Efficacy of Cyanoacrylate and Black Braided Silk for The Closure of Incision After Surgical Removal of Impacted Third Molars: A Systematic Review

Introduction: Wound closure is a part of any surgical procedure and the objective of laceration repair or incision closure is to approximate the edges of a wound so that natural healing process takes place. Over the years new biomaterials have been used as an alternate to conventional suture materials. Cyanoacrylate bio adhesives are one among them. They carry the advantage of rapid application, patient comfort, resistance to infection, hemostatic properties, and no suture removal anxiety. Hence this study was undertaken to study the effect of long chain cyanoacrylate as an adhesive for intraoral wound closure and also to explore its hemostatic and antibacterial effects.The aim of this study is to compare the efficacy of cyanoacrylate and black braided silk for the closure of surgical incision after removal of impacted third molars. Search Strategy: Databases searched: PubMed CENTRAL, Google Scholar, Cochrane, Bibliographies of Clinical Studies and Reviews. Hand search done from 1988 till October 2016. Selection Criteria: Clinical trials evaluating the severity of pain and hemostasis in the closure of incisions after surgically removed third molars. Results: The reviews found some clinical evidence that, there is significant difference between sutures and cyanoacrylate on postoperative pain following mandibular third molar surgery. There is also significant difference between sutures and cyanoacrylate on haemostasis following mandibular third molar surgery. Conclusion: The clinical evidence in this review is adequate to state that, there is a difference in postoperative pain and haemostasis following mandibular third molar surgery between black braided silk and cyanoacrylate.


Introduction
The removal of mandibular third molar is a common procedure in a dental clinic. After removal of an impacted third molar the conventional method of suturing the surgical wound is by using black braided silk and leaving the wound to heal by primary intention. Suturing in the most posterior area of the oral cavity is not easy, it takes time and good suturing skills. Besides the difficulty faced during operative procedure, the patient has to come for a second visit after seven days for suture removal. Moreover, incompatibility with the tissues may cause foreign body reactions and fistula formation. Over -tight sutures may lead to necrosis and ischemia. Black braided silk has an effect known as 'wicking' which makes the operated site to retain bacteria which is followed by secondary infection, because the knots become a favorable place for bacterial colonies. To overcome these difficulties more effective method of surgical wound closure has been found with better efficiency and fewer complications.
Tissue adhesives as adopted the idea of suture less wound closure. Plastic adhesives were discovered in 1949 and 10 years later COOVER et al. reported their use in surgical procedures. Cyanoacrylate glue is the general term used for quick super bonding glues used as two separate liquids, one for pouring into the mould and other used as a hardener.

Aim
Aim of this systematic review is to compare the efficacy of cyanoacrylate and black braided silk for the closure of incision after surgical removal of impacted third molars.

Structured Question
Does cyanoacrylate has better efficacy than black braided silk in the closure of incision after surgical removal of impacted third molars?

Materials and Methods
Sources used for identification of studies included or considered for this review, detailed search strategies were carried out on the following databases. Types of Studies: Randomized controlled trial or clinical trials evaluating and comparing the effectiveness of cyanoacrylate and black braided silk for the closure of incision after surgical removal of impacted third molars.

Types of Participants:
All participants undergoing third molar surgery.

Types of Outcome Measures
To evaluate severity of pain and hemostasis of cyanoacrylate and black braided silk for the closure of incision after surgical removal of impacted third molars.

Description Of Studies:
The search identified 1 article. Full articles were obtained. 3 hand searched article fulfilled the inclusion criteria. Therefore, a total of 4 articles fulfilled all criteria for inclusion.

Quality Assessment
The quality assessment of included trials was undertaken independently as a part of data extraction process. Four main quality criteria were examined.

Risk of Bias In Included Studies:
The assessments for the four main methodological quality items are shown in table. The study was assessed by to have a "high risk" of bias if it did not record a "yes" in 3 or more of the 4 main categories , "moderate" if 2 out of 4 categories did not record a "yes" and "low" if randomization , assessor blinding and completeness of follow up were considered adequate.

Discussion
Interpretation of Results: According to Sneha Sethiya et al. 1 , the severity of pain was significantly (p < 0.05) less in  Day 1 -There was significant difference in pain and hemostasis between the two groups. Day 2 -There was significant difference in pain but there was no significant difference in hemostasis between the two groups. Day 3 -There was significant difference in pain but there was no significant difference in hemostasis between the two groups. Day 4 -There was no significant difference in pain between the two groups. Day 5 -There was no significant difference in pain between the two groups. There was no significant difference in severity of pain in study group and control group. There was less significant difference in the bleeding in study group and control group on the 1 st and 2 nd postoperative days. There was no significant difference between the two methods on the third day

Cont. Table
the study group as compared to the control group on the1st, 2nd, and7th day postoperatively. Mann-Whitney U test was used to compare pain scores in both the groups. First cross-tabulation test was used to compare postoperative bleeding in both the groups and statistical analysis showed that there was significant difference in bleeding in the study group when comparison was done between the two groups on the1st postoperative day (p < 0.05).
According to Mehdi Ghoreishian et al. 2 , 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 > 0.05). 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 < 0.05); however, the bleeding index showed no significant difference (P > 0.05) between the 2 methods on the third day.
According to M. Gogulanathan et al. 3 , compared to the control group, the study group showed a statistically significant reduction in the durations for achieving local haemostasis. The mean time for achieving haemostasis in the study group was 200 times faster than that in the control group (1.2 s vs. 251.9 s). The postoperative pain score assessed on the first postoperative day was also significantly lower for the study group patients (2.0) as compared with the control group (3.5).
According to Ajit D. Joshi et al. 4 , there was significant difference in the severity of pain between the two methods on the right and left sides of the mandible at all times recorded (P < 0.05). The analysis showed that the severity of pain in closure with suture was more in first 3 days and later on it became same but marked elevation in pain have been noted on the second day. 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 < 0.05); however, the bleeding index showed no significant difference (P < 0.05) between the two methods on the third day. Patients were unable to make any significant remarks over the bleeding on 3rd postoperative day.

Defending The Result:
All the four studies discussed, compare the closure of surgical incisions after surgical removal of impacted third molars with silk sutures and cyanoacrylate. The two parameters assessed were pain and hemostasis. In the first and third study, the severity of pain and the bleeding was less in cyanoacrylate group as compared to control group. In the second study, there was no significant difference in severity of pain in both the groups. There was less significant difference in the bleeding in study group and control group on the 1 st and 2 nd postoperative days. In the fourth study, there was significant difference in severity of pain in both the groups. The postoperative bleeding was less significant in the control group as compared to study group on the 1 st and 2 nd days.

Quality of Evidence:
All studies included in the review were randomized controlled studies. All the four studies included in this review had a level of evidence 2. Risk of bias in one study showed a low risk of bias. Hence the interpretation obtained from these studies are reliable.

Summary
Aim of this systematic review is to compare the efficacy of cyanoacrylate and black braided silk for the closure of incision after surgical removal of impacted third molars. Randomized controlled trial or clinical trials evaluating and comparing the effectiveness cyanoacrylate and black braided silk for the closure of incision after surgical removal of impacted third molars.
Trials were selected if they met the following criteria. Randomized controlled clinical trials comparing silk sutures and cyanoacrylate for surgical closure in patients undergoing lower third molar surgery. The studies for inclusion in this review represents comparison of silk sutures and cyanoacrylate in reducing postoperative pain and bleeding after third molar surgery.
The databases PUBMED CENTRAL and MEDLINE were searched for the related topic till November 2016. The search identified 1 publication. Hand search was done and 3 articles were obtained. Full articles were obtained for 4 studies.
Therefore, a total of 4 publications fulfilled all criteria for inclusion.

Conclusion
From this systematic review it can be concluded that, cyanoacrylate is a better alternative for intraoral minor surgical procedures as tissue glue, was found to be haemostatic in nature, was helpful in reduction of pain and patients need not visit again for suture removal. Even this procedure was comfortable for the surgeon.