Int. J. Oral Maxillofac. Surg.

2008; 37: 341344

doi:10.1016/j.ijom.2007.11.016, available online at http://www.sciencedirect.com

Clinical Paper
Oral Surgery

A comparative study of the

effect of using a rubber drain on
postoperative discomfort
following lower third molar
surgery

Felix Nzube Chukwuneke1, Chima

Oji1, Dauda Birch Saheeb2
1
Department of Oral and Maxillofacial
Surgery, University of Nigeria, Teaching
Hospital, Enugu, Nigeria; 2Department of Oral
and Maxillofacial Surgery, University of Benin
Teaching Hospital, Benin-City, Nigeria

Felix NzubeChukwuneke, ChimaOji, Dauda BirchSaheeb: A comparative study of the

effect of using a rubber drain on postoperative discomfort following lower third molar
surgery. Int. J. Oral Maxillofac. Surg. 2008; 37: 341344. # 2007 International
Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights
reserved.
Abstract. The aim of this prospective randomized study was to evaluate the effect of
using a rubber drain on postoperative pain, swelling and trismus after lower third
molar surgery. Of 100 patients with impacted lower third molars referred for
surgical extraction, there were 40 males and 60 females, aged 1840 years
(mean = 26  6.2SD). The patients were randomly divided into two equal groups.
In the experimental group, a Penrose rubber drain was inserted into the extraction
socket near the buccal fold after surgery and left for 72 h. The control group was
selected using the same criteria and treated under the same surgical protocol as the
experimental group, but without use of a rubber drain. Pain, swelling and trismus
were evaluated at 24 h, 72 h and 5 days postoperatively in both groups. The results
of the study indicate that the use of a rubber drain reduces postoperative discomfort
in the form of swelling and trismus after lower third molar surgery, but seems to
have no effect on pain.

The removal of lower third molars is one

of the most frequently performed procedures in oral and maxillofacial surgery13,
and accounts for about 150400 million
dollars per year in the USA24 and a total of
approximately 50 million pounds in the
UK.19 Consequently, a vast amount of
resources, human and material, are
expended on third molar-related condi0901-5027/040341 + 04 $30.00/0

tions, second only to cardiac surgery in

private sector expenditure for 1993/94 in
the UK.5 Apart from the economic implications, third molar surgery gives rise to
significant morbidity, in the form of pain,
trismus and swelling, that may be severe
enough to interfere with normal activities.14 Reducing or minimizing these
postoperative sequelae after third molar

Keywords: third molar surgery; Discomfort;

Rubber drains.
Accepted for publication 21 November 2007
Available online 12 February 2008

surgery seems a laudable goal, particularly

if clinical healing is not compromised.
Several reports have focused on recovery
patterns following lower third molar surgery.16,23 Studies reviewed have not
pointed to the effectiveness of the routine
use of any systemic or local agent in
preventing or reducing postoperative
sequelae without other undesirable

# 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

342

Chukwuneke et al.

effects.18,23 An ideal agent for use after

lower third molar surgery should alleviate
pain, reduce swelling and trismus to a
minimum, promote healing, and have no
unwanted effects. As such an agent does
not exist, oral surgeons have devised several methods to minimize postoperative
sequelae to a tolerable level.2,6,10,15,18
The use of a drain in association with
the suture procedure is one such
method.1,2,6,15 Surgeons across the world
have used various types of drain after the
surgical removal of impacted mandibular
third molars with varying degrees of success.2,6,15 In Nigeria it is not the custom of
dental surgeons to use a rubber drain after
lower third molar surgery. The aim of this
study was to evaluate pain, swelling and
trismus variables after the surgical
removal of impacted lower third molars
with and without the use of a Penrose
rubber drain.
Patients and methods

A prospective randomized, single-blind

experimental study was undertaken to
determine the effect of using a Penrose
rubber drain on postoperative variables,
such as pain, swelling and trismus, which
occur after third molar surgery. One hundred patients with impacted lower third
molars referred for surgical extraction
participated. They were male and female
patients willing to undergo the following
visits: screening, surgical appointments,
and three follow-up research-related
appointments at 24 h, 72 h and 5 days.
All the patients were free from pain or
any other inflammatory symptoms, like
swelling, hyperemia and decreased mouth
opening due to temporomandibular joint
problems, at the time of surgery. The
patients were between the age of 18 and
40 years, with mesioangular, horizontal,
vertical and distoangular impaction of the
lower third molars. None were on medication that could interfere with the healing
process after surgery and only non-smokers were included in the study. None of
the patients had any systemic disease at
the time of surgery. Pregnant and lactating
females were excluded.
Ethical clearance was obtained from the
ethics committee of the University of
Nigeria Teaching Hospital, Enugu. All
the patients were informed of the risks
and benefits of the operation after which
they signed the operation consent form.

Local anesthesia was obtained using 2%

lignocaine hydrochloride with 1: 80,000
adrenaline, administered with a 3.5-cmlong 27 gauge hypodermic needle. A fullthickness three-sided flap was incised on
the buccal aspect of the impacted third
molar and reflected with periosteal elevator to expose the cortical bone. A round
bur in a straight hand piece was used in
conjunction with constant irrigation with
physiologic saline to uncover the impacted
tooth. The tooth was then removed with a
hospital pattern elevator. The suturing
procedure was accomplished using 4.0 silk
sutures only in the control group. In the
experimental group, after suturing, a Penrose rubber drain was inserted into the
socket near the buccal fold and left there
for 72 h, with the first review at 24 h
(Fig. 1). As prophylaxis, 2g amoxicillin
was administered 1 h before the surgical
procedure to each patient.6 All patients
were given postoperative instructions,
placed on a soft diet for the first 24 h,
and prescribed ibuprofen 400 mg to be
taken every 12 h for 4 days.

Evaluation procedure

Pain was evaluated during the preoperative and postoperative periods using a
visual analogue scale of 10 units in combination with a graphic rating scale.
Patients who had pain before surgery were
disqualified from participating. Statistical
analysis was performed using the Mann
Whitney U-test. Trismus was evaluated by
measuring the distance between the
mesial-incisal edges of the upper and
lower right central incisors at maximum
mouth opening in centimeters, as
described by USTUN et al.25, with dental
calipers before the surgical procedure, and

Surgical protocol

The surgical procedure was the same in all

cases and performed by the same surgeon.

Fig. 1. A patient with the Penrose rubber

drain in situ (arrow).

evaluated at 24 h, 72 h and 5 days postoperatively.

Evaluation of facial swelling was performed using a horizontal and vertical
guide with a tape on four reference points:
tragus, outer corner of the mouth, outer
canthus of the eye and angle of the mandible (Fig. 2). The horizontal measure corresponds to the distance between the outer
corner of the mouth and the tragus. The
vertical measure corresponds to the distance between the outer canthus of the eye
and the angle of the mandible (measurement of the craniometric point as
described by SOUZA and CONSONE21). The
arithmetic means of the two measurements
determine the facial measure. The percentage of facial swelling was obtained from
the difference between measurements
made in the preoperative and postoperative periods, dividing the result by the
value obtained in the preoperative period,
and multiplying it by 100, as described by
CERQUEIRA et al.6

Postoperative value
 Preoperative value
 100
Preoperative value
% of facial swelling
Evaluation of postoperative swelling was
also carried out at 24 h, 72 h and 5 days.
Statistical analysis was performed using
the Students t-test to assess the critical
value of t distribution. The level of significance was set at 0.05 where p < 0.05 is
considered significant and p > 0.05 nonsignificant.

Fig. 2. Tape-measuring method for evaluation of facial swelling. (ab) Distance between
the outer canthus of the eye and angle of the
mandible. (cd) Distance between the tragus
and outer corner of the mouth.

343

A comparative study of the effect of using a rubber drain on postoperative discomfort following lower third molar surgery
Table 1. Comparison of pain scores on visual analog scale between control and experimental
groups
Postoperative evaluation
24 h
72 h
5 days

Control (n = 50)

Experimental (n = 50)

6.5  0.95
2.5  0.91
2.0  1.1

6.5  0.78
3.5  0.82
1.5  0.91

n.s.
<0.05
<0.05

Table 2. Test of significance for swelling and mouth opening between the two groups at 24 h
Variable
Mean % of swelling
Mean mouth opening

Control
(n = 50)
12.7
1.39

Results

There was no significant difference

between the control group and the experimental group 24 h postoperatively
(Table 1) in regard to pain. At 72 h, the
mean pain score in the control group was
lower than that in the experimental group,
and this was statistically significant
(p < 0.05). At 5-day review the difference
between groups was statistically significant (p < 0.05) in favor of the experimental group.
At 24 h postoperatively, mean facial
swelling was significantly increased in
the control group (13%) almost doubling
that of the experimental group (7%). For
the rest of the evaluation period facial
swelling was higher in the control group
(Table 2). Evaluation at 72 h and 5 days
showed a gradual reduction in mean percentage of facial swelling in the control
group, but there were still significant differences between the control and experimental groups in favor of the experimental
group (Tables 3 and 4).
Trismus was determined as the degree
of mouth opening at 24 h postoperatively
in both groups (control 30% and experimental 40% of preoperative values)
(Table 5). At 72 h, there was an 11%
increase in the degree of mouth opening
in the control group compared to 15% in
the experimental group. At 5 days, both
groups showed an appreciable increase in
the degree of mouth opening compared to
preoperative values: 75% for patients in
the control group and 84% for patients in
the experimental group. Tests of significance performed between the two groups
showed that there were significant differences at 24 h, 72 h and 5 days in favor of
the experimental group (Tables 24).
Discussion

There has been much research on

impacted mandibular third molars in

Experimental
(n = 50)
7.3
1.78

5.8
11.7

<0.05
<0.05

developed countries, where several millions of dollars are spent annually on their
management.5,19,24 Morbidity following
lower third molar surgery still remains a
great concern to many clinicians.3,16,20
Surgeons have used primary and secondary closure of the surgical wound after
removal of impacted mandibular third
molars to minimize postoperative pain,
swelling and trismus. While some
authors4,22 are of the opinion that postoperative progress does not differ between
the two types of closure technique,
others12 observed that in cases of equal
intraoperative difficulty, open healing of
the surgical wound after third molar
removal produces less postoperative swelling and pain than occurs when the socket
is hermetically sutured. In this study, a
Penrose rubber drain was employed to
evaluate its effectiveness in reducing or
minimizing these postoperative variables.
FLYNN et al.7 reported that many clinicians
have been using a rubber drain in oral

surgery with varying degree of success

for evacuation of pooled blood and elimination of dead space in wounds.
Others6,15 have used tube drains for minimizing discomfort after third molar surgery with good results.
In 1995, AYAD et al.2 reported a statistically significant decrease in swelling,
trismus and pain in patients after use of
a Penrose rubber drain. The present study
also showed a reduction in swelling and
trismus. At 24 h of postoperative evaluation there was no significant difference in
pain between the two groups. At 72 h, pain
was experienced as significantly greater in
the control group but at 5 days the reverse
was true. These alternating changes in
significant difference between the control
and experimental groups could be due to
the presence of the Penrose rubber drain
irritating some of the patients in the
experimental group, which they might
have interpreted as pain. Not surprisingly,
at 5 days when the Penrose rubber drain
was no longer in situ the reverse was the
case, as pain became significant in the
control group. There is no standard instrument of measurement for objective comparative analysis of pain perception in
patients,17 pain being a subjective phenomenon.9 The results of this study show
that pain was at high intensity at 24 h in
both groups and gradually diminished in 5
days. This observation is in line with the
findings of other authors.6,11,15,20,19,25
Swelling was determined as devised by
SOUZA and CONSONE21 using the craniometrical points in soft tissue and a tape. This
method is in turn a modification of the
tape-measuring method of GABKA and

Table 3. Test of significance for swelling and mouth opening between the two groups in 72 h
Variable
Mean % of facial swelling
Mean mouth opening

Control
(n = 50)

Experimental
(n = 50)

4.5
1.87

3.7
2.5

2.2
9.1

<0.05
<0.05

Table 4. Test of significance for swelling and mouth opening between the two groups at 5 days
Variable
Mean % of facial swelling
Mean mouth opening

Control
(n = 50)

Experimental
(n = 50)

2.97
3.45

1.02
3.82

7.9
5.6

<0.05
<0.05

Table 5. Comparison between preoperative and postoperative mean mouth openings

Postoperative MMO (cm)
Group

Preoperative
MMO (cm)

Control (n = 50)
Experimental (n = 50)

4.58  0.2
4.57  0.2

24 h

72 h

5 days

1.39  0.13
1.78  0.19

1.87  0.19
2.5  0.45

3.45  0.33
3.82  0.33

Values are means  SD. MMO = mean mouth opening.

344

Chukwuneke et al.

MATSUMURA.8 The measurements obtained

were recorded in centimeters and converted to relative values. Obviously, this
method is not as accurate as computerized
tomography scanning or magnetic resonance imaging for making precise measurements of facial soft-tissue volume, but
it is a non-invasive, simple, cost-effective
and time-saving method, which provides
numerical data for determination of softtissue contour changes.25 Maximum facial
swelling is expected within 48 h of the
surgical procedure.6,21,25 This is in line
with the present findings: there was a
gradual decrease at 72 h and 5 days.
The trismus variable was greater at 24 h
in both groups, but there was a significant
difference at 24 h, 72 h and 5 days. This
shows that patients in whom the Penrose
drain was used experienced better mouth
opening postoperatively. The overall
result revealed that there is a significant
benefit to using a Penrose rubber drain in
minimizing swelling and trismus after the
surgical removal of mandibular impacted
third molars.
This study has demonstrated a simple
and drug-free method of minimizing the
postoperative discomfort that follows
lower third molar surgery. Oral surgeons
carrying out such procedures should consider the use of a Penrose rubber drain.

5.

6.

7.

8.

9.
10.

11.

12.

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Address:
Dr Felix Nzube Chukwuneke
Oral and Maxillofacial Unit
Faculty of Dentistry
UNTH
Enugu.
E-mail: ichiefn2002@yahoo.com