Postoperative Pain Relief After Surgical Removal of Impacted Third Molars: A Single-Blind, Randomized, Controlled Study to Compare Levobupivacaine and Mepivacaine

Aim: To compare the efficacy of 0.75% levobupivacaine with that of 3% mepivacaine for pain control after surgical removal of impacted mandibular third molars. Methods: Forty-two subjects (23 females and 19 males, mean age 23.5 ± 4) underwent surgical removal of third molars in two separate sessions. Within each patient, levobupivacaine was used to anesthetize one extraction side and for the other side, mepivacaine. Onset of anesthesia, duration of surgery, lip numbness, timing of pain appearance and analgesic consumption were evaluated. Results: There were no significant differences in onset of anesthesia, duration of surgical procedure, and lower lip numbness between the two groups (P > .05). Timing of pain appearance and of first drug consumption was significantly lower in the mepivacaine group (P < .05). Patients with levobupivacaine anesthesia had significantly lower visual analog (VAS) pain scores at 1 and 2 hours postoperatively than those with mepivacaine anesthesia. Conclusion: Levobupivacaine is a valid alternative to traditional local anesthetics for surgical removal of lower third molars. It presents better pain relief when compared to mepivacaine in the immediate postoperative period as evidenced by lower VAS scores.

anesthesia; levobupivacaine; oral surgery; postoperative pain; third molar

1. Bouloux GF, Punnia-Moorthy A. Bupivacaine versus lidocaine for third molar surgery: A double-blind, randomized, crossover study. J Oral Maxillofac Surg 1999;57: 510–514.

2. Porto GG, Vasconcelos BC, Gomes AC, Albert D. Evaluation of lidocaine and mepivacaine for inferior third molar surgery. Med Oral Patol Oral Cir Bucal 2007;12: E60–E64.

3. Nespeca JA. Clinical trials with bupivacaine in oral surgery. Oral Surg Oral Med Oral Pathol 1976;42: 301–307.

4. Feldman G, Nordenram A. Marcain, a new local anesthetic. A clinical trial with carbocain in the practice of oral surgery [in Swedish]. Sven Tandlak Tidskr 1966;59: 745–751.

5. Swerdlow M, Jones R. The duration of action of bupivacaine, prilocaine, and lignocaine. Br J Anaesth 1970;42: 335–339.

6. Covino BG, Giddon DB. Pharmacology of local anesthetic agents. J Dent Res 1981;60:1454–1459.

7. Vanhoutte F, Vereeke J, Verbeke N, Carmeliet E. Stereoselective effects of the enantiomers of bupivacaine on the electrophysiological properties of the guineapig papillary muscle. Br J Pharmacol 1991;103:1275–1281.

8. Aps C, Reynolds F. An intradermal study of the local anaesthetic and vascular effects of the isomers of bupivacaine. Br J Clin Pharmacol 1978;6:63–68.

9. Cox CR, Faccenda KA, Gilhooly C, Bannister J, Scott NB, Morrison LM. Extradural S(-) bupivacaine: Comparison with racemic RS-bupivacaine. Br J Anaesth 1998;80: 289–293.

10. Mather LE, McCall P, McNicol PL. Bupivacaine enantiomer pharmacokinetics after intercostal neural blockade in liver transplantation patients. Anesth Analg 1995; 80:328–335.

11. Bardsley H, Gristwood R, Baker H, Watson N, Nimmo

W. A comparison of the cardiovascular effects of levobupivacaine and racbupivacaine following intravenous administration to healthy volunteers. Br J Clin Pharmacol 1998;46:245–249.

12. Rood JP, Coulthard P, Snowdon AT, Gennery BA. Safety and efficacy of levobupivacaine for postoperative pain relief after the surgical removal of impacted third molars: A comparison with lignocaine and adrenaline. Br J Oral Maxillofac Surg 2002;40:491–496.

13. Arteagoitia I, Diez A, Barbier L, Santamaria G, Santamaria J. Efficacy of amoxicillin/clavulanic acid in preventing infectious and inflammatory complications following impacted mandibular third molar extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100: E11–E18.

14. Lacasa JM, Jimenez JA, Ferras V, et al. Prophylaxis versus preemptive treatment for infective and inflammatory complications of surgical third molar removal: A randomised, double-blind, placebo-controlled, clinical trial with sustained release amoxicillin/clavulanic acid (1000/62.5 mg). Int J Oral Maxillofac Surg 2007;36: 321–327.

15. Tuffin JR, Cunliffe DR, Shaw SR. Do local analgesics injected at the time of third molar removal under general anaesthesia reduce significantly post operative analgesics requirements? A double-blind controlled trial. Br J Oral Maxillofac Surg 1989;27:27–32.

16. Moore PA, Dunsky JL. Bupivacaine anesthesia—A clinical trial for endodontic therapy. Oral Surg Oral Med Oral Pathol 1983;55:176–179.

17. Moore PA, Hersh EV, Papas AS, et al. Pharmacokinetics of lidocaine with epinephrine following local anesthesia reversal with phentolamine mesylate. Anesth Prog 2008,55:40–48.

18. Laskin JL, Wallace WR, DeLeo B. Use of bupivacaine hydrochloride in oral surgery—A clinical study. J Oral Surg 1977;35:25–29.

19. Volpato MC, Ranali J, Ramacciato JC, de Oliveira PC, Ambrosano GM, Groppo FC. Anesthetic efficacy of bupivacaine solutions in inferior alveolar nerve block. Anesth Prog 2005;52:132–135.