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Open Journal of Stomatology, 2011, 1, 103-108
doi:10.4236/ojst.2011.13016 Published Online September 2011 (http://www.SciRP.org/journal/OJST/ OJST
).
Published Online September 2011 in SciRes. http://www.scirp.org/journal/OJST
Comparison of an alveolar expansion technique and buccal
guttering technique in the extraction of mandibular third
molar. A pilot study
Babatunde O. Akinbami, Lucky I. Ofomala
University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria.
Email: [email protected]; [email protected]
Received 30 May 2011; revised 4 July 2011; accepted 2 July 2011.
ABSTRACT
Background: The over-ambitious use of surgica l drills
for almost every case of third molar impaction is on
the increase in most established oral surgery centers.
The purpose of this study was to assess and compare
the severity of post operative symptoms of swelling
and pain that accompany the use of surgical drill in
the buccal guttering technique and the non applica-
tion of drill in an alveolar expansion technique.
Methods: Consecutive patients with bilateral im-
pacted lower third molars not associated with peri-
coronitis were included in the study, a total of 10 pa-
tients were included in the study. Extraction of both
impacted third molars was done consecutively on the
same day under local anaesthesia. Post operative
morbidities that were assessed clinically are swelling
and pain. Results: A total of 10 patients, 70% were
females and males were 30%. Age range was 27 - 35
yrs. Out of the eight patients that had the two differ-
ent techniques, 7 preferred the use of the alveolar
expansion technique in which drill was not used.
There were statistically significant differences in
swellings between these two techniques, (p < 0.01) but
no statistically significant differences in pain (p >
0.01). Conclusions: To avoid excessive swelling and
pain from over-ambitious cutting of soft tissues and
drilling of bone, alveolar expansion technique should
be considered first in patients with less dense bone.
Keywords: Alveolar Expansion Technique; Mandibular;
Third Molar; Extraction
1. INTRODUCTION
Extraction of any upright tooth can be routinely done
with the use of tooth extraction forceps especially when
the crown is intact. In cases of insufficient crown sub-
stance, crown/root fracture, and impaction, appropriate
elevators may have to be applied with or without the
removal of surrounding alveolar bone [1]. Bone around
impacted third molar is usually dense and further rein-
forced by the external oblique ridge. This requires the
use of cutting drills in buccal guttering technique or os-
teotomies in lingual split technique to remove bone
around the impacted, in other to allow manipulation of
the tooth out of the socket [2].
These techniques may occasionally not suffice with-
out tooth division technique using very sharp cutting
drills [3]. Drilling or cutting of the surrounding bone or
tooth is made possible by exposure through incision and
reflection of the overlying mucosa. Despite the fact that
these bone removing techniques creates space for the
tooth to be removed, the vibration and friction caused by
the rotating drills and the hits/taps of the osteotomies
and mallet are most times very inconvenient and un-
bearable for many patients treated under local anaesthe-
sia. In addition, the attending post-operative swelling,
trismus and pain as well as possible injuries to the con-
tiguous nerves affect the activities of the patients sig-
nificantly.
The use of graded sizes of Coupé land elevators alone
to create space between the tooth and bone, to remove
some bone around the tooth with carefully guided pres-
sure and subsequent elevation of the impacted tooth has
been of great benefit to some patients by minimizing the
post-operative morbidities. The aim of this study was to
compare the degree of post-operative morbidity in the
alveolar expansion technique and buccal guttering tech-
nique of the third molar extraction.
2. METHODS AND PATIENTS
The study was a prospective, cross over and comparative
analysis of the severity of the post-operative morbidities
of two techniques of extraction of mandibular third mo-
lar. These are the buccal guttering technique and an al-
B. O. Akinbami et al. / Open Journal of Stomatology 1 (2011) 103-108
104
veolar expansion technique. The study was conducted in
the department of Oral and Maxillofacial Surgery, Uni-
versity of Port Harcourt Teaching Hospital, Port Har-
court, Nigeria. Ethical clearance was obtained from the
hospital’s ethics and research committee and patients
gave their informed consent permitting the carrying out
of the procedures and participation in the conduction of
the research. Consecutive patients with bilateral im-
pacted lower third molar not associated with pericoroni-
tis were included and patients with local pathologies
were excluded.
A total of 10 patients were included in the study. Five
patients were in the first group and they had guttering
technique done on the right and alveolar expa nsion tech-
nique on the left side. Three patients were in the second
group and they had alveolar expansion technique on the
right side and buccal guttering technique on the left side.
The last 2 cases served as control to compare similar
technique in a patient. One control had buccal guttering
technique on both sides and the second had alveolar ex-
pansion technique on both sides.
Periapical x-rays were taken to assess the root con-
figuration, proximity to the inferior alveolar neurovas-
cular bundle and impaction ag ainst the second molar. All
the patients had similar type, class and depth of impac-
tion on either side according to the Pederson’s classifica-
tion. Extraction of both impacted third molars was done
consecutively on the same day under local anaesthesia
(2% lidocaine 1.8mls; 1:80,000 aldrenaline). Post opera-
tive morbidities that were assessed clinically are swell-
ing and pain. Subjective assessments also entailed asking
for the opinion of the patients on their preferred choice
of technique.
Alveolar Expansion Technique Procedure
With the partly exposed tooth, a 1cm long incision was
made on the overlying gum distal or mesial to crown.
Periosteal elevator was used to reflect soft tissue without
stripping of the gums from the buccal surface.
The smallest size of Coupé land chisel is applied with
moderate pressure, using the palmer pad of the distal
portion of the first finger to guid e the tip and prev ent the
elevator from slipping, the instrument was maneuvered
in between the tooth and the surrounding bone in other
to create space by chiseling out some chips of bone.
Some space is created for a larger Coupé land to go in to
further widen the socket, oozing blood helps to soften
bone around the tooth.
Manipulation continued carefully until enough space
is created to elevate the tooth, tooth can gradually be
elevated from the point of application which is usually
on the mesial side but elevation can also be done distally
or buccally. If much resistance is met while elevating,
then socket is not well expanded, and more space need
to be created. After successful elevation of the tooth into
a near erect position, it can be gently removed out of the
socket with extraction forceps.
Swelling was assessed on the patients by measuring
three distances with flexible calipers, the first distance
was from the region of the angle of the mandible to
commissure of the mouth (A), the second was from tra-
gus of the ear to commissure of the mouth (B), the third
distance extends from outer canthus to the region of the
angle of the mandible (C), all the distances assessed
horizontal (anterior-posterior) dimensions of the swell-
ings at the lower, middle and upper level respectively.
The measurements were taken just before the procedure,
24 hrs and 72 hrs and 1 week postoperative. Pain was
assessed by the patient at home at 3 hr, 6 hr, 12 hr, 24 hr
and 3 day and 1 week interval using the visual analogue
scale which ranges from 0 - 10 where 0 represents no
pain and 10 represents the most severe pain. Comparison
of pain and swelling in the two techniques was assessed
with Chi-square and p value less than 0.01 was consid-
ered significant.
3. RESULTS
Ten patients qualified for inclusion in the study out of
which 3 (30%) were males and 7 (70%) were females.
Age range was 27 - 35 yrs. All patients had similar type
of impacted mandibular third molar teeth bilaterally.
Three of the patients in the first group suffered from
mesio-angular impacted third molar teeth, 1 suffered
from vertically impacted third molar teeth, and 1 suf-
fered from horizontal impacted third molar teeth. In the
second group, one patient each suffered from me-
sio-angular, vertical and horizontal impacted third molar
teeth respectively. The first control suffered from hori-
zontal impacted and the second control suffered from
mesio-angular impacted third molar teeth. Of all the 10
patients, only the first control suffered from completely
buried impacted third molar teeth within alveolar bone
and also suffered from impacted third molar teeth buried
against the second molars. The morphology of the roots
in all the patients was favourable.
Out of the eight patients that had the two different
techniques done on either side, 7 preferred the use of the
alveolar expansion technique.
The average preoperative measurements were 9.8,
11.2 and 10.7 cm respectively for both sides of the face
in the first group of patients who had drill used on the
right si de. For the secon d grou p, th e av era ge v alu es w ere
9.3, 11 and 10.2 cm for both sides respectively who had
drill used on the left side, while the controls had 10.0,
11.0 and 10.5 cm for the case with drill on both sides
and 9.5, 10.5 and 10.0 cm for the case without drill on
both sides.
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opyright © 2011 SciRes. OJST
B. O. Akinbami et al. / Open Journal of Stomatology 1 (2011) 103-108
Copyright © 2011 SciRes.
105
OJST
The 24-hour average values for the first group were
10.7, 12.0 and 11.2 cm on the right side and 10.6, 11.7
and 11.0cm on the left side. For the second group, the
values were 9.7, 11.0 and 10.1 cm on the righ t and 10.2,
11.1 and 11.4 cm on the left. The two controls had
closely similar 24-hour values on both sides. The
72-hour value for each patient is shown in (Tables 1-3).
The 1-week average values for patients in first group
were 10.1, 11.5 and 10.9 cm on the right and 10.1, 11.2
and 10.8 cm on the left. The 1-week aver age values for
patients in second group were 9.5, 11.0 and 10.1cm on
the right and 9.8, 11.0 and 10.5 cm on the left. There
were statistically significant differences in swellings
between these two techniques, (p < 0.01).The 1-week
values fo r the c on tro ls ar e sh own in (Table 3).
The post operative pain rating of patients in the first
group is shown in (Table 4). The ratings were higher
on the right side in four of the patients but in all the
patients, there was decrease pain severity at every in-
terval. Pain ratings were higher on the left side in all
the patients in the second group and also there was de-
crease in pain severity at intervals (Table 5). There
were no statistically significant differences in pain be-
tween these two techniques, (p > 0.01).Pain severity
was slightly higher in the control that had drill used
compared to the other control. The values for the two
sides in both controls were almost similar (Table 6).
4. DISCUSSION
Many techniques have been used to remove impacted
third molar and, surgical techniques include buccal
guttering, lingual split, lateral trepanation, tooth divi-
sion and coronectomy [1-8]. Other techniques like
therapeutic agenesis of the tooth bud using electrocau-
tery, laser energy and use of sclerosing agents have
been tried in lower mammals and animals but no hu-
man clinical studies are available to attest the validity
of these later techniques [9]. Absi and sherpherd [10]
have compared the lingual split technique and buccal
guttering technique and they provided no evidence of
difference in either efficiency or outcome between the
two standard methods of removing lower third molars
[10]. Our study has evaluated an alveolar expansion
technique and we found that majority of patients except
Table 1. Post-operative swelling ratings in first group.
S/no. Gender Age SidePre-operative/cm Post-operative/cm
24 hrs 72 hrs 1 week
A B C A B C A B C A B C
1. M 26
Rt
Lt
9.5
9.5
11.0
11.0
10.0
10.0
12.0
11. 0
13.0
12.0
11. 0
11. 0
11. 5
11. 0
12.0
11. 0
10.0
10.0
10.5
10.0
11. 5
11. 0
10.5
10.0
2. F 30
Rt
Lt
10.0
10.0
12.0
12.0
11. 0
11. 0
11. 0
11. 5
12.5
12.0
11. 5
11. 0
11. 0
11. 0
12.5
12.0
11.0
11.0
10.5
10.5
12.5
11. 5
11. 0
11. 0
3. F 28
Rt
Lt
9.5
9.5
11.0
11.0
11. 0
11. 0
10.0
9.5
11. 5
11. 0
11. 0
11. 0
10.5
9.5
11. 5
11. 0
11.0
11.0
9.5
9.5
11. 0
11. 0
11. 0
11. 0
4. F 29
Rt
Lt
10.0
10.0
11.0
11.0
10.5
10.5
10.0
10.0
12.0
11. 5
10.5
10.5
10.0
10.0
11. 5
11. 2
10.5
10.5
10.0
10.0
11. 0
11. 0
10.5
10.5
5. F 35
Rt
Lt
10.0
10.0
11.0
11.0
11. 0
11. 0
10.5
11. 0
12.0
12.0
12.0
11. 5
10.0
10.0
11. 5
12.0
12.0
11.5
10.0
10.0
11. 5
11. 5
11. 5
11. 5
Rt-right, Lt-left, M-Male, F-Fe male.
Table 2. Post-operative swelling ratings in second group.
S/no. Gender Age SidePre-operative/cm Post-operative/cm
24 hrs 72 hrs 1 week
A B C A B C A B C A B C
1. F 28 Rt
Lt
8.5
8.5
10.5
10.5
10.0
10.0
8.6
9.2
10.5
10.7
10.2
11.2
8.6
9.0
10.5
10.7
10.2
10.8
8.5
9.0
10.5
10.6
10.2
10.5
2. F 27 Rt
Lt
10.0
10.0
11.0
11.0
9.5
9.5
10.0
11.0
11.0
11.2
9.5
12.0
10.0
10.5
11.0
11.1
9.5
11.0
10.0
10.5
11.0
11.0
9.5
10.0
3. M 29 Rt
Lt
9.5
9.5
11.5
11.5
11.0
11.0
10.5
10.5
11.5
11.5
10.5
11.0
10.5
10.5
11.5
11.5
10.5
11.0
10.0
10.0
11.5
11.5
10.5
11.0
B. O. Akinbami et al. / Open Journal of Stomatology 1 (2011) 103-108
106
Table 3. Post-operative swelling ratings in the controls.
S/no. Gender Age SidePre-operative/cm Post-operative/cm
24 hrs 72 hrs 1 week
A B C A B C A B C A B C
1. M Rt
Lt
10.0
10.0
11.0
11.0
10.5
10.5
10.5
10.6
12.0
12.1
11.4
11.5
10.5
10.7
12.1
12.0
11.6
11.5
10.2
10.3
11.2
11.4
10.6
10.6
A B C A B C A B C A B C
1.. F Rt
Lt
9.5
9.5
10.5
10.5
10.0
10.0
9.3
9.2
10.6
10.7
10.4
10.2
9.2
9.3
10.7
10.8
10.1
10.4
9.5
9.6
10.7
10.5
10.0
10.2
Table 4. Post-operative pain ratings in first group.
S/no. Side Post-operative pain Rating
3 hrs 6 hrs 12 hrs 24 hrs 48 hrs 72 hrs 1 wk
1. Rt
Lt 6
5 6
5 5
4 5
4 4
2 3
2 1
0
2. Rt
Lt 8
6 7
5 7
5 6
4 5
3 4
2 2
1
3. Rt
Lt 7
5 7
5 6
4 6
3 6
3 5
2 2
1
4. Rt
Lt 8
5 7
4 6
3 5
2 5
2 4
1 2
1
5. Rt
Lt 7
9 6
8 6
8 5
7 4
6 3
4 2
3
Table 5. Post-operative pain ratings in second group.
S/no. Side Post-operative pain Rating
3 hrs 6 hrs 12 hrs 24 hrs 48 hrs 72 hrs 1 wk
1. Rt
Lt
7
9
6
8
5
7
5
7
4
6
3
4
1
2
2. Rt
Lt
6
8
5
7
5
6
4
6
4
5
3
4
2
3
3. Rt
Lt
8
9
8
9
6
7
4
5
3
4
2
3
1
2
Table 6. Post-operative pain ratings in the controls.
S/no. Side Post-operative pain Rating
3 hrs 6 hrs 12 hrs 2 4 h rs 48 hrs 72 hrs 1 wk
1. Rt
Lt
7
7
7
7
6
6
3
4
3
3
2
3
2
3
3 hrs 6 hrs 12 hrs 2 4 h rs 48 hrs 72 hrs 1 wk
1. Rt
Lt
7
7
6
6
5
4
3
3
2
2
3
2
1
1
few with low pain threshold would like to avoid use of
drills when possible because of the vibrations and fric-
tion.
Friedman [1] debated on the issue of prophylactic and
theraupetic surgical extraction of lower third molar.
They documented the five myths associated with lower
third molars and from the point of view of public health
concluded that prophylactic is not justified. They also
C
opyright © 2011 SciRes. OJST
B. O. Akinbami et al. / Open Journal of Stomatology 1 (2011) 103-108 107
reported that complications like dry socket, secondary
infection and paraesthesia associated with lower third
molar extraction are more in the 25 - 34 years age group
rather than the 12 - 24 years and 35 - 83 years age group.
However, surgical extraction without drills for indicated
third molars could be achievable in some patients in any
of these age groups. The consideration of any technique
should not only be effectiveness and ease in removal of
the tooth but also the reduction in post-operative mor-
bidities like pain and swelling which were more in the
buccal guttering technique. Complications like dry
socket and fractures of the mandible are more in lingual
split technique and, occasionally in buccal guttering
technique especially in p atients with brittle bones when a
lot of bone is removed [1,5,6,10,1 1].
Garcia et al. [11] also reported that pain and trismus
were less with the use of only forceps, for extraction
than cases in which surgical extraction were done with
ostectomy, with or without coronal section and other
complex procedures. They found that trismus severity
after surgical extraction does not depend on difficulty of
surgery and pain, as revealed by reported analgesic use,
and likewise less severe after simple extractions [11].
Our study did not assess trismus because both sides were
done consecutively on same day and the differences in
the two techniques on trismus will not be easily appreci-
ated. Also in the study of Garcia et al, regardless of ex-
traction type, pain declines between days 1 and 5 after
surgery [11]. Findings in our study with respect to pain
and swelling reduction in the simpler proc edur e and with
periodic interval were similar to that of other reports
[12-15]. Spinal/supraspin al modulation which is pecu liar
and variable in different patients, as well as analgesic
control of pain altered the significance of difference in
pain severity in the two techniques. However, our find-
ings still reflect that sides with larger swellings still pro-
duce higher levels of pain. The swellings are inflamma-
tory responses to the incisions and reflections of mu-
coperiosteum as well as crushing injury to the lamella
and trabeculae bone surrounding the tooth. Despite the
fact that standard surgical precautions were followed in
both techniques in our study, it was found that swellings
were more in the buccal guttering technique due to ex-
tensive reflections and drillings of bone.
The alveolar expansion technique is however, better
applicable in younger patients with less dense bone, pa-
tients with soft tissue impacted third molar, vertically or
mesially impacted tooth with sufficient space for the
elevator to move the too th into, when there is no impac-
tion against the second molars and in cases of close
proximity of the neurovascular bundle with enough
clearance around the tooth. Absolute contraindications of
the use of this technique include high bone density, com-
pletely buried tooth/tooth with high Winter’s red line,
horizontal impaction associated with impaction against
the second molar, distal or vertical impaction with part
of the tooth buried under the ascending ramus, anteriorly
extended extern al obliqu e ridge and in patien ts with very
low pain thres hold.
5. CONCLUSIONS
To avoid excessive swelling and pain from over-
ambitious cutting of soft tissues and drilling of bone,
alveolar expansion technique should be considered first
in patients with less dense bone, close root/tooth related
neurovascular bundle, mesial or vertical with crown
level close to the occlusal level. Therefore, careful pa-
tient selection and effective blockage of the nerv es must
be the points of co nsideration to achieve success.
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