed that postoperative bleeding
with the cyanoacrylate method was less significant than
with suturing on the first and second days after surgery.
It may be the result of adhesive sloughed for drainage
from the surface of mucosa after 2 days due to some
foramens.
This study suggested that the efficacies of cyanoacrylate adhesive and suturing in wound closure were
similar. However, use of cyanoacrylate adhesive had
some advantages such as simplicity, higher speed, and
better hemostasis. Unfortunately, the small sample size,
possibility of complications other than bleeding and
pain, absence of an objective measurement technique,

and the cost of tissue adhesive were limitations of the

study.
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Reprint requests:
Rasoul Gheisari, DMD
Resident of Oral and Maxillofacial Surgery
Department of Oral and Maxillofacial Surgery
Alzahra Hospital
Isfahan University of Medical Sciences
Isfahan, Iran
r_gheisari@dnt.mui.ac.ir