Primary wound healing after lower third molar surgery: Evaluation of 2 different flap designs

doi:10.1067/moe.2002.119519

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology

Volume 93, Issue 1, January 2002, Pages 7-12

https://doi.org/10.1067/moe.2002.119519 Get rights and content

Abstract

Objectives: Wound dehiscences after lower third molar surgery potentially extend the time of postsurgical treatment and may cause long-lasting pain. It was the aim of this prospective study to evaluate the primary wound healing of 2 different flap designs. Methods: Sixty completely covered lower third molars were removed. In 30 cases, the classic envelope flap with a sulcular incision from the first to the second molar and a distal relieving incision to the mandibular ramus was used, whereas the other 30 third molars were extracted after preparation of a modified triangular flap first similarly described by Szmyd. Wound healing was controlled on the first postoperative day, as well as 1 and 2 weeks after surgery. Results: The overall result was a total of 33% wound dehiscence. In the envelope-flap group, wound dehiscences developed in 57% of the cases. This represents a relative risk ratio of 5.67, with a 95% CI from 1.852 to 12.336. With the modified triangular-flap technique, only 10% of the wounds gaped during wound healing. Conclusion: This study confirms evidence that the flap design in lower third molar surgery considerably influences primary wound healing. The modified triangular flap is significantly less conducive to the development of wound dehiscence. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:7-12)

Section snippets

Material and methods

A total of 60 completely covered lower third molars from 60 patients were removed by 3 experienced oral surgeons. Patients were between 15 and 60 years old, with the average age being 25 years. There were 32 female and 28 male patients.

The medical history revealed no sickness or medication that would influence the course of wound healing after oral surgery. The number of smokers among those 60 patients was 9, with 5 of them smoking occasionally (ie, up to 10 cigarettes a day), 3 patients

Results

Out of the 60 surgical sites, 20 dehiscences (33%) were found. Although on the first day after surgery, all wounds were well closed without any sign of a beginning rupture, after 1 week, 20 cases showed gaping wound margins distobuccal to the second molar. No additional dehiscence developed between day 7 and day 14 postsurgery. Neither the size nor the shape of the present dehiscences changed during this time.

The age of the patient did not influence the incidence of dehiscences. In the group of

Discussion

An envelope flap with a sulcular incision from the first to the second molar and a distal relieving incision to the mandibular ramus is a widely used technique for lower third molar surgery.3, 4, 5, 6, 7 There are definite advantages of this flap design. The surgical site is generously uncovered, ensuring a good overview during surgery. The sulcular incision can be prolonged mesially any time, in case cystic lesions should extend mesially or if additional endosurgery of the adjacent molars is

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Cited by (82)

Does pedicle flap design influence the postoperative sequel of lower third molar surgery and quality of life?
2022, Journal of Oral Biology and Craniofacial Research
To determine the impact of the buccal envelope flap and pedicle design on the post-operative outcome and quality of life following lower third molar surgery (QoL).
A randomized case-control clinical study was carried out from September 2017 to September 2019. In this study, a total number of 50 patients with mandibular third molar impaction underwent surgical removal of the same using buccal envelope flap (group A) and pedicle flap (group B). The patients were assessed postoperatively for pain, swelling, trismus, wound dehiscence, dry socket, and quality of life for one month.
In terms of pain, swelling, and trismus, there was no statistical difference between the two groups (p > 0.05). However, there was a statistically significant difference found in group B (pedicle flap) in terms of wound dehiscence, dry socket, and quality of life (p < 0.05).
The pedicle flap demonstrates fewer incidences of wound dehiscence, dry socket, and a better quality of life when compared to the envelope flap.
Does Minimal-Invasive Envelope Flap Reduce Side Effects Compared to Conventional Envelope Flap Following Impacted Third Molar Surgery? A Split-Mouth Randomized Clinical Trial
2021, Journal of Oral and Maxillofacial Surgery
The surgical removal of impacted third molars can lead to various postoperative consequences, which can be influenced by modifiable factors such as flap design. The present study aimed to determine whether a minimal-invasive envelope flap (MIEF) can reduce surgical consequences and improve life quality compared to conventional envelope flap (CEF) after removing impacted mandibular third molars.
This single-blinded, cross-over randomized clinical trial was conducted on adult patients with bilateral, symmetrically impacted mandibular third molars. The flap design for surgical removal of the third molar was the primary predictor variable. The primary outcome (pain) and secondary outcome variables (swelling, mouth opening limitation [MOL]) were recorded daily and on the second and seventh days after the surgery, respectively. Wound dehiscence and patients' postoperative quality-of-life scores (PPOQL) were recorded on the seventh day. The data were analyzed by Kolmogorov-Smirnov and paired sample t test using SPSS version 22. The P value < .5 was considered significant.
Sixty-eight impacted third molars of 34 subjects with a mean age of 22 ± 12.9 years (35% females) were followed. The postoperative pain level in the MIEF group at rest (0.80 ± 0.53) and chewing (2.10 ± 1.32) up to fifth day was significantly (P value < .01) lower than CEF group (2.40 ± 1.12 and 3.05 ± 1.13, respectively). The difference did not reach a significant level at rest and chewing on the sixth and seventh days (P value > .05). On the seventh day, the subjects in the MIEF group showed a significantly (P value < .001) lower level of swelling (1.13 ± 0.11) and MOL (8.28 ± 4.17) than the CEF group (3.2 ± 2.1 and 12.67 ± 4.92, respectively). Based on the PPOQL scale, patients in the MIEF group (1.82 ± 1.31) expressed a better recovery period than the CEF group (3.5 ± 2.1) (P value < .001).
Considering the reduction of pain, swelling, MOL, and wound dehiscence in MIEF cases, the application of MIEF in surgical removal of impacted mandibular third molars can lead to a significant reduction in postoperative consequences and also a noticeable improvement in PPOQL compared to CEF.
Does the Lingual-Based Mucoperiosteal Flap Reduce Postoperative Morbidity Compared With the Buccal-Based Mucoperiosteal Flap After the Surgical Removal of Impacted Third Molars? A Meta-analysis Review
2021, Journal of Oral and Maxillofacial Surgery
The lingual-based mucoperiosteal flap, a novel flap, was unclear about the effects on the prognosis of surgery for impacted mandibular third molars. This study aimed to compare the lingual- and buccal-based mucoperiosteal flaps with respect to postoperative responses and complications.
A systematic review with a meta-analysis was designed and the PubMed, Cochrane Library, EMBASE, and Web of Science databases and Google Scholar from January 1, 2000 to April 30, 2020 were searched for randomized clinical trials. The predictor variable was buccal- or lingual-based flap in the surgery, and the outcome variables were pain, swelling, trismus, operative time, and wound dehiscence. Other study variables were sex and retention depth of impacted teeth. RevMan 5.3 software was used for data analysis. Mean differences or standardized mean differences and risk ratios were computed to assess associations between 2 variables, where statistical significance was set at P < .05.
Seven publications met the inclusion criteria, contributing 370 subjects who had 590 teeth removed to sample. The lingual-based flap failed to significantly reduce postoperative discomfort. However, subgroup analysis revealed that subjects who underwent comma flap (a type of lingual-based flap) surgeries complained of milder pain than those who underwent buccal-based flap surgeries on day 1 (mean difference = −1.18, 95% confidence interval [CI] [−1.53, −0.83], P < .001) and day 7 (mean difference = −1.80, 95% CI [−2.13, −1.48], P < .001) after surgery. Significant differences were also observed on days 1, 3, and 7 regarding postoperative swelling and trismus (P < .01). In addition, the lingual-based flap was reported to cause a significantly lower rate of wound dehiscence (relative risk = 0.46, 95% CI [0.30, 0.69], P = .0002).
The lingual-based flap was associated with better primary wound closure in third molar removal. The comma flap, as a subtype, was preferable for relieving postoperative pain, swelling, and trismus over the buccal-based flap.
Comparison of two different flap designs for bilateral impacted mandibular third molar surgery
2020, Journal of Stomatology, Oral and Maxillofacial Surgery
We compared the effect of lingual-based triangular flap with buccal-based triangular flap on postoperative complications in impacted third molar surgery.
Thirty patients aged between 18 and 36 (mean age 19.65 ± 2.14) were included. They all had bilateral impacted third molars. We used buccal-based triangular flap on a randomly selected side (Group 1) and lingual-based triangular flap on the other side (Group 2). We evaluated pain during 7 days after the surgery; swelling and trismus on postoperative 2., 7. and 14. days; wound dehiscence and alveolar osteitis incidence on postoperative 7. and 14. days.
Pain was significantly higher in Group 2 during 7 days postoperatively (P < .05). Trismus and swelling were also more prominent in Group 2 on postoperative days 2 and 7. In Group 2, the duration of the surgery in was longer than Group 1 (P < .05). In Group 1, 17 patients (56.7%) had wound dehiscence and 6 patients (20%) in Group 2 (P < .05). No alveolar osteitis developed in either groups.
The buccal-based triangular flap seems better with regard to postoperative pain, swelling and trismus. On the other hand, the lingual-based triangular flap had a lesser incidence for wound dehiscence.
Envelope or triangular flap for surgical removal of third molars? A systematic review and meta-analysis
2020, International Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
Thus, the hypothesis of the present review was that there are postoperative differences in the variables mentioned above between the triangular and envelope flaps. Eighteen studies were included in the meta-analyses 3,10–14,16,19–27,29,30, and high heterogeneity was found for all variables, except for ecchymosis and osteitis. This was due to methodological differences in the measurement of the variables found in the studies.
The aim of this systematic review was to compare the triangular and envelope flaps in mandibular third molar surgery with regard to pain, oedema, and trismus. Secondary outcomes assessed were dehiscence, ecchymosis, alveolar osteitis, periodontal condition, and surgical time. The PRISMA guidelines and recommendations in the Cochrane Handbook were followed, and the review was registered before commencement (PROSPERO; CRD42018112373). The literature search was conducted in the Web of Science, PubMed, Virtual Health Library, Cochrane Library, and Scopus databases and in the grey literature; randomized clinical trials, indexed through November 2018 were included. Three reviewers independently examined the studies. Twenty studies were included in the qualitative analysis, of which 18 were included in the meta-analyses. The flap design did not influence pain, oedema, trismus, dehiscence, or osteitis. The triangular flap was associated with a greater occurrence of postoperative ecchymosis (odds ratio 4.58, 95% confidence interval 1.34 to 15.91, I² = 0) and lower periodontal probing depth on day 7 postoperative (standardized mean difference −1.36, 95% confidence interval −2.68 to −0.03, I² = 88%) when compared to the envelope flap in mandibular third molar surgeries.
Comparison of Postoperative Outcomes Between Envelope and Triangular Flaps After Mandibular Third Molar Surgery: A Systematic Review and Meta-Analysis
2020, Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
In contrast, only 3 studies reported incomplete outcomes data.5,12,18 Finally, the selection bias was unclear for 6 studies.13,22,26,29,30,32 Only 10 studies reported the operation time as an outcome.12,14,16,17,20,25,26,28,31,33
The objective of the present systematic review was to compare the postoperative outcomes between envelope and triangular flaps after mandibular third molar surgery.
The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched from the inception date to November 2018. Randomized and nonrandomized controlled trials were included if they had met certain inclusion and exclusion criteria. The predictor variable was the flap design, envelope or triangular. The outcome variables were operation time, pain, trismus, alveolar osteitis (AO) incidence, wound dehiscence, and swelling. The methodologic quality assessment was performed in accordance with the Cochrane Collaboration guidelines. The meta-analysis was performed using Review Manager, version 5.2.
A total of 21 studies were included for qualitative synthesis, 18 of which were included in the meta-analysis. The use of envelope flaps required less operation time than triangular flaps (P < .00001; I² = 9%). In the Pell and Gregory A and B subgroups, envelope flaps were associated with a significantly lower visual analog scale score at 3 (P = .05, I² = 0%) and 7 (P = .02; I² = 0%) postoperative days and with a greater postoperative interincisal distance at 7 postoperative days (P = .04; I² = 0%). In contrast, envelope flaps were associated with a greater AO incidence in the subgroup of split-mouth randomized controlled trials (P = .001; I² = 0%).
Envelope flaps required a shorter operation time than triangular flaps and were associated with less postoperative pain and trismus when applied to impacted mandibular third molars of Pell and Gregory Class A or B. In contrast, triangular flaps were associated with a decreased incidence of AO compared with envelope flaps.

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^*: Reprint requests: Norbert Jakse, MD, DDS, Department for Oral Surgery and Radiology, Dental School, Karl-Franzens University Graz, Auenbruggerplatz 12, 8036 Graz, Austria, [email protected]

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Oral and Maxillofacial SurgeryPrimary wound healing after lower third molar surgery: Evaluation of 2 different flap designs*

Abstract

Section snippets

Material and methods

Results

Discussion

Dent Clin North Am

Int J Oral Maxillofac Surg

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Am J Med

A study of periodontal hazards of third molars

Periodontol

Periodontal evaluation of two mucoperiosteal flaps used in removing impacted mandibular third molars

J Oral Maxillofac Surg

Surgical removal of the fully impacted mandibular third molar. The influence of flap design and alveolar bone height on the periodontal status of the second molar

J Periodontol

Third molar surgery: current concepts and controversies. Part 2

Oral Health

Die Entfernung unterer retinierter Weisheitszähne (II)

Schweiz Monatsschr Zahnmed

Oral and Maxillofacial Surgery
Primary wound healing after lower third molar surgery: Evaluation of 2 different flap designs*