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YIJOM-3214; No of Pages 8

Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx


http://dx.doi.org/10.1016/j.ijom.2015.07.007, available online at http://www.sciencedirect.com

Clinical Paper
Oral Surgery

Comparison of a new flap Ü.Yolcu1, A. H. Acar2


1
Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, Inönü University,
Malatya, Turkey; 2Department of Oral and

design with the routinely used Maxillofacial Surgery, Faculty of Dentistry,


Bezmialem Vakif University, Istanbul, Turkey

triangular flap design in third


molar surgery
Ü. Yolcu, A.H. Acar: Comparison of a new flap design with the routinely used
triangular flap design in third molar surgery. Int. J. Oral Maxillofac. Surg. 2015; xxx:
xxx–xxx. # 2015 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

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

2 Yolcu and Acar

impacted third molar surgery do not fol-


low this rule, as they involve incisions that
are placed on the extraction socket, result-
ing in a high incidence of mucosal dehis-
cence, followed by secondary wound
healing. In secondary healing, the buccal
flap is often tucked into the socket region
and organization of the coagulum in the
socket region may be disrupted. In addi-
tion, the surgical area is left unprotected
against oral pathogens and food residue.
This condition leads to delayed wound
healing and increases the risk of develop-
ing alveolar osteitis. Hence, existing
wound dehiscence at the distofacial edge
of the second molar probably extends the
postsurgical treatment period. This may
lead to an elevated level and duration of
postoperative pain and discomfort. Fur-
thermore, potential periodontal complica-
tions distal to the preceding second molar
may also occur.2,8–10,12 Numerous inves-
tigators advocate using primary wound
closure after mandibular third molar sur-
gery to obtain quicker mucosal healing
and superior amounts of bone regenera-
tion.8,13,14
Various incision and flap techniques, Fig. 1. Incision for the buccally based triangular flap.
each with variations, have been performed
for third molar surgery. The envelope flap
and triangular flap are the most commonly approved by the relevant ethics commit- the distobuccal corner of the second molar
use and preferred flap designs in impacted tee. crown. The incision was continuous, with
third molar surgery.9,11 The aim of this All surgical procedures were carried out a relieving vertical incision, oblique into
study was to compare a new flap design by the same surgeon (UY), who has more the mandibular vestibular fornix, aligned
with the routinely used triangular flap than 10 years of experience as a specialist with the mesiobuccal cusp of the second
design in the surgical removal of impacted in oral and maxillofacial surgery. For each molar (Fig. 1).
mandibular third molars. patient, the impacted teeth were removed For technique B (n = 22 teeth), a lin-
in two sessions using the two different flap gually based triangular flap was used to
designs. The time interval between the two remove the impacted mandibular third
sessions was at least 4 weeks. The flap molar on the contralateral side of the
Materials and methods
design and operated side of the mouth patient. An incision was made adjacent
This randomized, prospective, split-mouth were assigned randomly for each patient to the distal surface of the mandibular
study was performed at the Department of using envelopes prepared in advance. The second molar, and extended along the
Oral and Maxillofacial Surgery, Faculty of side of the first operation was defined by sulcus to the distobuccal corner of the
Dentistry, Inönü University. It involved 22 the patient. mandibular second molar. An oblique ves-
patients with impacted bilateral mandibu- Before starting the procedure, the oral tibular incision was made and extended
lar third molars that were symmetrically cavity was rinsed thoroughly with diluted into the vestibular fornix of the mandible,
positioned, mesially angulated, and povidone iodine solution for 30 s. Three aligned with the mesiobuccal cusp of the
retained in bone. The exclusion criteria millilitres of articaine HCl 4% with second molar. It was continued postero-
were the following: history of systemic 1:200,000 epinephrine (Ultracaine D-S superiorly towards the anterior border of
disease, use of medications, poor oral Ampul; Sanofi Aventis, Istanbul, Turkey) mandibular ramus (Figs 2 and 3).
hygiene and compromised dental and peri- was used as the local anaesthetic agent for A mucoperiosteal flap was raised
odontal status, smoking habit, allergy or inferior alveolar and lingual nerve block (Fig. 4). Bone was removed with a round
contraindications to the drugs or anaes- (2 ml), along with vestibular infiltration bur under copious irrigation with 0.9%
thetics used in the study, pregnancy or (1 ml). sterile saline, following which the tooth
lactation, and a noticeable local inflamma- Flaps were made using two techniques. was extracted. When necessary, the tooth
tion or pathology in the oral cavity that For technique A (n = 22 teeth), the im- was sectioned with a fissure bur. Primary
would influence the surgical procedure or pacted teeth were removed using a buc- wound closure was accomplished using
postoperative wound healing. cally based triangular flap, as first 4–0 silk sutures. The buccally based trian-
Before the procedure, each participant described by Szymd.15 An incision was gular flap was closed with three single
was informed about the surgical and post- made from the anterior border of the man- sutures distal to the second molar and
operative study protocol. Signed consent dibular ramus to the distal surface of the three single sutures in the perpendicular
indicating their agreement to participate in distobuccal cusp of the mandibular second incision line (Fig. 5). For the lingually
the study was obtained. The study was molar. It was extended along the sulcus to based triangular flap, the same suturing

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

Alternative flap design in third molar surgery 3

scale (VAS), with zero representing no


pain and 10 representing excruciating
pain. Patients were asked to mark the
position of their pain along the scale at
6 h and 12 h after the operation and in the
morning for 7 days post-surgery. The VAS
was converted to a numerical value by
millimetre measurement.
For the objective evaluation of swell-
ing, five distances were measured: (a) the
distance from the mandibular angle to the
lateral corner of the mouth; (b) the dis-
tance from the mandibular angle to the
nasal alar curvature, (c) the distance from
the mandibular angle to the lateral can-
thus of the eye, (d) the distance from the
tragus to the soft tissue pogonion, and (e)
the distance from the tragus to the lateral
corner of the mouth. Measurements
were performed twice with a thread,
transferred to a ruler, and recorded.
The facial measurement was calculated
as: (a + b + c + d + e)/5. The percentage
of facial swelling (%) was calculated
as: [(postoperative measurement–
preoperative measurement)/preoperative
measurement]  100.
Fig. 2. Incision for the lingually based triangular flap. The presence of alveolar osteitis (dry
socket) was determined clinically using
Blum’s criteria.16 On days 7, 14, and 21
postoperative, wound healing was
assessed and recorded as primary or sec-
ondary, depending on the absence or pres-
ence of dehiscence, respectively. Every
opening along the incision was recorded
as a wound dehiscence. Dental tweezers
were used to identify dehiscence.

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

4 Yolcu and Acar

opening from day 2 to day 21 postopera-


tive, although the difference was not sta-
tistically significant (P > 0.05) (Table 2).
The mean percentage of postoperative
facial swelling did not differ significantly
between the two groups (P > 0.05)
(Table 3).
The percentage occurrence of dehis-
cence at the buccally based triangular flap
sites was 68% on day 7, 36% on day 14,
and 9% on day 21 postoperative; at the
lingually based triangular flap sites, these
percentages were 46%, 23%, and 5%,
respectively. Differences in the percent-
age occurrence of dehiscence between the
two groups were not statistically signifi-
cant (Table 4). It was found that, while the
incision dehisced near the distal aspect of
the second molar at the buccally based
triangular flap sites, the oblique vestibular
incision dehisced in the proximity of the
Fig. 4. Raising of the mucoperiosteal flap in the lingually based triangular flap technique. distobuccal corner of the second molar at
all lingually based triangular flap sites.
While three cases of alveolar osteitis
were identified in the buccally based tri-
angular flap group, there was only one
case of alveolar osteitis in the lingually
based triangular flap group (P > 0.05). In
the lingually based triangular flap group,
one patient developed an infection within
the week of evaluation and was treated
with antimicrobials and anti-inflammatory
therapy.
The relationships between the postop-
erative morbidities (pain, swelling, tris-
mus, type of wound healing, and
presence of alveolar osteitis) and several
clinical variables (operation time, sex,
tooth sectioning) were also assessed and
found to be statistically insignificant with
respect to both flap groups (P > 0.05).
None of the patients reported any sen-
sory disturbances of the lingual or inferior
alveolar nerve.

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

Alternative flap design in third molar surgery 5

associated with the severity of postopera-


tive morbidities; it was attempted to elim-
inate the patient compliance factor, and all
other possible factors were kept as homo-
geneous as possible.
With the exception of a few flap
designs, it appears that the incisions of
many conventional flap designs are not
placed on sound bone. With the comma-
shaped flap described by Nageshwar,2 the
tongue-shaped flap designed by Ber-
wick,20 and the lingually based triangular
flap used in the present study, the incisions
are not placed on the bony defect formed
from the extraction of the impacted molar.
Nageshwar compared the conventional
modified envelope flap with comma-
shaped flap designs and found that pain
scores were significantly lower when the
comma-shaped flap design technique was
used.2 Also, it was found that the inci-
dence of swelling and trismus was lower in
the comma-shaped flap group, but this was
not statistically significant. Kumar et al.6
evaluated the effect of a comma-shaped
flap design and standard flap design
(Ward’s incision) on pain, swelling, and
trismus after impacted third molar sur-
gery. They observed that the comma-
Fig. 6. Closure of the lingually based triangular flap. shaped flap was associated with lesser
facial swelling, lower pain scores, and a
lower incidence of trismus. However, in
the present study it was found that there
was a significant difference in postopera-
tive pain, with higher pain scores in the
lingually based triangular flap group at
12 h post-surgery, and there were no sta-
tistically significant differences in the oth-
er variables between the study groups.
Wound closure following third molar
surgery may be primary or secondary in
nature.21 Different methods of achieving
secondary closure have been described in
the literature, which include drain place-
ment, mucosal excision, single suture
placement, and the sutureless technique.22
Primary or secondary wound closure tech-
niques may affect postoperative morbidi-
ty.21,22 With secondary closure, the
extraction socket remains vulnerable to
the ambient environment and may become
contaminated by oral pathogens and food
residue; this condition may lead to the
development of potential alveolar osteitis
or infection.16,22 Wound healing is
Fig. 7. Intraoperative image of closure of the lingually based triangular flap. delayed and postoperative wound care is
prolonged.14 However, secondary wound
closure facilitates the drainage of inflam-
compared to those following the use of the under similar clinical conditions. Further- matory exudates and fluids after surgery
traditional buccally based triangular flap. more, patients were selected from a simi- and aids in decreasing postoperative pain
In this study, to standardize the surgical lar age group, with each patient serving as and swelling.19,23 In primary closure,
protocol and to decrease the effects of their own control, and the teeth were which has been linked to the intensity of
variables on the final outcomes, all surger- symmetrically angulated. Thus, the flap pain and swelling postoperatively, the
ies were performed by a single surgeon design was the sole independent factor extraction socket is covered and sealed

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

6 Yolcu and Acar

Table 1. Pain levels assessed by VAS (in millimetres).


Time of assessment Buccally based triangular Lingually based triangular
post-surgery flap (mean  SD) flap (mean  SD) P-valuea
6h 53.82  2.82 65.68  2.24 0.16
12 h 52.59  2.79 69.95  2.31 0.04*
1 day 35.04  24.27 47.32  29.80 0.19
2 days 31.36  29.96 39.41  29.67 0.30
3 days 21.36  24.11 31.68  23.16 0.11
4 days 12.09  15.51 20.86  21.23 0.11
5 days 14.91  21.23 15.14  17.07 0.61
6 days 6.50  12.01 12.68  17.21 0.24
7 days 4.73  10.08 8.64  15.44 0.25
VAS, visual analogue scale; SD, standard deviation.
a
P-value, Mann–Whitney U-test.
*
P < 0.05.

Table 2. Maximum inter-incisal opening (in millimetres).


Buccally based triangular Lingually based triangular
Time of assessment post-surgery flap (mean  SD) flap (mean  SD) P-valuea
Preoperative 47.86  5.44 48.50  4.98 0.69
2 days 28.05  7.84 25.23  8.36 0.26
7 days 37.41  8.25 34.23  8.82 0.22
14 days 44.59  6.32 41.82  8.30 0.22
21 days 47.50  5.54 45.95  5.85 0.37
SD, standard deviation.
a
P-value, independent sample t-test.

Table 3. Percentage facial swelling.


Time of assessment post-surgery Buccally based triangular flap (mean  SD) Lingually based triangular flap (mean  SD) P-valuea
2 days 4.88  1.80 5.48  2.10 0.34
7 days 2.12  1.27 2.12  1.62 0.70
14 days 0.59  0.57 0.67  0.85 0.86
21 days 0.11  0.24 0.17  0.36 0.85
SD, standard deviation.
a
P-value, Mann–Whitney U-test.

Table 4. Outcomes of wound healing according to the technique used.


Buccally based triangular flap Lingually based triangular flap
Time of assessment post-surgery n (%) n (%) P-valuea
7 days
Primary 7 (31.8) 12 (54.5) 0.12
Secondary 15 (68.2) 10 (45.5)
14 days
Primary 14 (63.6) 17 (77.3) 0.32
Secondary 8 (36.4) 5 (22.7)
21 days
Primary 20 (90.9) 21 (95.5) 0.55
Secondary 2 (9.1) 1 (4.5)
n, number.
a
P-value, Pearson x2 test.

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

Alternative flap design in third molar surgery 7

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-
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4. Karaca I, Simşek S, Uğar D, Bozkaya S.
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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
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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

8 Yolcu and Acar

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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
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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