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OUTCOME OF MANAGEMENT OF MANDIBULAR THIRD MOLAR

IMPACTION BY COMPARING TWO DIFFERENT FLAP DESIGNS
1MUHAMMAD ASIF SHAHZAD, BDS, FCPS 2M RAFIQUE CHATHA, BDS, MDS (Hons), FCPS 3AQIB
SOHAIL, BDS, FCPS, MOMSRCPS (Glasgow) ABSTRACT
The aim of this study was to compare the outcome of management of mandibular third molar impaction in
terms of wound healing andperiodontalprobingdepthoftheadjacentsecondmolarinpatientstreatedbymarginal
flap versus paramarginal flap. This quasi experimental study consisted of sixty patients divided into twogroupsof
thirty each (ages 18 to 30 years), whorequiredsurgicalremovalofimpactedmandibularthirdmolars.Periodontal
probingdepthoftheadjacentsecondmolarwasrecordedpreoperatively.Amarginalflapwasusedinonerandomly
chosen half of the patients sample, and aparamarginalflapwasusedintheotherhalf.Theinfluenceoftheseflaps
on wound healing and periodontal probing depth of the adjacent second molar was studied postoperatively. No
wound dehiscence occurred with the use of marginal flap or the paramarginal flap at 1 and 2 weeksaftersurgery
(P>0.05). The buccal and distal probing depths of the adjacent second molar showed no significant difference
between marginalflapandparamarginalflapbeforesurgeryandat2weeksand4weeksaftersurgery(P>0.05).No
significant difference was found with the use of paramarginal flap instead of traditional marginal flap in the
removal of impacted mandibular third molar.
Key Words: Impacted mandibular third molar, marginal flap, paramarginal flap.
1 Assistant Professor Oral & Maxillofacial Surgery, Lahore Medical
& Dental College, Tulspura, Lahore 2 Principal Dental Section 3 Professor and Head Oral & Maxillofacial Surgery
Correspondence: Dr Muhammad Asif Shahzad, House No. 141-C, Punjab Co-operative Housing Society, DHA, Lahore Cell:
0333-4336976 Email: drasif_395@hotmail.com Received for Publication: March 29, 2014 Revision Received: April 15, 2014
Revision Accepted: April 19, 2014 INTRODUCTION
a periodontal pocket, loss of clinical attachment of the
The surgical removal of an impacted mandibular third molar is a common procedure associated with various
techniques and anecdotal opinion. Though a large majority of impacted teeth are removed surgical- ly1, many of
them can be extracted through a closed technique using extraction forceps.
gingiva or the bone loss of the second molar.2-4 Several studies have been undertaken on the different flap
techniques to prevent the periodontal complications to the adjacent second molar.5,6 The present studyevalu-ates
the outcomeofmanagementofmandibularthirdmolarimpactionbymarginalflapversusparamarginalflapinterms
of wound healing and periodontal pocket
Surgical extraction of mandibular third molar in- volves the manipulation of both soft and hard tissues,
depth of adjacent second molar after surgical removal of mandibular third molar.
due to which the patient usually experiences pain and limited mouth opening (trismus) in the early postop-
METHODOLOGY
erative period. Some patients also have periodontal disease and even complicated wound healing in the later
postoperative period.
The current study consisted of sixty patients and was carried out at Oral and Maxillofacial Surgery Unit of
Punjab Dental Hospital, Lahore from June 2006 to
Periodontal evaluation after the extraction of impacted mandibular third molars has raised the questions
concerning the direct effect of extraction on the health of the adjacent second molar. There may be
March 2007. Inclusion criteria: Patients with no his- tory of medical illness or taking any medication that could
influence the surgical procedure or postoperative wound healing, non-smokers, and healthy dental and periodontal
status. An attempt was made to include only those mandibular third molars that were of com- parable technical
difficulty, positioning and angulations as seen on periapical and panoramic radiographs.
The demographic data were recorded and informed consent was taken. A thorough history wastaken.Patients
were assessed clinically and were divided into two groups, A and B randomly by using random
235 Pakistan Oral & Dental Journal Vol 34, No. 2 (June 2014)

Flap designs influence in lower third molar surgery

numbers table. Those patients operated by using the marginal flap and bone cutting were kept under group A.
Patients operated by using the paramarginal flap and bone cutting were included in group B. Periodontal pocket
depth was measured by using the periodontal measuring probe( UNC 15) from the free gingival margin to the
bottom of the pocket in both groups.
Patients were operated under localanesthesia;2%lidocainewith1:100000adrenaline(MedicaineR;HounsCo;
Ltd; Korea). A standard surgical procedure was followed. The patients were operated by the same operator and
operative protocol. The marginal flap in- cision started near the mesiobuccal edge of the second molar to itsdistal
surface. A relievingincisionwasmadeinthemesialregionwithoutcuttingtheinterdentalpapilla.Anotherrelieving
incision was madealongthemandibularramus.(Fig1).Theparamarginalflapincisionwassimilartothatusedwith
the marginal flap; however, instead of making a sulcular incision in the second molar, an incisionwasmadewhile
maintain- ing a distance of 2 mm from the free gingival margin (Fig 2).
Then, a full thickness mucoperiosteal flap was el- evated. Minimum ostectomy and tooth sectioning was
performed by using the round bur and the fissure bur respectively while preserving the distal bone adjacent to the
second molar. The flap was approximated by in- terrupted sutures with 3/0 mersilk (Ethicon). Aftertheprocedure,
the patients were given general instructions. All patients were given Amoxicillin(500mg3timesadayfor7days),
diclofenac (50mg 3 times a day for 3 days) and 0.2% chlorhexidine gluconate mouth rinses for 7 days. Wound
dehiscence was noted at seventh postoperative day. The wound was considered to be dehisced if there wasgaping
along the entire incision
line.7 Periodontal pocket depth was measured from the free gingival margin to the bottom of thepocketat2and4
weeks postoperatively.
DATA ENTRY AND STATISTICAL ANALYSIS
The data entry package was developed using SPSS version 17. Data collection and data entry were done
simultaneously and tabulation plan was developed.
The qualitative variables in the demographic data likegenderandmandibularsideofimpactionwerepresented
as proportions and percentagesandquanti-tativevariablelikeagewerepresentedasmeansandstandarddeviations.
The comparison of the outcome of the two groups regarding wound healing was assessed by using chisquaretest.
The periodontal pocket depth of the adjacent second molar was compared for the marginal flap and paramarginal
flap and as there was a difference, it was tested for significance by t-test.
RESULTS
A total of 60 patients divided into 2 groups of 30 patients of marginal flap and paramarginal flap each were
included in our study sample.
Marginal flap groupincludedpatientsofagesrang-ingbetween18to30years(mean/SD,23.43+/-3.31).While
patients in paramarginal flap group were of ages ranging between 18 to 30 years (mean/SD, 24.17+/-3.15). The
results regarding the wound healing showed no statisticaldifferencebetweenthetwogroupsat1weekand2weeks
after surgery as both groups showed the same results regarding uncomplicated wound healing and no wound
dehiscence was found (Table 1).
TABLE 1: WOUND HEALING IN MARGINAL VERSUS PARAMARGINAL FLAP GROUPS
Wound Healing Flap type Uncomplicated Wound healing Wound dehiscence Total At 1 & 2 weeks Marginal
30 0 30 At 1 & 2 weeks Paramarginal 30 0 30 Total 60 0 60
TABLE 2: PREOPERATIVE AND POSTOPERATIVE PROBING DEPTHS ON THE BUCCAL AND
DISTAL SURFACES OF ADJACENT SECOND MOLAR GROUPS
IN MARGINAL VERSUS PARAMARGINAL FLAP
Probing depths Flap type Before Surgery 2 weeks after surgery 4 weeks after surgery Buccal Depth (mm)
Probing
Marginal (n=30)
2.56+/-0.31 3.23+/-0.29 2.28+/-0.28
(Mean/SD) Paramarginal
(n=30)
2.44+/-0.30 3.10+/-0.36 2.27+/-0.29
Distal Probing
Marginal Depth (mm)
(n=30)
3.52+/-0.24 4.10+/-0.25 3.25+/-0.34
(Mean/SD) Paramarginal
(n=30)
3.43+/-0.31 3.98+/-0.31 3.23+/-0.31
236 Pakistan Oral & Dental Journal Vol 34, No. 2 (June 2014)

Flap designs influence in lower third molar surgery

The values for periodontal probing depth on the buccal and distal surface of adjacent second molar before
surgery and at 2 weeksand4weeksaftersur-gerydidnotindicatesignificantdifferencesbetweenthemarginaland
paramarginal groups. However both techniques had the following evolution: asignificantincreaseinprobingdepth
at 2 weeks after surgery (P<0.001), and a significant decrease at 4 weeks after surgery (P<0.001). (Table 2)
DISCUSSION
Third molar surgery has been associated with a variety of complications. Flap design is one of the factors
influencing the severity of these complications.7-10 For this reason, two different flap designs were compared:
marginal flap, which is the traditional technique for
third molar surgery, and paramarginal flap, which is a variation of the latter.
It was found that the results regarding primary wound healing were not differentforeachoftheseflapdesigns
and also similar levels of periodontal pocket depth of the adjacent second molar were found for both techniques
during the study.
The results of present study were notinagreementwithJakseetal7studyinregardsthatflapdesigninfluences
primary wound healing after third molar surgery. His study confirmed evidence that the flap design in lower third
molar surgery considerably in- fluences primary wound healing.
In present study, no statistical difference regard- ing wound dehiscence was found on comparing the marginal and
paramarginal flaps. This could be due Fig 1: An illustration of the incision for marginal flap
to the use of triangular mucoperiosteal flaps used in both techniques.
Periodontal pocket formation in the second molar is a common postoperative complication in third mo- lar
surgery. Several explanations for this have been advanced.10-15 In the current study, the marginal and the
paramarginal flap created a bigger postoperative pocket in terms of the distalandbuccalprobingdepthsat2weeks
after surgery ascomparedtobeforesur-gery.Withrespecttoprobingdepth,inbothgroupsofpatients,itwasfound
that measurement before third molar surgery and 4 weeks after surgery did not change significantly. Nevertheless,
several clinical studies have found an increase in pocket depthandabonydefectonthedistalsurfaceofthesecond
molar after third molar removal.2,10 In a retrospective study, Kugelberg et al2 found that 2 yearsafterlowerthird
molar surgery, 43.3% of the cases had probing depths of 7 mm or more and 32.1% had intrabony defects
Fig 2: An illustration of the incision for paramarginal
flap
of 4 mm or more on the distal aspect of the adjacent second molar. In contrast, Groves and Moore16 found a
decreased pocket depth after surgery. Quee et al3 and Schofield et al4 also reported nodifferencesinperi-odontal
healing related to flap design. Other studies have reported that exposure of the alveolar bone to the buccal cavity,
even without surgical procedures, causes bone resorption.6,17-19 Considering this, it would be expected that the
paramarginal flap would provide better results, at least for bone level, becausethisflappreservesastripofmucosa
on the buccal surfaceofthesecondmolars.Therearetwopossibleexplanationsforwhythisdidnothappen.First,it
is possible that bone resorption is more intense and clinically important inareaswherethealveolarboneisthinner,
such as in the anterior region of the mandible and all of the maxilla, but notatthebuccalregionofthemandibular
second molars. Second, during the extraction of teeth with a great mesiodistal or horizontal angulation, it was
observed that both the ostectomy as well as the
237 Pakistan Oral & Dental Journal Vol 34, No. 2 (June 2014)

Flap designs influence in lower third molar surgery

application of dental elevators traumatized thestripofmucosapreservedbytheparamarginalflap.Itispossiblethat
this contributed to delayed periodontal healing and explains the results observed with the flap.
Ash20 cautioned that periodontal pathology affecting the distal aspect of second molars with adjacent third
molars had been overlooked. The absence of increased pocket depth at 4 weeks in this study was not a conse-
quence of flap design.Instead,itmightbecausedbytheconservativesurgicaltechniqueused,whichmaintainedthe
distal bone to the second molar in every case, andbytheyouthfulnessofthestudygroup.Inaccordwiththis,some
authors10 suggested that increased second molarpocketdepthisrelatedtoostectomy.However,otherauthors21-24
believe that flapdesignandpatientagemighthaveaneffectonsecondmolarperiodontalstatus.Therecouldalsobe
more complications when there was generalized inflammation.10 As the patientsinourstudywerebetween18and
30 years of age and had no periodontal disease before surgery, these two variables did not interfere in the results.
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238 Pakistan Oral & Dental Journal Vol 34, No. 2 (June 2014)

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