evaluation of postoperative comfort after 3rd molar
DESCRIPTION
third molar extraction is expected to cause many complications and affect the quality life of the patient. here is a study about patient comfortTRANSCRIPT
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Evaluation of postoperative discomfort after impacted mandibular third molar surgery using three different types of flapAndrea Enrico Borgonovo, MD, DMD1/Adriano Giussani, DDS2/Giovanni Battista Grossi, MD, DMD3/ Carlo Maiorana, MD, DDS4
Objective: The surgical extraction of an impacted third molar involves a wide range of consequences such as trismus, swell-ing, and pain, as well as more significant complications, tem-porary or permanent, that can manifest altered sensitivity of the tongue or lips. The purpose of this prospective study was to evaluate the effects of three different flaps on postoperative discomfort considering trismus, edema, and pain, after the extraction of impacted third molars. The data derived from the analysis of the surgical trials performed at the Oral Surgery Unit, Department of Surgical, Reconstructive and Diagnostic Sciences, IRCCS Policlinico, University of Milan, directed by Professor F. Santoro, MD. Method and Materials: This study, developed over 2 years, involved 238 patients for a total of 238 extractions of impacted mandibular third molars. The 238 sur-geries were performed on 114 men and 124 women: 54 avul-sions were performed with the elevation of an envelope flap
(Group 1), 48 avulsions through the elevation of a triangular flap (Group 2), and the remaining 136 avulsions were per-formed using a trapezoidal flap (Group 3). Results: Trismus was significantly reduced (P < .05) in patients treated with envelope flap, as was the swelling perceived by the patient (P < .05). Pain was closely related to the elevation of a muco-periosteal flap and osteotomy. Our study does not reveal statis-tically significant differences between the three types of flap used; however, the number of analgesic tablets taken was lower in cases of elevation of a less traumatic flap (envelope and triangular flaps). Conclusion: The data collected in this study indicate the envelope flap as the most suitable for the reduction of the expression of postoperative complications such as swelling and trismus. (Quintessence Int 2014;45:319330; doi: 10.3290/j.qi.a31333)
Key words: discomfort, flap, impacted third molar, surgery
ORAL SURGERY
Andrea Enrico Borgonovo
cedure in the oral cavity. They are present in 90% of the
population, of whom 33% have at least one impacted
third molar.2,3 These impactions are probably the result
of both genetic and environmental factors.1,4
The surgical extraction of an impacted third molar
involves a wide range of consequences such as trismus,
swelling, and pain, as well as more significant complica-
tions, temporary or permanent, that can manifest
altered sensitivity of the tongue or lips.
It is therefore important to assess the risks related to
surgery and compare them with the possible patho-
Third molars are the most commonly impacted teeth,1
and their removal is the most frequent surgical pro-
1 Clinical Assistant Professor, Postgraduate School of Oral Surgery, University of Milan, Fondazione IRCCS C Granda, Ospedale Maggiore Policlinico, Milan, Italy.
2 Resident, Postgraduate School of Oral Surgery University of Milan, Fondazione IRCCS C Granda, Ospedale Maggiore Policlinico, Milan, Italy.
3 Head of the Department of Implantology, Fondazione IRCCS C Granda, Osped-ale Maggiore Policlinico, Milan, Italy.
4 Professor and Director of Postgraduate School of Oral Surgery, University of Milan, Fondazione IRCCS C Granda, Ospedale Maggiore Policlinico, Milan, Italy.
Correspondence: Dr Adriano Giussani, Dental Clinic, Fondazione IRCCS C Granda, Ospedale Maggiore Policlinico, University of Milan, Via della Commenda 10, 20122 Milan, Italy. Email: [email protected]
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logic changes when third molars remain in place: in
about 33% of cases the risk consists in the possibility of
causing pathologic changes.5
The purpose of this prospective study was to evalu-
ate the effects of three different flaps on postoperative
discomfort considering trismus, edema, and pain, after
the extraction of impacted third molars. The data
derived from the analysis of the surgical trials per-
formed at the Oral Surgery Unit, Department of Surgi-
cal, Reconstructive and Diagnostic Sciences, IRCCS
Policlinico, University of Milan, directed by Professor F.
Santoro, MD.
All authors agreed that third molars should be
extracted for therapeutic reasons when they are associ-
ated with pathologic conditions such as untreatable
caries lesions, infections, cysts, and root and bone
resorption.
However, in 35% of cases third molars are extracted
even in the absence of disease due to strategic reasons,
either to facilitate or allow second molar treatment
(conservative treatment, prosthetics, periodontics, and
orthodontics), or for prophylactic purposes, in order to
avoid the occurrence of possible future complications.6
Prophylactic extraction is recommended only in par-
ticular conditions, when the risk-benefit ratio appears
particularly favorable, thus justifying the avulsion of
nonsuffering elements.
The extraction of impacted teeth is associated with
a large number of operative complications.7-10 It is
therefore essential to provide complete information to
the patient about the risks and benefits of this type of
surgery.
The flap design depends on some factors closely
related to the characteristics of the impacted tooth,
such as the depth of inclusion and the morphology and
anatomy of the tooths root. It has to be planned pre-
operatively. The flap must ensure sufficient surgical
access in order to facilitate the extraction without caus-
ing excessive tissue tension, it has to prevent injuries to
adjacent anatomic structures (buccinator nerve, lingual
nerve, and facial artery),11-14 and it allows proper reposi-
tioning to avoid dehiscence.
The envelope flap can be used in cases of partial
inclusion of teeth in the mucosa. This kind of flap is
indicated in situations that do not require a consider-
able dislocation and ostectomy to allow the extraction
of the teeth. It represents the most conservative flap
(Fig 1).
The triangular flap is indicated in cases of partial or
total bone inclusions. These flaps allow good access to
the operative site and permit a major osteotomy to
complete avulsion (Fig 2).
The trapezoidal flap is larger than the other flap
designs and is indicated in cases of particularly com-
plex inclusions, such as a third molar that is near impor-
tant anatomic structures, or for particular root confor-
mations (eg, diverging curved apices) (Fig 3).15
METHOD AND MATERIALS
The aim of this prospective study was to evaluate the
magnitude of the postoperative discomfort in a sample
of healthy subjects who need surgical extraction of an
impacted mandibular third molar, in relation to the flap
Fig 1 Envelope flap. Fig 2 Triangular flap. Fig 3 Trapezoidal flap.
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design. The study related to the Oral Surgery Unit,
Department of Surgical, Reconstructive and Diagnostic
Sciences, IRCCS Policlinico, University of Milan.
Impacted third molars considered in this study
belonged to Pell and Gregory classification 2B, in verti-
cal position.
It was attempted to create a homogenous distribu-
tion of the cases. The trapezoidal flap, which allows
greater intraoperative vision, was employed in patients
who were uncooperative, who had a reduced interinci-
sal distance (less than 3 cm), or in patients with small
mouths.
Exclusion criteria were patients with systemic or
psychiatric diseases or allergies to medications, unco-
operative subjects, pregnant or lactating women,
patients who did not follow the antibiotic therapy, and
those with episodes of pericoronitis less than 1 month
previously, severe periodontal disease, or tooth-associ-
ated cysts. Patients were also excluded if, after extrac-
tion of the mandibular third molar, they failed to
appear at the control visit 7 days later or did not com-
plete the forms after surgery. Cases where a flap was
not necessary for the extraction were also excluded.
All patients underwent antibiotic prophylaxis with
2 g of oral amoxicillin + clavulanic acid (Augmentin,
Clavulin), 1 hour before surgery.16
The sample was divided into three groups accord-
ing to the type of flap. All data were transferred to a
spreadsheet in Excel 2011 (Microsoft), and statistical
analysis was performed using SPSS 17 (SPSS). P values
greater than .05 were not considered significant.
The study was carried out and presented in accor-
dance with the ethical standards laid down in the Dec-
laration of Helsinki, and informed consent was
obtained from all participants prior to their enrollment
in the study.
Surgical procedurePreoperatively, panoramic radiographs and informed
consent were obtained. Interincisal distance was mea-
sured to evaluate the objective assessment of trismus.
All patients were treated by the same surgeon and
dental assistant under standard clinical conditions.
Before beginning any surgical procedure, the
patient used chlorhexidine 0.2% mouthwash for 1 min-
ute.16 Mepivacaine without adrenaline was used for
troncular anesthesia, and mepivacaine with adrenaline
1:100,000 was used for local anesthesia in all study
patients.
Once the flap was reflected, the surgical site was
inspected. Any bone overlying the crown of the
impacted third molar was removed with a surgical bur;
a fissure bur was used if the tooth required sectioning,
under irrigation with saline solution (Figs 4 to 6). Dental
follicular soft tissue was removed and the socket thor-
oughly irrigated. Finally, the flap was repositioned and
sutured (Ethicon, 3-0 silk).
The duration of surgery was recorded in minutes,
from the incision to the end of the suture. At the end of
the surgery the patient took one tablet of analgesic
(paracetamol 500 mg) and an ice-pack was instantly
applied to combat postoperative edema.
Fig 4 Envelope flap: intrasulcular incision. Fig 5 Flap reflection. Fig 6 Site exploration.
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Postsurgical evaluationSeven days after surgery the interincisal distance was
measured again during the control visit. The progress
of the healing process was also assessed. All assess-
ments were made by the same author who had previ-
ously performed the preoperative evaluations.
In the final phase, the patient completed a form that
recorded the number of analgesic tablets taken, in
order to quantify objectively the pain, and the Postop-
erative Symptom Severity (PoSSe scale),17 where
patients expressed how the side effects during the
postoperative period influenced their quality of life.
This questionnaire was divided into subscales corre-
sponding to seven main adverse effects, and for each
possible answer there was a score ranging from 0 to a
variable number. It is a valid and reliable measure of the
severity of symptoms after extraction of third molars,
and of the impact of those symptoms on patients per-
ceived health.
RESULTS
The study, developed over 2 years, involved 238
patients for a total of 238 extractions of impacted man-
dibular third molars. The 238 surgeries were performed
on 114 men and 124 women: 54 avulsions were per-
formed with the elevation of an envelope flap (Group
1), 48 avulsions through the elevation of a triangular
flap (Group 2), and the remaining 136 avulsions were
performed using a trapezoidal flap (Group 3). The mean
time of surgery was 25.6 minutes (range 14 to 45 min-
utes) for Group 1, 27.7 minutes (range 12 to 45 min-
utes) for Group 2, and 19.9 minutes (range 7 to 50
minutes) for Group 3 (Table 1). No patients had wound
infections, or abnormalities of the healing process. The
summary of data collected is shown in Table 2.
Evaluation of trismusTrismus seems to be influenced by the type of flap
(Table 3). The analysis of variance (ANOVA) found statis-
tically significant differences between the values for the
variation of the interincisal distance in the three study
groups (P = .031) (Table 4). Since three variables were
compared, Bonferroni post hoc test was used to study
the significance of the comparisons. A statistically sig-
nificant difference was found between Group 1 (enve-
lope flap) and Group 2 (triangular flap) (P = .040). There
was no statistically significant difference between
Group 1 (envelope flap) and Group 3 (trapezoidal flap)
(P = .089), or between Group 2 (triangular flap) and
Group 3 (trapezoidal flap) (P = 1.00) (Table 3).
Evaluation of painTable 5 shows the number of analgesic tablets taken by
patients within 7 days postoperatively, in order to
evaluate objectively the perceived pain.
The ANOVA test denotes the absence of a statisti-
cally significant difference among the three groups of
patients (P = .162) (Table 6).
Evaluation of PoSSe scaleThe values of the questionnaire and the individual sub-
scales are shown in Table 7. The level of significance of
each subscale was rated (Table 8), and the appear-
ance subscale was the only one that showed statisti-
cally significant values for ANOVA (P = .000). By per-
forming the Bonferroni post hoc test we noticed that
differences were statistically significant between
Group 1 (envelope flap) and Group 2 (triangular flap)
(P = .005), and between Group 1 (envelope flap) and
Group 3 (trapezoidal flap) (P = .000).
In the literature there are few data concerning post-
operative discomfort related to the type of flap per-
formed, and those consider only two variances, the
envelope flap and the triangular flap. For this reason
the statistical analysis was revised excluding Group 3
(trapezoidal flap), in order to compare the data of this
study with previous studies (Table 9). P values greater
than .05 were not considered significant.
Evaluation of trismusTrismus is influenced by the type of flap performed
(Table 10).
ANOVA found statistically significant differences
between the values for the variation of the interincisal
distance in the two study groups (P = .014) (Table 11).
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Table 2 Summary of collected data in the three groups
Parameter
Envelope flap Triangular flap Trapezoidal flap
Mean Mean SD Mean Mean SD Mean Mean SD
Total PoSSe 32.13 31.32 12.31 36.81 35.77 14.39 37.07 35.33 13.60
PoSS
e su
bsc
ales
Eating 11.23 10.50 4.71 12.19 10.50 5.19 13.13 13.13 5.07
Speech 2.80 2.50 2.17 3.39 3.75 2.23 3.10 2.50 2.37
Sensation 2.19 2 2.86 2.29 1 3.52 2.22 0.00 3.45
Appearance 2.86 3 2.37 4.59 4.5 2.63 4.97 4.50 2.89
Pain 7.75 7.13 3.69 8.69 7.13 4.01 8.37 9.50 4.38
Sickness 0.90 0.00 1.62 0.83 0.00 1.66 0.67 0.00 1.37
Interference 4.40 4.41 1.94 4.83 5.23 2.51 4.61 4.96 2.26
Used painkillers 4.87 3.00 4.21 4.25 3.00 3.59 5.59 4.00 4.63
Difference in interincisal distance (mm)
6.56 4.50 7.00 10.63 6.50 9.32 9.46 7.00 8.29
Age 26.70 26.00 7.08 26.69 26.00 6.13 27.34 26.00 7.97
SD, standard deviation.
Table 1 Summary of the three groups
Parameter Envelope flap (n = 54) Triangular flap (n = 48) Trapezoidal flap (n = 136) Total (n = 238)
Age (years) 26.7 26.68 27.33 27.06
SexMale 18 24 72 114
Female 36 24 64 124
SmokerYes 12 15 45 72
No 42 33 91 166
Time of surgery (min) 25.6 27.7 19.9 24.33
Table 4 Comparison of interincisal differences ( trismus): analysis of variance
Sum of squares df Mean square P
Between groups 477.412 2 238.706 .031
Within groups 15960.319 235 67.916
Total 16437.731 237
df, degrees of freedom.
Table 3 Comparison of interincisal differences ( trismus) detected in the three groups
Flap type N Mean SD SE Min Max
Envelope flap 54 6.56 6.995 0.952 0 26
Triangular flap 48 10.63 9.321 1.345 0 35
Trapezoidal flap 136 9.46 8.293 0.711 0 36
Total 238 9.03 8.328 0.540 0 36
SD, standard deviation; SE, standard error.
Table 6 Pain: analysis of variance
Sum of squares df Mean square P
Between groups 69.214 2 34.607 .162
Within groups 4436.034 235 18.877
Total 4505.248 237
df, degrees of freedom.
Table 5 Comparison of number of painkillers taken (as an indicator of pain) in the three groups
Flap type N Mean SD SE Min Max
Envelope flap 54 4.87 4.212 0.573 0 14
Triangular flap 48 4.25 3.594 0.519 0 14
Trapezoidal flap 136 5.59 4.626 0.397 0 21
Total 238 5.16 4.360 0.283 0 21
SD, standard deviation; SE, standard error.
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Evaluation of painTable 12 shows the number of analgesic tablets taken
within 7 days postoperatively by patients from the two
groups, in order to evaluate objectively the perceived
pain. In this case the ANOVA test denotes the absence
of a statistically significant difference between the two
groups of patients (P = .428) (Table 13).
Evaluation of PoSSe scaleThe values of the questionnaire and the individual sub-
scales are shown in Table 14.
The appearance subscale of the questionnaire is
the only one to be statistically significant using ANOVA
(P = .001) (Table 15). Compared with results of this
study, the literature is in agreement.
Table 7 Evaluation of PoSSe scale in the three groups
Flap type N Mean SD Min Max
Total PoSSe
Envelope flap 54 32.1280 12.30772 5.11 56.46
Triangular flap 48 36.8098 14.38729 9.01 67.93
Trapezoidal flap 136 37.0719 13.60133 5.38 81.65
Total 238 35.8973 13.58307 5.11 81.65
PoSSe eating
Envelope flap 54 11.232 4.7122 0.0 21.0
Triangular flap 48 12.192 5.1895 0.0 21.0
Trapezoidal flap 136 13.127 5.0716 0.0 21.0
Total 238 12.508 5.0566 0.0 21.0
PoSSe speech
Envelope flap 54 2.801 2.1710 0.0 7.5
Triangular flap 48 3.385 2.2325 0.0 8.8
Trapezoidal flap 136 3.097 2.3715 0.0 8.8
Total 238 3.088 2.2984 0.0 8.8
PoSSe sensation
Envelope flap 54 2.19 2.862 0 12
Triangular flap 48 2.29 3.525 0 16
Trapezoidal flap 136 2.22 3.448 0 16
Total 238 2.23 3.327 0 16
PoSSe appearance
Envelope flap 54 2.861 2.3720 0.0 12.0
Triangular flap 48 4.594 2.6330 0.0 12.0
Trapezoidal flap 136 4.974 2.8850 0.0 12.0
Total 238 4.418 2.8479 0.0 12.0
PoSSe pain
Envelope flap 54 7.7454 3.69495 0.00 14.26
Triangular flap 48 8.6852 4.00922 0.00 17.63
Trapezoidal flap 136 8.3703 4.38276 0.00 19.00
Total 238 8.2920 4.15756 0.00 19.00
PoSSe sickness
Envelope flap 54 0.90 1.618 0 6
Triangular flap 48 0.83 1.658 0 8
Trapezoidal flap 136 0.67 1.369 0 6
Total 238 0.76 1.486 0 8
PoSSe interference with activities
Envelope flap 54 4.4009 1.94366 0.00 7.16
Triangular flap 48 4.8288 2.51395 0.00 9.90
Trapezoidal flap 136 4.6112 2.25614 0.00 9.90
Total 238 4.6074 2.23993 0.00 9.90
SD, standard deviation.
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Table 9 Summary of collected data in the envelope and triangular flap groups
Envelope flap Triangular flap
Mean Mean SD Mean Mean SD
Total PoSSe 32.13 31.32 12.31 36.81 35.77 14.39
PoSS
e su
bsc
ales
Eating 11.23 10.50 4.71 12.19 10.50 5.19
Speech 2.80 2.50 2.17 3.39 3.75 2.23
Sensation 2.19 2.00 2.86 2.29 1.00 3.52
Appearance 2.86 3.00 2.37 4.59 4.50 2.63
Pain 7.75 7.13 3.69 8.69 7.13 4.01
Sickness 0.90 0.00 1.62 0.83 0.00 1.66
Interference 4.40 4.41 1.94 4.83 5.23 2.51
Used painkillers 4.87 3.00 4.21 4.25 3.00 3.59
Difference in interincisal distance (mm)
6.56 4.50 7.00 10.63 6.50 9.32
Age 26.70 26.00 7.08 26.69 26.00 6.13
SD, standard deviation.
Table 8 PoSSe scale: analysis of variance
Sum of squares df Mean square P
Total PoSSe
Between groups 994.834 2 497.417 .067
Within groups 42731.630 235 181.837
Total 43726.464 237
PoSSe Eating
Between groups 144.915 2 72.458 .058
Within groups 5914.902 235 25.170
Total 6059.817 237
PoSSe Speech
Between groups 8.708 2 4.354 .440
Within groups 1243.314 235 5.291
Total 1252.022 237
PoSSe Sensation
Between groups 0.301 2 0.150 .987
Within groups 2623.447 235 11.164
Total 2623.748 237
PoSSe Appearance
Between groups 174.456 2 87.228 .000
Within groups 1747.696 235 7.437
Total 1922.152 237
PoSSe Pain
Between groups 24.391 2 12.195 .496
Within groups 4072.223 235 17.329
Total 4096.614 237
PoSSe Sickness
Between groups 2.434 2 1.217 .578
Within groups 520.807 235 2.216
Total 523.241 237
PoSSe Interference with activities
Between groups 4.656 2 2.328 .631
Within groups 1184.437 235 5.040
Total 1189.092 237
df, degrees of freedom.
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Table 14 Evaluation of PoSSe Scale in the two groups
Flap type N Mean SD Min Max
Total PoSSe
Envelope flap 54 32.1280 12.30772 5.11 56.46
Triangular flap 48 36.8098 14.38729 9.01 67.93
Total 102 34.3312 13.46583 5.11 67.93
PoSSe Eating
Envelope flap 54 11.232 4.7122 0.0 21.0
Triangular flap 48 12.192 5.1895 0.0 21.0
Total 102 11.683 4.9413 0.0 21.0
PoSSe Speech
Envelope flap 54 2.801 2.1710 0.0 7.5
Triangular flap 48 3.385 2.2325 0.0 8.8
Total 102 3.076 2.2087 0.0 8.8
PoSSe Sensation
Envelope flap 54 2.19 2.862 0 12
Triangular flap 48 2.29 3.525 0 16
Total 102 2.24 3.175 0 16
PoSSe Appearance
Envelope flap 54 2.861 2.3720 0.0 12.0
Triangular flap 48 4.594 2.6330 0.0 12.0
Total 102 3.676 2.6332 0.0 12.0
PoSSe Pain
Envelope flap 54 7.7454 3.69495 0.00 14.26
Triangular flap 48 8.6852 4.00922 0.00 17.63
Total 102 8.1876 3.85570 0.00 17.63
PoSSe Sickness
Envelope flap 54 0.90 1.618 0 6
Triangular flap 48 0.83 1.658 0 8
Total 102 0.87 1.629 0 8
PoSSe Interference with activities
Envelope flap 54 4.4009 1.94366 0.00 7.16
Triangular flap 48 4.8288 2.51395 0.00 9.90
Total 102 4.6023 2.22922 0.00 9.90
SD, standard deviation.
Table 13 Pain: analysis of variance
Sum of squares df Mean square P
Between groups 9.780 1 9.780 .428
Within groups 1547.093 100 15.471
Total 1556.873 101
df, degrees of freedom.
Table 12 Comparison of number of painkillers taken (as an indicator of pain) in the two groups
Flap type N Mean SD Min Max
Envelope flap 54 4.87 4.212 0 14
Triangular flap 48 4.25 3.594 0 14
Total 102 4.58 3.926 0 14
SD, standard deviation.
Table 11 Comparison of interincisal differences ( trismus): analysis of variance
Sum of squares df Mean square P
Between groups 420.828 1 420.828 .014
Within groups 6676.583 100 66.766
Total 7097.412 101
df, degrees of freedom.
Table 10 Comparison of interincisal differences ( trismus) detected in the two groups
Flap type N Mean SD Min Max
Envelope flap 54 6.56 6.995 0 26
Triangular flap 48 10.63 9.321 0 35
Total 102 8.47 8.383 0 35
SD, standard deviation.
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DISCUSSION
Surgery of impacted third molars is associated with
significant postoperative discomfort.7-10 For this reason
several authors have followed different surgical proto-
cols in order to identify the most effective treatment.
Data from the present study demonstrate that con-
cerning the extraction of an impacted mandibular third
molar the use of a mucoperiosteal envelope flap can be
effective in reducing postoperative discomfort, most
specifically in the reduction of the expression of trismus
and swelling.
All patients underwent antibiotic prophylaxis (2 g
amoxicillin 1 hour before surgery), in order to reduce
the incidence of infection of the surgical wound.16,17
Pain is closely related to the elevation of a muco-
periosteal flap and osteotomy. Our study does not
reveal statistically significant differences between the
three types of flap used; however, the number of anal-
gesic tablets taken was lower in cases of elevation of a
less traumatic flap (envelope and triangular flaps).
In patients treated with envelope flap, trismus was
significantly reduced (P < .05) as well as the swelling
perceived by the patient (P
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value 67.93) and trapezoidal flap (mean 37.08, maxi-
mum value 81.65).
In a study by Garca et al,19 218 patients needing the
avulsion of mandibular third molars were divided into
three groups: the first group did not need any flap ele-
vation, the second group needed a full-thickness muco-
periosteal flap for the extraction, and the third group
needed a flap and osteotomy. The assessment of tris-
mus was obtained by comparing the interincisal dis-
tance before and after surgery: differences were not
significant in the first group, while significant in the
second and third groups. Similar considerations have
also been assessed by analyzing the pain experienced
by patients, which was higher in the second and third
groups compared to patients who were not subject to
a flap and osteotomy.
Sandhu et al20 compared the effects of flap design
on postoperative sequelae such as pain, swelling, tris-
mus, and wound dehiscence after bilateral surgical
avulsion of the mandibular impacted third molars. They
selected 20 patients aged 20 to 30 years, and the
interincisal distance and some facial measurements
were recorded before surgery. An envelope flap was
used on one side and a triangular flap was used on the
contralateral side. Pain, swelling, trismus, and wound
dehiscence were evaluated after surgery. The pain and
the rate of wound dehiscence were significantly greater
in the case of elevation of an envelope flap, compared
to the other group (P .05).
Erdogan et al21 compared the effects of an envelope
flap and a triangular flap on trismus, pain, and swelling:
20 patients with bilateral impacted mandibular third
molars were placed in a double-blind, prospective, and
randomized trial. One third molar was extracted by the
elevation of an envelope flap, and the other using a
triangular flap. Trismus was determined by measuring
maximum interincisal distance, swelling using facial
measurements, and pain using a visual analog scale
(VAS) and the number of analgesic tablets taken. The
swelling and VAS scores were lower in cases of enve-
lope flap, while no significant difference was deter-
mined by analyzing the data for trismus and pain.
Kirk et al22 considered 32 patients with bilateral
impacted third molars which were extracted using an
envelope flap for one tooth, and a triangular flap for
the other. Postoperative pain was recorded using a
VAS, and postoperative swelling was assessed by com-
paring models of laser scans of each patients cheek
before and 2 days after surgery. There were no statisti-
cally significant differences between the designs of the
flap in terms of severity of postoperative pain and tris-
mus. A statistically significant difference was observed
in postoperative swelling after 2 days: the triangular
flap was associated with increased swelling, and the
envelope flap with a higher incidence of alveolar oste-
itis (AO). The flap designs used did not seem to affect
patients in terms of postoperative pain and trismus.
Koyuncu and Cetingl23 tried to estimate the influ-
ence of flap design on AO and postoperative side
effects following third molar surgery. Eighty patients
with impacted mandibular third molars participated in
the study. The envelope flap design was associated
with a higher incidence of AO, but this was not statisti-
cally significant. On the second day, postoperative pain
and swelling were observed as significantly different
with the envelope flap technique.
Dolanmaz et al24 evaluated envelope and modified
triangular flaps for postoperative pain and swelling
after mandibular impacted third molar surgery. Postop-
erative pain and swelling were evaluated until day 7
using two verbal rating scales. Authors found no sig-
nificant difference between the envelope and modified
triangular flaps regarding postoperative pain and swell-
ing after impacted third molar surgery.
CONCLUSION
Surgery of the mandibular impacted third molars may
cause severe discomfort to the patient postoperatively.
The related factors and the methods that can be imple-
mented to reduce the disease should be known to
every oral surgeon. It is reasonable to think that the
incision of soft tissues and ostectomy necessary to
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enhance the extraction increase the discomfort in
terms of postoperative trismus, swelling, and pain.
Although the choice of flap is conveyed by the
degree of complexity of extraction, the inclusion depth,
and the spatial arrangement of the impacted tooth, a
triangular or trapezoidal flap can simplify the operators
intervention in case of uncooperative patients with
poor mouth opening. Difficulty opening the mouth
(interincisal distance less than 30 mm)25 can inhibit the
use of drills and require osteotomy and odontotomy,
complicating the surgical procedure and lengthening
the operating time. In these cases, the use of a triangu-
lar or trapezoidal flap may be advisable.
The envelope flap is easier to perform and to suture,
compared to a triangular or trapezoidal flap, but does
not facilitate access to the surrounding structures, mak-
ing it more difficult to perform osteotomy. The triangu-
lar and trapezoidal flaps allow for easier access to sur-
rounding structures, facilitating the osteotomy
required to extract the tooth. However, in the latter two
types of flap suturing is more complex, and more
extensive exposure of the bone surface tends to trigger
increased bone resorption by osteoclasts.26-28 It is nota-
ble, however, that after performing an envelope flap
there is a higher chance of finding a distal dehiscence
of the wound. Regardless of the design of the flap, the
periodontal condition of the second molar is compro-
mised.29-31
The data from the present study indicate the enve-
lope flap as the most suitable for the reduction of the
expression of postoperative complications such as
swelling and trismus.
The search for an optimal surgical approach for the
removal of third molars is extremely important. The
decision to use a certain type of flap is closely linked to
the preference of the surgeon and the degree of com-
plexity of extraction of the impacted tooth.32,33 How-
ever, when a choice between different types of flap is
possible, the conclusions drawn from this study may
help the surgeon to choose the approach that gives the
least discomfort to the patient in the healing phase.
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