Influence of two different flap designs on the sequelae of mandibular third molar surgery

Effect of a Thermosensitive Hydroxybutyl Chitosan Hydrogel on Postoperative Sequalae and Quality of Life After Impacted Mandibular Third Molar Extraction

BACKGROUND

Third molar (M3) extraction is a common surgery in oral and maxillofacial surgery, and composite wound dressings such as hydroxybutyl chitosan (HBC) may improve postoperative sequala following M3 removal.

PURPOSE

The study purpose was to measure and compare differences in pain, swelling, trismus, wound healing, and quality of life (QOL) between the HBC and the control sides in patients undergoing M3 removal.

STUDY DESIGN, SETTING, SAMPLE

This study is a double-blind, split-mouth, randomized clinical trial. Patients who required M3 removal between June 2022 and May 2023 were included. Exclusion criteria included seafood allergies, smoking, poor oral hygiene, and systemic diseases.

PREDICTOR VARIABLE

The predictor variable was the socket treatment technique. Subjects were randomly assigned to the HBC or control (physiological saline) side.

MAIN OUTCOME VARIABLE

The primary outcome variables, including pain assessed by visual analog scale, swelling, and maximal incisional opening, were measured on the first, third, and seventh postoperative days. The secondary outcome variables included QOL and wound healing score measured on the third and seventh days after surgery.

COVARIATES

The covariates included age, sex, and operation time.

ANALYSES

The Shapiro‒Wilk test was used to evaluate the normality of the data distribution. The paired t test or Wilcoxon signed-rank test was adopted. Statistical significance was set at P < .05.

RESULTS

The study included 60 patients (mean age: 25.81 ± 4.91; 23 (38%) males, 37 (62%) females). A statistically significant difference in the level of pain (HBC: 37.58 ± 4.39 mm, control: 47.00 ± 4.33 mm, day 1, P < .001; 21.88 ± 3.25 mm, 35.95 ± 1.57 mm, day 3, P < .001), maximal incisional opening (23.92 ± 1.38 mm, 18.22 ± 1.82 mm, day 1, P < .001; 30.00 ± 1.61 mm, 23.78 ± 1.70 mm, day 3, P < .001), and swelling (6.86 ± 0.70 mm, 7.15 ± 0.80 mm, day 3, P = .006) was detected after surgery. A statistically significant difference in QOL was detected (HBC: 13.70 ± 1.65, control: 18.60 ± 2.14, day 3, P < .001).

CONCLUSION AND RELEVANCE

The application of HBC hydrogels to wounds after impacted mandibular M3 extraction reduces postoperative sequalae, promotes wound healing and improves postoperative QOL.

Influence of Surgical Technique on Post-Operative Complications in the Extraction of the Lower Third Molar: A Retrospective Study

The surgical extraction of the impacted third molar is frequently associated with several complications. The purpose of this study is to assess how two different surgical protocols affect post-operative complications during the extraction of the lower impacted third molars. In order to compare and evaluate two different techniques (triangular flap vs. envelope flap), and the relative post-extraction complications, two groups of 150 patients each underwent to surgical impacted third molar extraction and 60 days of follow-up. The complication rate in the two groups was 14.00% in group A and 17.33% in group B. There was a strong association between smoking (OR: 2.8) and the use of oral contraceptives (OR: 1.75) with complications. The age- and sex-related incidence of complications in hard tissue healing has great variability in the literature; the analysis performed on our data did not show a statistically significant association between them. Even though related to a higher incidence of transient changes in sensitivity, it was found that the envelope flap saw a lower percentage of complications. There is still no clarity on which is the best protocol for the extraction of the lower impacted third molar, and the choice often depends on the surgeon's experience.

A Comparison Between Comma Incision and Ward's Incision in Third Molar Extraction in Terms of Postoperative Sequel

Aim We aim to look at the differences between the standard Ward's incision and the comma-shaped incision and how they affect complications after surgery to remove an impacted mandibular third molar. Materials and methods Mandibular third molars had to be carefully extracted from a total of 40 patients who were randomly divided into two groups of 20 patients each. At first, patients were evaluated before surgery. In group A, a standard Ward's incision was made, and in group B, a comma incision was made to match the mucoperiosteal fold. Afterward, the impacted third molars were carefully removed. The evaluation criteria for pain, swelling, lockjaw, and healing of wounds were done before surgery, after three hours, and on the first, third, and seventh day after surgery. Result The pain scores that were recorded right after surgery, three hours later, and on days 1, 3, and 7 in the surgical area with comma-shaped incision were all lower than the pain scores that were recorded in the area where standard incisions were made. Enlarging was less with comma entry point than with standard Ward's incision. After surgery, there was a big difference between the two entry points in how the mouth opened and how the wounds were fixed. These findings showed that the comma incision is better than the standard Ward's incision when it comes to pain, enlargement, lockjaw, and healing of wounds. Conclusion The study results showed that the comma-shaped incision was better than the traditional method (Ward's incision) because there were fewer problems after surgery.

A Rare Case of Concrescence of Mandibular Third Molar and Supernumerary Fourth Molar

Concrescence reveals a rare developmental anomaly in which two fully formed teeth are joined along the root surfaces by cementum, and generally occurs in maxillary molars, especially in a third molar and a supernumerary tooth. Very few cases have been reported about the concrescence of a third molar and a supernumerary fourth molar. Based on our available knowledge, this case report described a rare presentation in which concrescence is observed between a third molar and a supernumerary fourth molar in the mandible by diagnosing with cone-beam CT and histological examination.

Influence of a novel suturing technique on periodontal health of mandibular second molar following impacted third molar surgery: a split-mouth randomized clinical trial

BACKGROUND

Surgical extraction of the third molar is the most common surgical procedure in the oral surgery field and is associated with several complications. This study aimed to compare the effects of a newly presented suturing technique with the routine suture after surgical removal of the third molar on the postoperative complications.

MATERIALS AND METHODS

This randomized clinical trial was designed as a split-mouth double-blinded investigation. Twenty patients were involved in the current study. After the surgical removal of the third molar, the new suturing technique was used to close the wound on one side of the patient randomly (case side), and the other side was sutured by the routine simple interrupted stitches (control side). Pain, edema, trismus, pocket depth, and the attachment loss of the distal of the second molar were assessed following the surgery. The data were statistically analyzed and compared between the sides.

RESULTS

Pain and edema following the surgery in the control side were significantly less than in the case side. The pocket depth and the gingival attachment loss of the distal aspect of the second molar in the case side were significantly less than in the control side. No case of dry socket was observed in the case side.

CONCLUSION

It seems that the newly presented suturing technique is able to keep the wound margins close to each other and may be helpful in reducing the periodontal complication of the second molar following the surgical removal of the impacted third molars.

Distal-triangular flap design for impacted mandibular third molars: a randomized controlled trial

OBJECTIVES

This prospective study was performed to evaluate whether the distal-triangular flap was a practical alternative surgical approach for extracting mandibular third molars.

METHODS

Sixty participants with impacted mandibular third molars were randomly divided into three groups: group A, distal-triangular flap; group B, Szmyd flap; and group C, envelope flap. The impacted third molars were extracted by the corresponding flapping method. During a three-month follow-up observation after the extraction, the postoperative pain, swelling, mouth opening, and periodontal status were recorded and analyzed by ANOVA and chi-square tests.

RESULTS

The 60 participants had successful extraction and 3-month follow-up observation. No participant suffered from postoperative infections, lower lip disorder, or tongue sensory disorders. No statistical differences were found in the postoperative symptoms and signs of the three flap designs, such as postoperative pain, swelling, mouth opening, and periodontal status (P>0.05).

CONCLUSIONS

The distal-triangular flap was as safe and reliable as the Szmyd and envelope flaps but more advantageous because of its convenient operative field exposure and low requirement for the patient's mouth opening. Thus, the distal-triangular flap is one of the alternative flap options for extracting impacted mandibular third molars.

Does Minimal-Invasive Envelope Flap Reduce Side Effects Compared to Conventional Envelope Flap Following Impacted Third Molar Surgery? A Split-Mouth Randomized Clinical Trial

PURPOSE

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.

MATERIAL AND METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

The influence of flap design on patients' experiencing pain, swelling, and trismus after mandibular third molar surgery: a scoping systematic review

Third molar removal surgery usually comes accompanied by postoperative discomfort, which could be influenced by the surgical approach chosen. This scoping systematic review aimed at compiling the available evidence focused on the influence of flap design, including envelope flap (EF), triangular flap (TF), and modified triangular flap (MTF), on postoperative pain, swelling, and trismus, as primary outcome measures, and any result mentioning healing promotion or delay, as secondary outcome measure, after mandibular third molar extraction surgery. An electronic search, complemented by a manual search, of articles published from 1999 to 2020 was conducted in the Medline (PubMed), EMBASE and Web of Science databases including human randomized controlled trials, prospective, and retrospective studies with at least 15 patients. The risk of bias of the included studies was assessed either with the Cochrane’s Risk of Bias tool or with the Newcastle-Ottawa scale. Every step of the review was performed independently and in duplicate. The initial electronic search recovered 2102 articles. After applying the inclusion criteria, 12 articles were included. For patient’s perceived postoperative pain, TF and MTF frequently reported better results than EF. For swelling, the literature is divided, despite a trend favoring EF. For trismus, data showed that its occurrence is mostly associated with the duration of the surgery rather than with the chosen flap. For healing, the limited data is inconclusive. Finally, randomized studies showed a high risk of bias, whereas nonrandomized studies were mostly of good quality and low risk of bias. Although there was no clear consensus regarding the influence of different flap designs for third mandibular molar extraction on postoperative clinical morbidities; the surgeon’s experience, estimated surgical difficulty, molar position and orientation, and surg ery duration should be considered when choosing among the different flap designs.

Influence of Surgical Flap Design (Envelope and Szmyd) for Removal of Impacted Mandibular Third Molars on Clinical Periodontal Parameters: A Clinical Trial

The aim of the study was to assess the influence of flap designs (Envelope flap (EF) and Szmyd flap (SF)) for impacted mandibular third molar extraction, on periodontal pocket depth (PPD), clinical attachment loss (CAL) and bone levels (BL) of second molar. Sixty patients indicated for third molar extractions with healthy second molars were allocated into two groups: EF and SF (n = 30). Third molars were assessed for angulation, root patterns, depth of impactions and relation with ramus (Pell and Gregory classification). Extraction of third molars was performed and PPD, CAL and BL around second molars at 0, 3 and 6 month (mon) follow-ups (FU) were assessed clinically and radiographically. ANOVA, Chi-square and Fisher’s exact test were employed to compare periodontal factors between EF and SF groups, considering p ≤ 0.05 as significant. Sixty participants with a mean age of 23.22 ± 3.17 were included in the study. Based on angulation, the most common impaction in the EF and SF groups was mesio-angular (EF, 50%; SF, 36.7%). Buccal and distal PPD showed a significant increase (p < 0.001) in both EF and SF patients from baseline to 6 mon. EF patients showed significantly higher distal and buccal CAL (6.67 ± 0.18 mm; 6.91 ± 0.17 mm) and BL (7.64 ± 0.16 mm; 7.90 ± 0.15 mm) as compared to SF patients (CAL, 6.76 ± 0.26 mm; 6.91 ± 0.17 mm-BL, 7.42 ± 0.38 mm; 7.34 ± 0.34 mm) at 6 mon FU. SF showed better soft tissue attachment (PPD and CAL) and bone stability (less bone loss) around second molars compared to EF after third molar extractions regardless of the patient, tooth and operator factors.

Third molar surgery: Past, present, and the future

Third molar surgery is the most common ambulatory procedure done by oral and maxillofacial surgeons. Surgical approaches for the removal of third molars have been published since the 20th century. This article reviews the history and development of extraction techniques through a literature review. The literature was selected through a search of an electronic database. Key words for the Medline search were "mandibular/maxillary third molar," "impacted mandibular/maxillary third molar," "mandibular/maxillary third molar flap design," and "mandibular/maxillary third molar incision." The search was restricted to English-language articles. Additionally, a manual search in the major oral surgery journals and books was performed. The aim of this article is to examine the evolution of third molar surgery, recognize pioneering techniques, and compare these techniques to current approaches. Common approaches employed today are discussed and treatment philosophies with thoughts for future therapies are provided.

"Effects of flap modification on third molar extraction outcomes"-A randomised split mouth study

Aim

The main purpose of this experimental study was to compare whether modifications in flap design influence the post-operative outcome of third molar surgeries.

Materials and methods

This study was designed as a randomized, single-blinded,split-mouth cross-over comparative study. The predictor variables were the flap type; Conventional Ward's was used to expose the tooth with a difference in the anterior release incision between the groups.Oblique anterior releasing incision and vertical anterior releasing incisions were used for the control and study group respectively.The primary outcome variables were pain measured using VAS (Visual analogue scale), swelling in mm; mouth opening measured in mm, periodontal probing depth in a mm, wound healing by modified Landry's score and surgical accessibility. Statistical significance was set at 5% (α = 0.05).

Result

Twenty five patients with bilateral, mirror-image impacted mandibular third molars participated in the study.The study group was associated with moderate swelling that was not statistically significant. .The outcome variables i.e. pain, wound healing, mouth opening, and periodontal pocket depth had no statistical difference on comparing the two groups. In terms of accessibility, the control group was found to be better with the statistical significance of p = 0.00184.

Conclusion

Modifying conventional Ward's design influences the degree of swelling and surgical accessibility. Vertical anterior releasing incision in conventional Ward's has no advantage over conventional Ward's with oblique anterior releasing incision.

Surgical techniques for the removal of mandibular wisdom teeth

BACKGROUND

Pathology relating to mandibular wisdom teeth is a frequent presentation to oral and maxillofacial surgeons, and surgical removal of mandibular wisdom teeth is a common operation. The indications for surgical removal of these teeth are alleviation of local pain, swelling and trismus, and also the prevention of spread of infection that may occasionally threaten life. Surgery is commonly associated with short-term postoperative pain, swelling and trismus. Less frequently, infection, dry socket (alveolar osteitis) and trigeminal nerve injuries may occur. This review focuses on the optimal methods in order to improve patient experience and minimise postoperative morbidity.

OBJECTIVES

To compare the relative benefits and risks of different techniques for surgical removal of mandibular wisdom teeth.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 8 July 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2019, Issue 6), MEDLINE Ovid (1946 to 8 July 2019), and Embase Ovid (1980 to 8 July 2019). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different surgical techniques for the removal of mandibular wisdom teeth.

DATA COLLECTION AND ANALYSIS

Three review authors were involved in assessing the relevance of identified studies, evaluated the risk of bias in included studies and extracted data. We used risk ratios (RRs) for dichotomous data in parallel-group trials (or Peto odds ratios if the event rate was low), odds ratios (ORs) for dichotomous data in cross-over or split-mouth studies, and mean differences (MDs) for continuous data. We took into account the pairing of the split-mouth studies in our analyses, and combined parallel-group and split-mouth studies using the generic inverse-variance method. We used the fixed-effect model for three studies or fewer, and random-effects model for more than three studies.

MAIN RESULTS

We included 62 trials with 4643 participants. Several of the trials excluded individuals who were not in excellent health. We assessed 33 of the studies (53%) as being at high risk of bias and 29 as unclear. We report results for our primary outcomes below. Comparisons of different suturing techniques and of drain versus no drain did not report any of our primary outcomes. No studies provided useable data for any of our primary outcomes in relation to coronectomy. There is insufficient evidence to determine whether envelope or triangular flap designs led to more alveolar osteitis (OR 0.33, 95% confidence interval (CI) 0.09 to 1.23; 5 studies; low-certainty evidence), wound infection (OR 0.29, 95% CI 0.04 to 2.06; 2 studies; low-certainty evidence), or permanent altered tongue sensation (Peto OR 4.48, 95% CI 0.07 to 286.49; 1 study; very low-certainty evidence). In terms of other adverse effects, two studies reported wound dehiscence at up to 30 days after surgery, but found no difference in risk between interventions. There is insufficient evidence to determine whether the use of a lingual retractor affected the risk of permanent altered sensation compared to not using one (Peto OR 0.14, 95% CI 0.00 to 6.82; 1 study; very low-certainty evidence). None of our other primary outcomes were reported by studies included in this comparison. There is insufficient evidence to determine whether lingual split with chisel is better than a surgical hand-piece for bone removal in terms of wound infection (OR 1.00, 95% CI 0.31 to 3.21; 1 study; very low-certainty evidence). Alveolar osteitis, permanent altered sensation, and other adverse effects were not reported. There is insufficient evidence to determine whether there is any difference in alveolar osteitis according to irrigation method (mechanical versus manual: RR 0.33, 95% CI 0.01 to 8.09; 1 study) or irrigation volume (high versus low; RR 0.52, 95% CI 0.27 to 1.02; 1 study), or whether there is any difference in postoperative infection according to irrigation method (mechanical versus manual: RR 0.50, 95% CI 0.05 to 5.43; 1 study) or irrigation volume (low versus high; RR 0.17, 95% CI 0.02 to 1.37; 1 study) (all very low-certainty evidence). These studies did not report permanent altered sensation and adverse effects. There is insufficient evidence to determine whether primary or secondary wound closure led to more alveolar osteitis (RR 0.99, 95% CI 0.41 to 2.40; 3 studies; low-certainty evidence), wound infection (RR 4.77, 95% CI 0.24 to 96.34; 1 study; very low-certainty evidence), or adverse effects (bleeding) (RR 0.41, 95% CI 0.11 to 1.47; 1 study; very low-certainty evidence). These studies did not report permanent sensation changes. Placing platelet rich plasma (PRP) or platelet rich fibrin (PRF) in sockets may reduce the incidence of alveolar osteitis (OR 0.39, 95% CI 0.22 to 0.67; 2 studies), but the evidence is of low certainty. Our other primary outcomes were not reported.

AUTHORS' CONCLUSIONS

In this 2020 update, we added 27 new studies to the original 35 in the 2014 review. Unfortunately, even with the addition of these studies, we have been unable to draw many meaningful conclusions. The small number of trials evaluating each comparison and reporting our primary outcomes, along with methodological biases in the included trials, means that the body of evidence for each of the nine comparisons evaluated is of low or very low certainty. Participant populations in the trials may not be representative of the general population, or even the population undergoing third molar surgery. Many trials excluded individuals who were not in good health, and several excluded those with active infection or who had deep impactions of their third molars. Consequently, we are unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars. The evidence is uncertain, though we note that there is some limited evidence that placing PRP or PRF in sockets may reduce the incidence of dry socket. The evidence provided in this review may be used as a guide for surgeons when selecting and refining their surgical techniques. Ongoing studies may allow us to provide more definitive conclusions in the future.

Patient morbidity after impacted third molar extraction with different flap designs. A systematic review and meta-analysis

BACKGROUND

To review the literature on the effect of different surgical flaps upon patient morbidity (pain perception, trismus, swelling and osteitis) after impacted third molar extraction.

MATERIAL AND METHODS

An electronic and complementary search of main databases and grey literature was performed up to January 2019 to retrieve randomized clinical trials. The Cochrane risk of bias assessment tool was used for methodological appraisal. A random-effects meta-analysis was conducted of pain perception and trismus.

RESULTS

From the initially 1314 screened studies, only 11 were included in the qualitative synthesis, and 5 in the meta-analysis. There were no statistically significant differences in pain between the envelope and triangular flap designs over time, except on the sixth postoperative day, when the envelope flap proved more painful. Regarding trismus, statistically significant differences were observed on the seventh postoperative day, with greater mouth opening in the envelope flap group than in the triangular flap group. There were no clear differences in swelling and osteitis among the flap designs.

CONCLUSIONS

Despite its limitations, the present meta-analysis found no clear differences in patient morbidity between the different flap designs.

Envelope or triangular flap for surgical removal of third molars? A systematic review and meta-analysis

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

PURPOSE

The objective of the present systematic review was to compare the postoperative outcomes between envelope and triangular flaps after mandibular third molar surgery.

MATERIALS AND METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.

Effects of low-level laser therapy following surgical extraction of the lower third molar with objective measurement of swelling using a three-dimensional system

The aim of the present study was to evaluate and compare the effects of single- and two-dose low-level laser therapy (LLLT) on the postoperative swelling, trismus and pain of patients undergoing extraction of impacted mandibular third molars. In addition, edema was volumetrically measured with a 3dMD face system. A total of 45 patients were randomly divided into three treatment groups (15 patients in each group) as follows: Group 1, receiving routine management with ice application and serving as the control group; Group 2, receiving a single dose of LLLT immediately following surgery; and Group 3, receiving two doses of LLLT, immediately following surgery and on day 2 after surgery. In the present study, a gallium-aluminum-arsenide (0.3 W, 40 sec, 4 J/cm²) diode laser device was applied extraorally at the insertion point of the masseter muscle. The trismus, pain level and facial swelling of the patients were evaluated. The visual analog scale (VAS) was used to examine the pain degree, while a 3dMD face photogrammetric system was used to evaluate the volumetric alterations of the swelling. The results indicated no statistically significant differences in the mean swelling or trismus among the three groups. The mean VAS measurements did not differ significantly among the groups at postoperative day 2; however, significantly reduced VAS values were observed in Group 2 compared with Group 1 at postoperative day 7 (P<0.05). The present study demonstrated that, although single-dose or two-dose LLLT had beneficial effects on the swelling, trismus and pain level, a significant reduction was only observed in the pain level at postoperative day 7.

The flap recovery on the impacted lower third molar surgery comparing 3 different flap designs: a clinical study

Aim

The purpose of the study was to analyze the healing of the deep and superficial lower first and second molars periodontium, after the surgical extraction of the contiguous impacted third molar, comparing 3 mucoperiosteal flap designs.

Materials and methods

150 patients which had to undergo a impacted lower third molar surgery were enrolled in this study. They were checked from day 0 to day 90, in order to focus on the recovery quality of the soft tissues around the lower second molar, comparing 3 different flap designs.

Results

No intraoperatory incident happened. The complete recovery of the periodontium around the second molar has been shown in each patient after 90 days from surgery and each adverse reaction happened within the sixth week after surgery. Only 2 slight gengival recessions 0,5 mm have been find out.

Conclusions

The impacted third molar surgery is an operation that, if rightly programmed and performed, is relatively safe. Besides, the correct handling and management of periodontium around the second molar and the choice of the flap type to be used support a correct recovery on the second molar periodontium, avoiding any long-term damage.

Clinical significance

This study wanted to analyze the healing of the deep and superficial lower second molar periodontium, after the impacted lower third molar surgery. In order to improve the surgical technique used for lower third molar germectomies, we wanted to compare 3 different kind of flap designs.

Wound Dehiscence after Wisdom Tooth Removal in Mandibular Mesioangular Class IB Impactions: Triangular Transposition Flap versus Envelope Flap

Background and aims. Wound dehiscence after lower third molar surgery extends the postoperative treatment period and may cause long-standing pain. The aim of this study was to compare wound dehiscence after removal of wisdom teeth in the most prevalent mandibular impaction (mesioangular class IB) by two different soft tissue flap designs.

Materials and methods. Partially-erupted mandibular third molars with mesioangular class IB impaction (Pell and Gregory classification) were selected. Split mouth technique was used to compare the two flap designs (envelope vs. triangular transposition flap—TTF). The patients were recalled one week and a month later and rechecked for dehiscence, infection, and dry socket formation.

Results. There were no cases of infection in either group. However, three cases of dry socket in the envelope group and four in the TTF group were recorded. In the envelope group, dehiscence occurred in 43% of cases during the first week, with 67% of cases being a large dehiscence (diameters of more than 5 mm). Extra appointments (those requested by the patient exclusively related to the problem of the hole distal to the second molar) were scheduled in 10% of cases in the envelope group. In the TTF group, dehiscence occurred during the first week for the same impaction in 19% of cases with large dehiscence cases occurring in 65% of cases and extra appointment rate at 4.1%.

Conclusion. According to theresults in the evaluated operation, TTF may prevent postoperative wound dehiscence more probably than the envelope flap.

Grading of Extraction and Its Relationship with Post-operative Pain and Trismus, along with Proposed Grading for Trismus

BACKGROUND

Extraction of mandibular third molars are somewhat a matter of interest because of its malpositioning , curved roots, proximity to vital structures due to this the procedure is often associated with post operative complications like pain and trismus. The extraction of third molar was classified in four grads according to the difficulty of the procedure.

AIMS

The purpose of this paper is to find any significant relationship between grading of extraction and post operative complications like pain and trismus.

MATERIALS AND METHODS

A total number of 180 patients need to go for extraction of third molar was included in the study. The variables taken into account were grading of extraction, pain six hour post operatively trismus one day after extraction, and trismus five day after extraction. The four grades of extractions as described by Parent in 1974 were statistically analyzed by computing pearson product moment correlation coefficient with post operative pain and trismus first and fifth day to find any co relation between them.

RESULTS

The grading of extraction was found significantly correlated with post operative pain, trismus one day after and fifth day of surgery.

Surgical techniques for the removal of mandibular wisdom teeth

BACKGROUND

The surgical removal of mandibular wisdom teeth is one of the most common operations undertaken in oral and maxillofacial surgery. The most common indication for surgery is infection about a partially erupted tooth that is impacted against bone or soft tissues. Other indications include unrestorable caries, pulpal and periapical pathology, fracture of the tooth and cyst development, amongst others. Most commonly the benefits of surgical removal of a wisdom tooth include alleviation of the symptoms and signs of pericoronitis and its potential consequences. However, surgery is frequently associated with postoperative pain, swelling and trismus. Less commonly complications include infection, including dry socket, trigeminal nerve injuries and rarely fracture of the mandible.

OBJECTIVES

To compare the relative benefits and risks of different techniques for undertaking various aspects or stages of the surgical extraction of mandibular wisdom teeth.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 21 March 2014), CENTRAL (The Cochrane Library 2014, Issue 1), MEDLINE (OVID) (1946 to 21 March 2014) and EMBASE (OVID) (1980 to 21 March 2014). We searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for ongoing trials. There were no restrictions regarding language or date of publication in the electronic searches.

SELECTION CRITERIA

RCTs comparing surgical techniques for removal of mandibular wisdom teeth.

DATA COLLECTION AND ANALYSIS

Two review authors conducted assessment of relevance, risk of bias and data extraction. Study authors were contacted for additional information. RRs were used for dichotomous data and MDs for continuous data, unless the event rate was very low and Peto ORs were used. The pairing of the split-mouth studies was taken into account in the analysis for both dichotomous and continuous outcomes, and parallel group and split-mouth studies were combined using the generic inverse variance method. Random-effects models were used provided there were more than three studies (fixed-effect models otherwise).

MAIN RESULTS

A total of 35 trials (2569 patients) were included. The interventions under consideration fell into seven broad categories, with many comparisons including only a small number of trials. Twenty-one of the trials were assessed at high risk of bias, the remaining 14 as unclear. The results are described in the summary of findings tables.Triangular flaps were associated with a 71% reduction in alveolar osteitis at one week (RR 0.29, 95% CI 0.11 to 0.78; three trials, moderate quality) and reduction in pain at 24 hours (MD -0.21, 95% CI -0.32 to -0.10; two trials, moderate quality) compared with envelope flaps. There was no evidence of a difference in overall infection rates, in maximum mouth opening or in permanent sensation. However, there was some evidence that residual swelling after one week was slightly increased in the triangular flap groups compared to envelope flap types (MD 0.66 mm, 95% CI 0.26 to 1.07; two trials, low quality). We found no data on temporary sensation, or adverse events.There was low quality evidence from two studies, looking at the use of a retractor during third molar surgery, to indicate more cases of temporary altered sensation (up to one month) when a retractor was used (Peto OR 5.19, 95% CI 1.38 to 19.49; two trials, low quality). One study reported that this did not persist for more than six months in either group. We found no data for use of a retractor on other primary outcomes or adverse effects (including fracture of the mandible).Due to the small number of studies, the different comparisons evaluated, the variable outcomes reported and the paucity of useful data for all primary outcomes we were not able to draw any conclusions concerning bone removal in third molar surgery.There was insufficient evidence from single studies of very low quality on irrigation method (manual versus mechanical) or irrigation volume (low or high) to determine whether there were differences or not for the outcomes of alveolar osteitis or postoperative infection. We found no data for any of the other primary outcomes.There was insufficient evidence (low to very low quality) that any wound closure technique (primary versus secondary) was superior to another for the outcomes of alveolar osteitis, postoperative infection or maximum mouth opening achieved after seven days, or reactionary bleeding. There was evidence that secondary wound closure was associated with reduced pain at 24 hours (MD 0.79, 95% CI 0.35 to 1.24; four trials, moderate quality) and slightly reduced swelling after one week (MD 0.33, 95% CI 0.09 to 0.57; seven trials, moderate quality).We found no data on other primary outcomes.There was some evidence that the use of a surgical drain was associated with less postoperative swelling (MD -0.90, 95% CI -1.62 to -0.19; five trials, moderate quality) and greater maximum mouth opening one week after surgery (MD 3.72 mm, 95% CI 2.84 to 4.59; two trials, moderate quality). There was insufficient evidence from a single study (low quality) to determine whether the presence of a drain made any difference to pain at 24 hours postoperation. There were no data for the other primary outcomes.Although two RCTs compared coronectomy with complete extraction, flaws in the design and the unit of analysis of these studies meant that there were no reliable data available for inclusion.

AUTHORS' CONCLUSIONS

The thirty-five included trials looked at a range of different surgical techniques. The comparisons related to seven broad aspects of the surgical procedures for impacted mandibular third molars: type of surgical flap raised, use of retractors, techniques for bone removal, wound irrigation, wound closure, wound drainage, and complete/incomplete tooth removal. The quality of the body of evidence for each of these comparisons was very low to moderate due to the small number of trials and patients, and the majority of the trials being at high risk of bias (65%) with the remainder at unclear risk of bias.The evidence for making changes to surgical practice is therefore limited. However, it is useful to describe the state of the research evidence supporting practice so that surgeons can make an informed choice in adopting new techniques, or continuing with established techniques.