Lingual split versus surgical bur technique in the extraction of

impacted mandibular third molars: a systematic review

Ben Steel, BDS MFDS RCSEd, Middlesbrough, UK
JAMES COOK UNIVERSITY HOSPITAL
The relative merits of different surgical techniques to extract impacted mandibular third molars have been debated
for many years. A simple classication is those using a bur and those using a chisel. This article seeks to identify any
differences in postoperative outcomes between the surgical bur and lingual split techniques. Using inclusion criteria allowing
randomized controlled trials only, 5 studies are identied of which 4 are used in the analysis. The following outcomes are
investigated: pain, swelling, trismus, bleeding, delayed healing/infection, and disturbance to lingual and inferior alveolar
nerve function. The limited analysis allowed by the number and size of the studies leads to tentative conclusions of no
difference between postoperative pain and swelling, and some evidence of less trismus for the lingual split technique. There
is some weak evidence of a similar incidence of neurological sequelae between the 2 techniques, but this is not a strong
conclusion owing to the small size of the included studies. There are inadequate data regarding bleeding and delayed
healing/infection for analysis. (Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:294-302)
Debate has taken place for many years on the relative
postoperative morbidities of different methods of surgical
extraction of impacted mandibular third molars. The num-
ber of techniques is numerous, each with its own varia-
tions, which when combined represent a rather heteroge-
neous area with many variables. The main surgical
methods, however, can be broadly categorized as using a
chisel or a bur. The standard method in the United King-
dom today is the surgical bur technique, although some
surgeons still use a chisel as a rst-line. The surgical bur
technique uses burs under irrigation to remove bone to
produce space for elevator application and tooth delivery,
via a buccal approach. The lingual split (or split bone)
technique, however, uses chisels and was rst described in
print by Ward in 1956.
1
The technique described com-
prises exposure of the buccal and lingual aspects of the
third molar. Chisel cuts vertically just distal to the second
molar and at 45 to this toward the distal end of the third
molar allow removal of this piece of bone and create a
mesiobuccal elevation point. Another split distal to the
third molar, followed by a twist to separate the distolin-
gual piece of bone, creates the space for tooth delivery. In
that described by Lewis in 1980,
2
the distolingual piece of
bone is left in situ. Unlike for the surgical bur technique,
raising of a lingual ap is always necessary, which may be
an important consideration given the intense debate
around any link between this and lingual nerve damage.
3
Much literature has been produced on the subject of
extraction of lower third molars but some of this is limited
in its helpfulness in comparing different techniques, as the
vast majority comprises uncontrolled studies and case
series. Comparison between such studies is difcult be-
cause of great disparities in surgical variables that are not
standardized or controlled. Therefore, determination of
the relative morbidities associated with different tech-
niques is difcult from such studies. Particularly, few
studies appear to look specically at the lingual split
technique, which has been criticized as leading to a higher
rate of lingual nerve sequelae and has fallen out of favor
over the decades. The preferred means of comparing 2
interventions or techniques is the randomized controlled
trial (RCT), which is the only study type eligible for
inclusion in this article.
The rationale of this systematic review was to gather
together all the available high-quality evidence so as to
make a comparison of the lingual split and the surgical
bur techniques, in terms of postoperative outcomes.
This does not seem to have been previously undertaken.
By limiting the review to consider only RCTs, the
greatest strength of conclusions may be reached. The
particular postoperative outcomes to be addressed by
this review are the following:
Pain
Swelling
Trismus
Bleeding
Delayed healing/infection
Disturbance of lingual nerve function
Disturbance of inferior alveolar nerve function
In addition, a comparison of the operating times for the
2 techniques was drawn.
Senior House Ofcer, Oral and Maxillofacial Surgery Department,
James Cook University Hospital, Middlesbrough, UK.
Received for publication Apr 1, 2011; returned for revision Jun 5,
2011; accepted for publication Jul 21, 2011.
2012 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
doi:10.1016/j.tripleo.2011.07.028
Vol. 114 No. 3 September 2012
294
METHODS AND SEARCH STRATEGY
An electronic search of the PubMed, Ovid MEDLINE,
and Cochrane CENTRAL online databases was con-
ducted from their respective dates of inception to No-
vember 2010. The search criteria initially comprised
the following: ((mandibular OR lower) AND (third
molar OR wisdom) AND lingual split. The low yield
led to the use of another search term omitting the
reference to lingual split: ((mandibular OR lower) AND
(third molar OR wisdom) AND (pain OR swelling OR
trismus OR infection OR bleeding OR lingual OR
inferior alveolar OR trigeminal OR labial OR lingual
OR nerve). The abstracts of yielded results were re-
viewed and the full text obtained of those with apparent
relevance. The references of identied papers were
cross-checked for unidentied articles and the individ-
ual databases of key subject journals were searched
using the same terms as above. These journals were the
Journal of Oral and Maxillofacial Surgery, Interna-
tional Journal of Oral and Maxillofacial Surgery, Jour-
nal of Oral Surgery, and the British Journal of Oral
and Maxillofacial Surgery. The searches were limited
to articles published in the English language. No at-
tempt was made to identify unpublished material or to
contact authors of published studies for further infor-
mation.
Only prospective randomized controlled clinical tri-
als (RCTs) were eligible for inclusion in this review.
The inclusion criteria mandated random allocation of
patients to groups to be treated with either the lingual
split or surgical bur techniques, with a minimum of 10
patients in each group and a minimum follow-up period
of 7 days. All included articles must have given clear
descriptions of the surgical techniques used and the
means and methods of data collection. Details regard-
ing postoperative pain must have been provided in
quantitative format, such as a visual analogue scale
(VAS) or other scoring system, or for split-mouth stud-
ies enabled determination of the most painful side.
Swelling and trismus must also have been provided in
quantitative format, either as a VAS or other subjective
system, or means of objective measurement. In split
mouth studies, identication of the most swollen side
must have been determinable, either subjectively or
otherwise. Infection and bleeding complication gures
must have been quoted with reference to objective
diagnostic criteria. Disturbance to lingual or inferior
alveolar nerve function data were accepted in both
subjective (patient-reported) or objective (subject to
clinical tests) format.
RESULTS
The initial search of the PubMed database with the rst
search term yielded 19 results. The use of the second
term yielded 1213 results. Searching of the other data-
bases and journal indexes did not produce any further
studies. Of the identied articles, 1105 were excluded
on review of the abstract as either irrelevant or clearly
not a randomized controlled trial meeting the other
criteria (the title was used if an abstract was not avail-
able). The remaining 106 were read in full text and 5
RCTs identied.
4-8
Cross-checking of the references of
all of the full-text articles did not yield any further
studies. Four articles involving a comparison between
the 2 groups in question but without randomization
were identied.
9-12
A comparison by Rood
9
of 384
lingual split with 406 surgical bur methods with respect
to neurological outcomes gave no details of allocation
of participants to treatment groups. Similarly, a com-
parison by Yates et al.
10
used groups of patients from
different institutions, again with no randomization. Un-
fortunately, the full text of one of the identied RCTs,
8
published in the Egyptian Dental Journal, proved un-
obtainable despite exploration of numerous avenues,
with even the Journals publisher unable to supply a
copy. All of the remaining 4 RCTs met criteria for
inclusion for one or more of the outcome variables and
details for each were recorded on a data capture sheet
(Table I). The publication dates for these RCTs ranged
from 1988 to 2007 and the total number of participants
ranged between 20 and 90. Across all 4 studies, 122
teeth were extracted using each of the 2 techniques.
Two papers originated from the United Kingdom
4,5
and
1 each from Turkey
6
and India.
7
All of the outcome
measures listed earlier, with the exception of bleeding,
were investigated by some or all of the included stud-
ies. The full results of the included studies are shown in
Table II.
The quality of the RCTs found was poor, a big
weakness being small numbers of participants (a max-
imum of 30 per group). Criteria used for assessment of
risk of bias were those published by the Cochrane
Collaboration
13
; the ndings being shown in Table III.
All of the RCTs stated that allocation of participants to
particular surgical methods (or in the split-mouth trials,
of the sides) was randomized but no further details were
given. Likewise, no details of any allocation conceal-
ment were given. In trials of this kind it is not possible
for surgeons, and depending on the method, assessors,
to be blinded as to the intervention; however, patients
may be soonly 2 of 4 articles mentioned this. None
mentioned any blinding of assessors and none gave any
details of patients lost to follow-up, or whether the
number of participants stated had been quoted to take
any such people into account. By virtue of being lim-
ited to either local or general anesthetic, all of the
studies potentially introduced bias, as the outcomes
following these methods of anesthesia may not neces-
OOOO REVIEW ARTICLE
Volume 114, Number 3 Steel 295
Table I. Details and methods of included rendomized controlled trials
Randomized
controlled
trial Patient details Surgical details Surgeon details Pain Swelling Trismus
Delayed
healing/infection
Disturbance of
lingual nerve function
Disturbance of
inferior alveolar nerve
function
Details of
surgical
time
given
Praveen
et al.
(2007)
7
90 patients -30
lingual split,
30 surgical
bur, and 30
simplied split
bone, reviewed
7 d postop,
questionnaire
lled out by
participants
All LA
Buccal triangular ap
and lingual
Howarths in all
cases. Simplied split
bone technique not
described
All procedures
completed by
same surgeon,
no details of
surgeon
experience with
these techniques
given
VAS, 4 point,
immediately
postop and
at 6, 24,
48 h and
7 d postop
VAS, 4 point, immediately
postop and at 6, 24, 48 h
and 7 d postop, and
indicate which side more
swollen
Not investigated Examined by an
independent
observer at
7 d postop
for
satisfactory
wound
healing
Presence or absence
of sensory
disturbance
recorded by patient
immediately
postop and at 6,
24, 48 h and 7 d
postop
Presence or absence
of sensory
disturbance
recorded by patient
immediately postop
and at 6, 24, 48 h
and 7 d postop
Yes
Mocan
et al.
(1996)
6
20 patients -10
lingual split,
10 surgical
bur, reviewed
on the 1st, 2nd
and 7th postop
days
All LA
A lingual Howarths
placed in all cases,
buccal triangular ap,
teeth not sectioned,
closed with silk
sutures, no antibiotics
used
No details given of
whether one or
multiple
surgeons
involved, or
their experience
with these
techniques
100-mm VAS
used at
noon daily
for 6 d
postop
Stereometric
photogrammetry used to
measure extraoral
swelling, measured on
the rst and second
postop day as compared
with immediately preop
Caliper
measurement
of interincisal
distance on
days 1, 2,
and 7
Not investigated Not investigated Not investigated Yes
Absi and
Shepherd
(1993)
5
Split-mouth
study, 52
patients with
bilateral
impacted lower
8s, reviewed
7 d postop,
questionnaire
lled out by
participants
All GA, both teeth
extracted at the same
time
Buccal triangular ap,
lingual Howarths
placed in all cases,
closed with 2 sutures
Same surgeon
carried out all
procedures.
Stated the
surgeon is
experienced
with no further
details
VAS, 4 point,
at 6, 24,
48 h, and
7 d postop
VAS, 3 point, at 6, 24,
48 h and 7 d postop, and
indicate which side more
swollen
Not investigated Examined by an
independent
observer at
7 d postop
for
satisfactory
wound
healing
Presence or absence
of sensory
disturbance
recorded by patient
at 6, 24, 48 h, and
7 d postop
Presence or absence
of sensory
disturbance
recorded by patient
at 6, 24, 48 h, and
7 d postop
Yes
Middlehurst
et al.
(1988)
4
Split mouth
study, 30
patients,
bilateral
impacted lower
8, reviewed 1
and 7 days
postop
All GA, both teeth
extracted at the same
time
L-shaped ap, lingual
Howarths placed in
all cases, 2 catgut
sutures in horizontal
part of incision only
Same surgeon
carried out all
procedures,
level of
experience with
these techniques
not described
Patient asked
which side
most
painful on
the 1st and
7th postop
days
Patient asked which side
the most swollen on the
1st and 7th postop days,
independent observer
recorded the presence
and location of any
swelling on those days
Not investigated Quality of
healing
assessed by
independent
observer on
the 1st and
7th postop
days no
further details
Presence of labial or
lingual sensory
impairment
assessed by
independent
observer on the 1st
and 7th postop
daysno further
details
presence of labial or
lingual sensory
impairment
assessed by
independent
observer on the 1st
and 7th postop
daysno further
details
No
GA, general anesthetic; LA, local anesthetic; postop, postoperative; preop, preoperative; VAS, visual analog scale.
O
R
A
L
A
N
D
M
A
X
I
L
L
O
F
A
C
I
A
L
S
U
R
G
E
R
Y
O
O
O
O
2
9
6
S
t
e
e
l
S
e
p
t
e
m
b
e
r
2
0
1
2
Table II. Results of randomized controlled trials by outcome measure
RCT Pain Swelling Trismus
Delayed
healing/infection
Disturbance of lingual nerve
function
Disturbance of inferior alveolar
nerve function Operating time
Praveen
et al.
(2007)
7
Mean data from 4-point
VAS (where 1 nil and 4
maximal pain)
immediately postop 1.0
for surgical bur and
lingual split methods. 6-h
data not presented. At
24 h 2.0 vs 2.5,
respectively (P value .0),
at 48 h 1.5 vs 1.9
(P value .02) and 7 d 1.0
vs 1.1 (P value .047), thus
giving higher pain scores
for the lingual split
technique at all intervals
from 24 h (statistically
signicant for all intervals
from 24 hours on)
Mean data from 4-point
VAS, according to the
results table, (where 1 nil
and 4 maximal pain)
immediately postop 0.0 for
surgical bur and lingual
split methods. 6-h data not
presented. At 24 h 1.9 vs
1.7, respectively (P value
.047), at 48 h 1.3 vs 1.2 (P
value .058), at 7 d 0.3 vs
0.2 (P value .1), thus
giving lower swelling
scores for the lingual split
technique at all intervals
from 24-h onwards
(statistically signicant for
all intervals from 24 hours
on)
Not investigated Examined by an
independent
observer at 7 d
postop for
satisfactory
wound healing.
Formal data not
presented but
stated that 2
patients in the
lingual split group
had delayed
healing probably
due to wound
infection.
Diagnostic criteria
for satisfactory
healing given but
not for infection
Presence or absence of disturbance
recorded by patient on
questionnaire via 4-point VAS
scale. Immediately postop 1.0
for both surgical bur and lingual
split methods. 6-h data not
presented. At 24 h 2.9 vs 2.6,
respectively (P value .004 -), at
48 h 3.0 vs 2.8 (P value .08) and
at 7 d 3.0 vs 2.9 (P value .36),
not statistically signicant
except at 24 h postop, ie, no
difference observed
Presence or absence of
disturbance recorded by
patient on questionnaire via
4-point VAS scale.
Immediately postop 1.0 for
both surgical bur and lingual
split methods. 6-h data not
presented. At 24 h 3.0 vs 2.9,
respectively (P value .36
statistically signicant), at
48 h 3.2 vs 3.0 (P value 1.0),
at 7 d 3.0 vs 3.0 (P value 1.0),
not statistically signicant
except at 24 h postop, ie, no
difference observed
Mean time for lingual
split 19.6 minutes.
Mean time for
surgical bur technique
18.53 minutes
Mocan
et al.
(1996)
6
Analysis of VAS data (on
1-100 mm scale where 1
is nil and 100 maximal
pain) by variance between
groups on days 1 through
6 and with Mann-Whitney
U test for data from days
1 and 2 suggest no
statistically signicant
difference (data in graph
form only); P .12
The results from the
stereometric
photogrammetry
demonstrated no
statistically signicant
difference between the 2
groups, increased swelling
for both shown on the rst
postop day with a further
increase to day 2 (no
further measurements),
P .88
Measured with calipers
on the 1st, 2nd, and
7th postop days
interincisally, found
to be signicantly
less (P .03) in the
lingual split group
especially on the 1st
postop day
It is stated that none
of the group
suffered from
delayed healing
without
qualication
It is stated that no one
experienced sensory impairment
of the inferior alveolar or lingual
nerves without qualication
It is stated that no one
experienced sensory
impairment of the inferior
alveolar or lingual nerves
without qualication
Mean time for the
lingual split 15.8 min
(range 11.4-22.0
minutes), mean time
for the surgical bur
method 11.1 minutes
(range 6.0-21.3
minutes)
Absi and
Shepherd
(1993)
5
Mean data from 4-point
VAS at 6 h postop 2.67
for lingual split vs 2.71
for surgical bur, at 24 h
2.25 vs 2.14, respectively,
at 48 h 1.85 vs 1.75, at
7 d 0.85 vs 0.90. None of
these differences
statistically signicant.
Peaked at 6 h postop for
both groups then fell
signicantly
Mean data from 3-point VAS
at 6 h postop 1.90 for
lingual split vs 1.87 for
surgical bur side, at 24 h
2.40 vs 2.29, respectively,
at 48 h 2.00 vs 2.02, at
7 d 0.60 vs 0.60. None of
these differences
statistically signicant.
Peaked at 24 h postop for
both groups then fell
signicantly
Not investigated 6 sockets failed to
heal satisfactorily
with reference to
given criteria (1
acute abscess and 5
dry sockets), with
3 in each group
(not specied
which had the
abscess), therefore
no signicant
difference observed
Recorded as present or absent by
the patient. At 6 h postop, 21%
of the lingual split and 23% of
the surgical bur sides recorded
this. At 24 h this was 17% vs
23%, respectively, at 48 h 10%
vs 15% and at 7 d 2% vs 8%.
At 7 d these percentages
represented 1 complaint of
disturbance on the lingual split
side and 4 on the surgical bur
side. These differences were not
statistically signicant.
Recorded as present or absent by
the patient. At 6 h post-op
12% of the lingual split and
17% of the surgical bur sides
recorded this. At 24 h this was
10% vs 13%, respectively, at
48 h 8% and 8% and at 7 d
2% vs 0%. At 7 d these
percentages represented a
complaint of disturbance on
one lingual split side only.
The differences were not
statistically signicant.
Mean time for the
lingual split 7.6 min
(range 4-15 minutes),
mean time for the
surgical bur method
8.3 min (range 4-15
min). The difference
not statistically
signicant.
O
O
O
O
R
E
V
I
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7
sarily be the same. One article was found to be poten-
tially biased by an uneven mix of impactions within
each group.
6
Of the 4 articles, 3 stated that all proce-
dures were carried out by the same surgeon, the other
not giving any details of the surgeons. Only one men-
tioned the level of experience of the surgeon with the
techniques, stating they were experienced without
further qualication. This is important information, as a
good and equal level of prociency in both techniques
is a prerequisite for valid results.
The results for each of the outcome measures ad-
dressed in this review are considered separately in the
following sections. Unfortunately, owing to the lack of
quantitative data from the included studies, and its
heterogeneity, quantitative analysis was only possible
for pain and swelling. No statistical analysis was pos-
sible for the other outcomes.
Pain
Of the 4 included studies, 3 presented data in the
form of a VAS, 2 as 4-point and 1 as a 100-mm scale,
and the fourth by stating which side was the most
painful (the magnitude of any difference was not in-
vestigated). The points in time of pain measurement
were broadly similar, between immediately and 7 days
postoperative. Individually, studies by Absi and Shep-
herd
5
and Mocan et al.
6
reported no statistically signif-
icant difference between the 2 groups; however,
Praveen et al.
7
did observe such a difference, with more
pain in the lingual split group. Mean VAS scores (4-
point scale) in this study for the surgical bur and lingual
split techniques, respectively, at 24 hours postoperative
were 2.0 versus 2.5 (P .0), at 48 hours 1.5 versus 1.9
(P .02), and at 7 days 1.0 versus 1.1 (P .047).
Middlehurst et al.
4
, in their split mouth study of 30
participants, reported the pain to be worst on the lingual
split side in 9 and the surgical bur side in 18 patients. It
was equal on both sides in 3 patients.
It was not possible to combine the results for all 4
studies in a statistical analysis. Middlehurst et al.
4
did
not provide data in a form suitable for combination with
the VAS gures of the other 3. Mocan et al.,
6
although
using a VAS to measure pain, did not include enough
statistical details for incorporation into a larger analy-
sis. Therefore, only combination of the results of
Praveen et al.
7
and Absi and Shepherd
5
was possible
(total 82 patients). Analysis was performed for results
at 24 hours, 48 hours, and 7 days postoperaive. The
unpaired t test was used, as calculated with GraphPad
Software (GraphPad Software, Inc, La Jolla, CA). For
24 hours, the t value was 1.83 (P .0684), for 48 hours
t was 1.8119 (P .0719), and for 7 days t was 0.0426
(P .9661). None of these values are statistically
signicant. T
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ORAL AND MAXILLOFACIAL SURGERY OOOO
298 Steel September 2012
Table III. Assessment of the quality of included randomized controlled trials
RCT
Sequence generation was
the allocation sequence
adequately generated?
Allocation concealment
was allocation
adequately concealed?
Blinding of participants, personnel,
and outcome assessors was
knowledge of the allocated
intervention adequately prevented
during the study?
Incomplete outcome data
were incomplete outcome
data adequately
addressed?
Selective outcome reporting
are reports of the study
free of suggestion of
selective outcome
reporting?
Other sources of bias was the study
apparently free of other problems
that could put it at a high risk of
bias?
Praveen et al.
(2007)
7
YES
Stated allocation selected
randomly, further
details not given, point
in time at which this
done not described
UNCLEAR
No mention made
UNCLEAR
Patients blinded to surgical
technique, surgeons were not.
Because of nature of
intervention, no mention of
outcome assessors.
UNCLEAR
No mention made of
whether all patients
returned for follow-up
with adequately
completed
questionnaires, or if
any were lost to
follow-up; this may be
because all did so
UNCLEAR
Not mentioned whether any
patients lost to follow-up
NO
Only cases suitable for local
anesthetic included
Mocan et al.
(1996)
6
YES
Stated allocation selected
randomly, further
details not given, point
in time at which this
done not described
UNCLEAR
No mention made
UNCLEAR
No mention made
UNCLEAR
No mention made of
whether all patients
returned for follow-up;
this may be because
all did so
UNCLEAR
Not mentioned whether any
patients lost to follow-up
YES
Distribution of types of impaction
not even across the patients for
each surgical technique, eg, 2 of
10 lingual split patients had
distoangular impactions; none in
the surgical bur method did so,
all cases undertaken under local
anesthetic.
Absi and
Shepherd
(1993)
5
YES
The side to be treated with
each technique in this
split-mouth study
selected randomly,
further details not given,
consecutive patients
included in trial
UNCLEAR
No mention made
UNCLEAR
Patients blinded to surgical
technique, surgeons were not.
Because of nature of
intervention, no mention of
outcome assessors.
UNCLEAR
No mention made of
whether all patients
returned for follow-up;
this may be because
all did so
UNCLEAR
Not mentioned whether any
patients lost to follow-up
NO
All cases undertaken under general
anesthetic
Middlehurst
et al. (1988)
4
YES
The side to be treated with
each technique in this
split-mouth study
selected randomly,
further details not given
UNCLEAR
No mention made
UNCLEAR
No mention made
UNCLEAR
No mention made of
whether all patients
returned for follow-up;
this may be because
all did so
UNCLEAR
Not mentioned whether any
patients lost to follow-up
NO
All cases undertaken under general
anesthetic
O
O
O
O
R
E
V
I
E
W
A
R
T
I
C
L
E
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1
1
4
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2
9
9
Swelling
All 4 included studies investigated this outcome.
Two
5,7
presented data in the form of a VAS scale (both
4 point). One
6
used stereometric photogrammetry, a
specialized photography technique comparing stan-
dardized position photographs of patients from before
surgery to the rst and second postoperative days (thus
examining extraoral swelling only) to measure swelling
objectively. The remaining study indicated which side
was the most swollen only.
4
Absi and Shepherd
5
re-
ported no statistically signicant difference between the
2 groups, however Praveen et al.,
7
as for pain, did nd
such a difference, with less swelling in the lingual split
group. In this study, mean VAS scores (on 4-point
scale) for the surgical bur and lingual split techniques,
respectively, at 24 hours postoperative were 1.9 versus
1.7 (P .047), at 48 hours postoperative 1.3 versus 1.2
(P .058), and at 7 days 0.3 versus 0.2 (P .10).
Middlehurst et al.,
4
in their split mouth study of 30
participants, reported swelling to be greater on the
lingual split side in 8 patients and on the surgical bur
side in 19 patients. It was the same on both sides in 3
patients. The magnitude of any difference was not
investigated.
Only the results of 2 of the 4 studies could be
combined in a statistical analysis (Praveen et al.
7
and
Absi and Shepherd
5
) for the same reasons as for pain.
Use of the unpaired t test produced a t value of
0.0334 (P .9734) at 24 hours postoperative, at 48
hours t was 0.4455 (P .6566), and at 7 days
postoperative t was 1.2761 (P .2037). None of
these values are statistically signicant.
Trismus
Only one study investigated this outcome, which
included a total of 10 patients per technique.
6
Trismus
was reported to be signicantly less in the lingual split
group (P .03) at 1, 2, and 7 days postoperative
(especially on the rst day) when mouth opening was
measured interincisally with calipers.
Delayed healing/infection
All studies gave details of outcomes in relation to
delayed healing and infection, although one
6
gave no
details of how this information was gleaned.
6
Across all
studies (total 122 extractions per technique), at least 5
lingual split sockets and 3 surgical bur sockets report-
edly involved infection or delayed healing. Praveen et
al.
7
reported 2 lingual split sockets with delayed heal-
ing probably due to wound infection without further
qualication or reference to diagnostic criteria for in-
fection. Absi and Shepherd
5
reported a total of 5 dry
sockets and 1 abscess across all patients, with 3 in each
group, although which group contained the abscess is
not mentioned. Mocan et al.
6
reported no delayed
healing, and Middlehurst et al.
4
reported 1 case of
postoperative alveolitis without further details. Over-
all, therefore, the reporting of such events was poor,
with 2 studies quoting diagnostic criteria for delayed
healing and none for infection or alveolitis. This pre-
cluded combined statistical analysis.
Disturbance of lingual nerve function
All 4 included studies gave details relating to this
outcome but one did not provide any details of data
collection.
6
Praveen et al.
7
used a VAS scale for patient
reporting, in the study by Absi and Shepherd
5
partici-
pants reported the presence or absence of disturbance
postoperatively, and Middlehurst et al.
4
used assess-
ment by an independent observer of the presence of
labial or lingual sensory impairment. No further de-
tails were given. The period of data collection in all
studies encompassed 6 hours to 7 days postoperatively.
All of these studies either did not use, or did not
describe use of, objective testing to determine the pres-
ence of any disturbance to function of this nerve.
Praveen et al.
7
reported no statistically signicant
difference between the groups and Mocan et al.
6
stated
that no one experienced sensory impairment of the
inferior alveolar or lingual nerves without qualica-
tion. Absi and Shepherd
5
reported a rate of disturbance
of lingual nerve function at 7 days postoperative to be
2% for the lingual split and 8% for the surgical bur
techniques. The differences did not demonstrate statis-
tical signicance at any point. Middlehurst et al.
4
re-
ported that of 30 participants, 7 (all of whom experi-
enced the greatest pain and swelling on the lingual split
side) had the presence of labial or lingual sensory
impairment when assessed by an independent ob-
server. Whether this was at the reviews on the rst or
seventh postoperative days, or if this was demonstrated
objectively, is not clear. All of these cases were said to
have shown resolution by 3 months postoperative. Dis-
turbance to function of the lingual and inferior alveolar
nerves were not differentiated in the results. Because of
the heterogeneous nature of reporting of this outcome,
no combined statistical analysis was possible.
Disturbance of inferior alveolar nerve function
The collection of data on this outcome was under-
taken in the same manner as for lingual nerve function.
The results were broadly similar to its counterpart in
that Praveen et al.
7
found no statistically signicant
difference between the 2 techniques and Mocan et al.
6
reported no cases of disturbance of function of this
nerve, without qualication. This was shared by the
participants of the study by Middlehurst et al.,
4
none of
whom experienced any disturbance. Absi and Shep-
ORAL AND MAXILLOFACIAL SURGERY OOOO
300 Steel September 2012
herd
5
reported the rate of disturbance at 7 days post-
operative to be 2% for the lingual split side (comprising
1 patient) and 0% for the surgical bur side. The gures
in this study did not demonstrate statistical signicance
at any point. Owing to the heterogeneous nature of
reporting of this outcome, no combined statistical anal-
ysis was possible.
Operating time
Three of 4 studies reported operating times for the 2
techniques.
5-7
The range reported for the lingual split
technique was 4.0 to 22.0 minutes and that for the
surgical bur technique was 4.0 to 21.3 minutes. The
calculated mean for lingual split across the 3 studies
was 12.4 minutes, and for the surgical bur the mean was
11.9 minutes.
DISCUSSION
This review has shown is that the number of RCTs on
this issue is limited, and those that do exist involve
small numbers of participants. Assessment of the qual-
ity of these trials judged them to be poor. Excluding
nonrandomized studies from this review removed the
opportunity to look at the ndings of these other stud-
ies, which although not the highest and ideal gold
standard of evidence, would nevertheless yield useful
information. It may be that large case series could
identify postoperative problems that a small RCT could
not, especially those occurring at relatively low fre-
quency. This review, however, looked only at RCTs so
as to gather only the highest-quality evidence to draw
conclusions.
The ndings of this review indicate that there is no
difference in the postoperative pain experienced after
use of the 2 techniques. Individually, one study re-
ported signicantly less pain in the lingual split group,
7
2 no difference
,6
and the remaining study less when the
lingual split was used
4
(no statistical tests applied). It
was possible to combine the data for only 2 of the 4
studies,
5,7
which failed to meet the 5% condence
interval. Similarly for swelling, Praveen et al.
7
reported
signicantly more swelling in the lingual split group,
echoed by Middlehurst et al.,
4
but no difference was
reported by Absi and Shepherd
5
or Mocan et al.
6
.
Again, combined analysis of the data from Absi and
Shepherd
5
and Praveen et al.
7
failed to meet statistical
signicance. Therefore, it must be concluded from this
that there is either no difference between the 2 tech-
niques with regard to pain and swelling, or inadequate
research to identify any difference. Only one study, that
by Mocan et al.
6
, investigated trismus. It reported sig-
nicantly less in the lingual split group. Despite the
objective means of data collection, the small sample
size (10 per group) means considerable caution must be
applied. All 4 studies looked at delayed healing/infec-
tion but, owing to the small sample sizes and inade-
quate reporting of these outcomes, it was not possible
to draw any conclusions for this outcome. It was dif-
cult to combine results regarding disturbance of inferior
alveolar and lingual nerve function, but 2 studies re-
ported no statistically signicant difference between the
2 techniques and the other 2 studies did not experience
any neurological complications. A systematic review
by Pichler and Beirne,
14
using inclusion criteria that
allowed nonrandomized studies, found reports of tem-
porary lingual nerve disturbance associated with the
lingual split technique to range between 6.64% and
19.80%, and for permanent disturbance between 0%
and 1.02%. The gures for the surgical bur technique
were 0.60% to 9.61% for temporary and 0% to 1.97%
for permanent effects. An editorial by McGurk and
Haskell
15
reported overall gures as collated from sev-
eral studies to be 15% for temporary and 0.05% for
permanent lingual nerve effects associated with the
lingual split technique. This contrasted with the gures
for the surgical bur, with 0.8% to 11.0% suffering
temporary (depending on whether a lingual ap raised)
and 0.3% to 0.5% suffering permanent disturbance.
Rood
16
reported a rate of lingual nerve disturbance at 6
months of 0.07%, and of inferior alveolar nerve distur-
bance of 0.40%, from 1400 patients on whom the
lingual split was used. Because temporary and perma-
nent effects were not distinguished in the present re-
view, it is difcult to draw comparisons. It would
therefore seem there is some weak evidence of similar
incidences for the 2 techniques, although this is not a
strong conclusion owing to the small size of the in-
cluded studies.
There are several important limitations to this re-
view. As previously discussed, only RCTs have been
included, thus excluding the large amount of informa-
tion that is available in nonrandomized studies. The
small number of RCTs published, and the small num-
bers of patients involved (total 122 per group), make it
difcult to reach strong conclusions. These difculties
are compounded by the heterogeneity of study methods
presenting obstacles to combined statistical analysis.
The literature search and analysis was done by 1 per-
son, thus possibly introducing biases, however I feel
that the search methods were sufciently rigorous to
render it very unlikely that eligible studies were missed
with this search process.
It seems that owing to the inadequate quantity and
quality of material yielded by the searches, a further
review, including nonrandomized studies, such as con-
trolled studies and case series, may be a worthwhile
exercise. However, more informative would be a suf-
ciently powered RCT with a good number of partici-
OOOO REVIEW ARTICLE
Volume 114, Number 3 Steel 301
pants. This would be the best way to obtain strong data
to reliably compare these 2 techniques. Where such a
task would sit within the priorities of modern oral and
maxillofacial surgery research is open to debate.
CONCLUSIONS
In this review comparing the lingual split and surgical
bur techniques, a total of 5 RCTs were identied, of
which 4 were obtainable and entered the analysis. De-
sign heterogeneity precluded much meaningful statisti-
cal analysis, but overall the results demonstrate no
difference between the 2 techniques with regard to
postoperative pain and swelling. Given the very limited
power of these studies, it can be concluded only very
tentatively that, from the data available, there does not
seem to be any difference as far as healing/infection
and disturbance of inferior alveolar or lingual nerve
function are concerned. There is some very tentative
evidence that trismus is less for the lingual split tech-
nique. All of these ndings are based on a small num-
ber of relatively small studies, so the strength of these
conclusions is limited. Further research in this area, and
consideration of these ndings alongside the results of
nonrandomized trials, may be helpful.
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Reprint requests:
Ben Steel, BDS MFDS RCSEd
Oral and Maxillofacial Surgery Department
James Cook University Hospital
Marton Road
Middlesbrough, TS4 3BW, UK
b_steel_1_the@yahoo.co.uk
ORAL AND MAXILLOFACIAL SURGERY OOOO
302 Steel September 2012