Evaluation of postoperative comfort after 3rd molar

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Q U I N T E S S E N C E I N T E R N AT I O N A L

VOLUME 45 NUMBER 4 APRIL 2014

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


Between groups 69.214 2 34.607 .162

Within groups 4436.034 235 18.877

Total 4505.248 237


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


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


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


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


Total 238 8.2920 4.15756 0.00 19.00

PoSSe sickness

Envelope flap 54 0.90 1.618 0 6


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


Total 238 4.6074 2.23993 0.00 9.90


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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


Table 8 PoSSe scale: analysis of variance


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


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Table 14 Evaluation of PoSSe Scale in the two groups


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


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


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


Table 13 Pain: analysis of variance


Between groups 9.780 1 9.780 .428

Within groups 1547.093 100 15.471

Total 1556.873 101


Table 12 Comparison of number of painkillers taken (as an indicator of pain) in the two groups


Envelope flap 54 4.87 4.212 0 14


Total 102 4.58 3.926 0 14


Table 11 Comparison of interincisal differences ( trismus): analysis of variance


Between groups 420.828 1 420.828 .014

Within groups 6676.583 100 66.766

Total 7097.412 101


Table 10 Comparison of interincisal differences ( trismus) detected in the two groups


Envelope flap 54 6.56 6.995 0 26


Total 102 8.47 8.383 0 35


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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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Borgonovo et al


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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Borgonovo et al


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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Evaluation of postoperative comfort after 3rd molar

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