Académique Documents
Professionnel Documents
Culture Documents
Clinical Paper
Oral Surgery
Abstract. The aim of this study is to introduce a new flap design in the surgical
removal of impacted mandibular third molars – a lingually based triangular flap –
and to compare this flap design with the routinely used triangular flap. This
randomized, prospective, split-mouth study involved 22 patients with impacted
bilateral mandibular third molars that were symmetrically positioned, mesially
angulated, and retained in bone. The impacted teeth were removed in two sessions,
using two different flap designs: the new alternative flap and the traditional
triangular flap. Postoperative complications (pain, swelling, trismus, alveolar
osteitis, and wound dehiscence) were recorded on days 2, 7, 14, and 21. The data
obtained were analysed using the x2 test, the Mann–Whitney U-test, and Pearson’s
correlation. In terms of the severity of postoperative facial swelling and trismus,
there were no statistically significant differences between the flap designs
(P > 0.05). The alternative flap exhibited higher pain scores at 12 h post-surgery
(P < 0.05). In addition, the alternative flap group exhibited less wound dehiscence, Key words: impacted third molar; triangular
although this was not statistically significant. Moreover, all wound dehiscence in flap; primary wound healing.
this group occurred on sound bone. In conclusion, these results show that this new
flap design is preferable to the routinely used flap for impacted third molar surgery. Accepted for publication 14 July 2015
The mandibular third molars, or wisdom the surgical removal of an impacted third Consequently, many surgical approaches
teeth, are present in 90% of the population, molar, such as pain, swelling, trismus, al- have been tried to minimize these compli-
with 33% exhibiting at least one impacted veolar osteitis (dry socket), nerve damage, cations, such as the use of surgical drains,
third molar. Owing to the high incidence and compromised periodontal status of the different wound closure techniques, and
rate of impacted third molars, their surgical adjacent second molar, still pose a major various flap designs.2,6,8–11
excision is probably the most frequently problem for surgeons and patients. Postop- In oral surgical procedures, it is desir-
performed operation in oral and maxillofa- erative morbidity has important medical, able to place the mucoperiosteal incision
cial surgery.1–6 Morbidities associated with legal, and economic implications.7 on sound bone. Many flap designs used in
0901-5027/000001+08 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Yolcu U, Acar AH. Comparison of a new flap design with the routinely used triangular flap design in
third molar surgery, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.07.007
YIJOM-3214; No of Pages 8
Please cite this article in press as: Yolcu U, Acar AH. Comparison of a new flap design with the routinely used triangular flap design in
third molar surgery, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.07.007
YIJOM-3214; No of Pages 8
Statistical analysis
Data were analyzed using IBM SPSS Sta-
tistics version 21.0 (IBM Corp., Armonk,
NY, USA). Data for individual parameters
Fig. 3. Intraoperative image of the lingually based triangular flap. were initially tested for normal distribu-
tion using the Shapiro–Wilk test. Differ-
ences in individual parameters among the
technique was used vertically, and the Patients were recalled on days 2, 7, 14, groups were tested using an independent
posterior portion of the incision was su- and 21 postoperative, and were evaluated sample t-test for normally distributed vari-
tured with four single sutures (Figs 6 and for the parameters of pain, facial swelling, ables (trismus and operation time) and the
7). The duration of each procedure from maximum mouth opening, wound dehis- Mann–Whitney U-test for non-normally
the start of the incision to the time of last cence, and other variables. During each distributed variables (swelling and pain).
suture placement was noted. Further, the postoperative visit, data were collected Additionally, Pearson’s correlation test
need or lack thereof for tooth sectioning and recorded by the same surgeon was used to assess if a statistically signifi-
was recorded. (AHA) who was blinded to the surgical cant relationship existed between two
Following surgery, the patients were technique used. categorical variables. Differences were
prescribed paracetamol (Minoset, Trismus was assessed by measuring considered significant if the P-value was
500 mg 3 1; Bayer Turk, Istanbul, the maximum inter-incisal opening less than 0.05.
Turkey) and chlorhexidine gluconate/ben- (in millimetres) – the distance between
zydamine hydrochloride mouth wash the incisal margin of the upper and
Results
(Kloroben, 3 1; Drogsan, Ankara, lower central incisors – using a standard
Turkey) for 3 days and 5 days, respective- ruler. This measurement was repeated A total of 22 patients (16 women and
ly. Antibiotics were not prescribed before twice. six men), aged between 19 and 28 years
or after the procedure. Sutures were re- The level of postoperative pain was (mean standard deviation, 22.23 2.49
moved on day 7 postoperative. evaluated using a 10-cm visual analogue years), participated in this study.
Please cite this article in press as: Yolcu U, Acar AH. Comparison of a new flap design with the routinely used triangular flap design in
third molar surgery, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.07.007
YIJOM-3214; No of Pages 8
Discussion
There have been many studies on the
morbidities following surgical removal
of impacted mandibular third molars.
Fig. 5. Closure of the buccally based triangular flap. Postoperative complications of impacted
third molar surgery such as pain, swell-
ing, trismus, and alveolar osteitis, ad-
versely affect the patient’s quality of
The average time taken to perform the When compared to the buccally based life. As a consequence, different surgical
surgery was 18.23 6.17 min for the buc- triangular flap group, the lingually based strategies such as various flap designs,
cally based triangular flap group and triangular flap group exhibited the follow- different closure techniques, the use of
20.41 3.97 min for the lingually based ing: (1) a higher mean VAS score at 12 h drugs and ice packs, surgical drains, and
triangular flap group (P = 0.17). post-surgery, which was statistically sig- laser applications have been used to pre-
Bone was removed in all cases; teeth nificant (P = 0.04); (2) higher pain scores vent or minimize these postoperative
were sectioned in 13 cases (59.1%) in the at 6 h and on each of the first 7 days post- complications.8,11,17–19
buccally based triangular flap group and in surgery, although this was not statistically In this study, the postoperative out-
11 cases (50%) in the lingually based significant (P > 0.05) (Table 1); and (3) comes of an alternative flap design,
triangular flap group (P = 0.55). inferior maximal inter-incisal mouth the lingually based triangular flap, were
Please cite this article in press as: Yolcu U, Acar AH. Comparison of a new flap design with the routinely used triangular flap design in
third molar surgery, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.07.007
YIJOM-3214; No of Pages 8
Please cite this article in press as: Yolcu U, Acar AH. Comparison of a new flap design with the routinely used triangular flap design in
third molar surgery, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.07.007
YIJOM-3214; No of Pages 8
hermetically with a mucosal flap.18 Early intention.8,10 Irrespective of the applica- adjacent tooth, and potentially prolong the
primary closure is desired in certain cases, tion of primary wound closure techniques, postoperative treatment period.1,4,10
particularly in those taking bisphospho- wound dehiscence may occur distal to the Very few studies in the literature have
nates, undergoing radiotherapy, who are neighbouring second molar during the first assessed wound dehiscence during the
immunosuppressed, etc. Delayed primary phase of wound healing. This region may early wound healing period after impact-
closure may result in alveolar osteitis, undergo secondary healing without any ed third molar surgery. Sandhu et al.
postoperative infection, and osteomyelitis additional discomfort or consequences. compared the effects of envelope and
in these cases. However, such dehiscence may lead bayonet flap designs on postoperative
Complete closure, or closed healing, to the development of alveolar osteitis, wound dehiscence.12 They found that
potentially enhances healing by primary compromise the periodontal status of the wound dehiscence occurred significantly
Please cite this article in press as: Yolcu U, Acar AH. Comparison of a new flap design with the routinely used triangular flap design in
third molar surgery, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.07.007
YIJOM-3214; No of Pages 8
more frequently in the envelope flap There was less wound dehiscence and on post-operative complications in surgical
group (35%) when compared to the bay- potential for infection with this alternative removal of impacted third molars. J Clin
onet flap group (5%). Jakse et al.10 found flap, but postoperatively there was initially Diagn Res 2013;7:1514–8.
that wound dehiscence developed in 57% greater pain. Further larger studies are 7. Baqain ZH, Al-Shafii A, Hamdan AA,
of cases in which the envelope flap was required to determine the advantages Sawair FA. Flap design and mandibular third
used, but in only 10% of cases in which and disadvantages of this new flap tech- molar surgery: a split mouth randomized
the modified triangular flap was used. nique in third molar surgery, including clinical study. Int J Oral Maxillofac Surg
Suarez-Cunqueiro et al.24 also stated that different types of impaction. 2012;41:1020–4.
8. Goldsmith SM, De Silva RK, Tong DC, Love
wound dehiscence occurred in 14.8% of In conclusion, it was determined that
RM. Influence of a pedicle flap design on
para-marginal flap cases, whereas none there was no significant difference be-
acute postoperative sequelae after lower
occurred with the use of a marginal flap. tween the lingually based triangular flap third molar removal. Int J Oral Maxillofac
As understood from these studies, the and the traditional buccally based triangu- Surg 2012;41:371–5.
flap design in third molar surgery con- lar flap regarding postoperative complica- 9. Dolanmaz D, Esen A, Isik K, Candirli C.
siderably influences primary wound heal- tions after impacted third molar surgery, Effect of 2 flap designs on postoperative pain
ing. In the current study, it was and the new incision design is preferable and swelling after impacted third molar sur-
determined that there was no significant for impacted third molar surgery. gery. Oral Surg Oral Med Oral Pathol Oral
difference in wound dehiscence and al- Radiol 2013;116:244–6.
veolar osteitis between the lingually 10. Jakse N, Bankaoglu V, Wimmer G, Eskici A,
Funding
based triangular flap design and the buc- Pertl C. Primary wound healing after lower
cally based triangular flap design. Of No source of funding for this study. third molar surgery: evaluation of 2 different
note, in none of the cases of wound flap designs. Oral Surg Oral Med Oral
dehiscence in the lingually based trian- Pathol Oral Radiol Endod 2002;93:7–12.
gular flap group was the dehiscence lo- Competing interests 11. Kirk DG, Liston PN, Tong DC, Love RM.
cated on the tooth extraction sockets; all We declare that we have no conflict of Influence of two different flap designs on
dehiscence was located on sound bone. interest. incidence of pain, swelling, trismus, and
Damage to the lingual nerve after third alveolar osteitis in the week following third
molar extraction is a rare complication. molar surgery. Oral Surg Oral Med Oral
However, the incidence of lingual nerve Ethical approval Pathol Oral Radiol Endod 2007;104:1–6.
12. Sandhu A, Sandhu S, Kaur T. Comparison of
damage shows variability across clinical The study was approved by the Ethics two different flap designs in the surgical
studies.25,26 There are some risk factors, Committee of Malatya Clinical Investiga- removal of bilateral impacted mandibular
such as the depth and position of the tions (protocol number 2012/177). third molars. Int J Oral Maxillofac Surg
impacted tooth, anatomical variations, 2010;39:1091–6.
and flap design.25–27 In the present study, 13. Dimitroulis G. Handbook of third molar
lingual nerve damage did not occur in any Patient consent
surgery. Melbourne: Butterworth-Hein-
of the patients, although the number of Not required. mann; 2001: 89–91.
cases was not sufficient to evaluate this 14. Dubois DD, Pizer ME, Chinnis RJ. Compar-
parameter. However it was observed that ison of primary and secondary closure tech-
the lingually based triangular flap was References niques after removal of impacted mandibular
more secure in the prevention of lingual 1. Kirtiloğlu T, Bulut E, Sümer M, Cengiz I. third molars. J Oral Maxillofac Surg 1982;
nerve damage, because the incision, dis- Comparison of 2 flap designs in the peri- 40:631–4.
section, and suturing were performed odontal healing of second molars after fully 15. Szmyd L. Impacted teeth. Dent Clin North
away from the lingual side. impacted mandibular third molar extrac- Am 1971;15:299–318.
Various risk factors have been linked to tions. J Oral Maxillofac Surg 2007;65: 16. Blum IR. Contemporary views on dry socket
the intensity and frequency of postopera- 2206–10. (alveolar osteitis): a clinical appraisal of
tive complications,5–7,9 such as the age and 2. Nageshwar. Comma incision for impacted standardization, aetiopathogenesis and man-
sex of the patient, medications consumed, mandibular third molars. J Oral Maxillofac agement: a critical review. Int J Oral Max-
smoking habits, time of the day when sur- Surg 2002;60:1506–9. illofac Surg 2002;31:309–17.
gery is performed, degree of difficulty in 3. Silva JL, Jardim EC, dos Santos PL, Pereira 17. Ogundipe OK, Ugboko VI, Owotade FJ. Can
FP, Garcia Junior IR, Poi WR. Comparative autologous platelet-rich plasma gel enhance
performing the surgery, duration of the
analysis of 2-flap designs for extraction of healing after surgical extraction of mandib-
surgery, experience of the operator, magni-
mandibular third molar. J Craniofac Surg ular third molars? J Oral Maxillofac Surg
tude of the ostectomy, and poor oral hy- 2011;69:2305–10.
2011;22:1003–7.
giene. No relationship between the 18. Sanchis Bielsa JM, Hernández-Bazán S,
4. Karaca I, Simşek S, Uğar D, Bozkaya S.
following variables and postoperative com- Peñarrocha Diago M. Flap repositioning
Review of flap design influence on the health
plications (pain, swelling, trismus, type of versus conventional suturing in third molar
of the periodontium after mandibular third
wound healing, and alveolar osteitis) was molar surgery. Oral Surg Oral Med Oral surgery. Med Oral Patol Oral Cir Bucal
found in the present study: sex, duration of Pathol Oral Radiol Endod 2007;104:18–23. 2008;1:138–42.
the surgery, and tooth sectioning. 5. Freudlsperger C, Deiss T, Bodem J, Engel M, 19. Osunde OD, Adebola RA, Saheeb BD. A
The aim of this study was to introduce a Hoffmann J. Influence of lower third molar comparative study of the effect of suture-less
new flap technique and to compare this anatomic position on postoperative inflam- and multiple suture techniques on inflamma-
technique to that used routinely in clinical matory complications. J Oral Maxillofac tory complications following third molar
practice – the triangular flap technique. Surg 2012;70:1280–5. surgery. Int J Oral Maxillofac Surg 2012;
Better healing was observed with the lin- 6. Kumar BS, Sarumathi T, Veerabahu M, 41:1275–9.
gually based triangular flap, as the suture Raman U. To compare standard incision 20. Berwick WA. Alternate method of flap re-
line does not lie over the socket area. and comma shaped incision and its influence flection. Br Dent J 1966;21:295–6.
Please cite this article in press as: Yolcu U, Acar AH. Comparison of a new flap design with the routinely used triangular flap design in
third molar surgery, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.07.007
YIJOM-3214; No of Pages 8
21. Obimakinde OS. Impacted mandibular third Marginal flap versus paramarginal flap in surgery. A retrospective clinical study. Oral
molar surgery: an overview. Dentiscope impacted third molar surgery: a prospective Surg Oral Med Oral Pathol Oral Radiol
2009;16:2. study. Oral Surg Oral Med Oral Pathol Oral Endod 1997;84:345–8.
22. Osunde OD, Adebola RA, Omeje UK. Man- Radiol Endod 2003;95:403–8.
agement of inflammatory complications in 25. Valmaseda-Castellón E, Berini-Aytés L, Address:
third molar surgery: a review of the litera- Gay-Escoda C. Lingual nerve damage after Ümit Yolcu
ture. Afr Health Sci 2011;11:530–7. third lower molar surgical extraction. Oral Oral and Maxillofacial Surgery Department
23. Hashemi HM, Beshkar M, Aghajani R. The Surg Oral Med Oral Pathol Oral Radiol Faculty of Dentistry
effect of sutureless wound closure on post- Endod 2000;90:567–73. Inönü University
operative pain and swelling after impacted 26. Walters H. Reducing lingual nerve damage 44280 Malatya
mandibular third molar surgery. Br J Oral in third molar surgery: a clinical audit of Turkey
Tel: +90 535 9574903; Fax: +90 442 3411107
Maxillofac Surg 2012;50:256–8. 1350 cases. Br Dent J 1995;25(178):140–4.
E-mail: drumityolcu@hotmail.com
24. Suarez-Cunqueiro MM, Gutwald R, Reich- 27. Fielding AF, Rachiele DP, Frazier G. Lingual
man J, Otero-Cepeda XL, Schmelzeisen R. nerve paresthesia following third molar
Please cite this article in press as: Yolcu U, Acar AH. Comparison of a new flap design with the routinely used triangular flap design in
third molar surgery, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.07.007