Mandibular third molar removal in young patients: an evaluation of 2 different flap designs

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.

Does surgical removal of mandibular third molar influence the periodontal status of the adjacent second molars? A systematic review

Objective: This study aimed to assess the influence of mandibular third molar surgical removal on the periodontal status of adjacent second molars and to investigate the potential impact of the flap design. Methods: A systematic review of the literature, registered in PROSPERO, has been carried out from Pubmed and Scopus databases following PRISMA guidelines from January 2010 to January 2022. PICO method was used to select the relevant articles. Studies comparing the periodontal status of the second molar before and after mandibular third molar removal were considered. Results: Twenty-three studies involving 1067 patients were included. The two main parameters studied were periodontal pocket depth and clinical attachment level. The envelope flap and the triangular flap were the most commonly used flap techniques. Periodontal health of adjacent second molar was maintained or improved in most of the included studies. The flap design did not seem to have a significant influence either. Conclusion: Avulsion of impacted third molar in healthy young adults does not impair the periodontal health of adjacent second molars. Further studies, with higher levels of evidence, are needed to confirm these results and to identify possible risk factors (such as age, impaction depth or periodontal disease) responsible for poorer healing.

Periodontal Healing after Lower Third Molars Extraction: A Clinical Evaluation of Different Flap Designs

Periodontal healing after third molars extraction seems to be influenced by the choice of different flap techniques. The purpose of the present study was to assess the clinical condition of adjacent first and second molar sites, after the extraction of lower third molars, performed through different flap designs. Eighty patients, aged between 14 and 30 years, were analyzed for periodontal parameters of VPI, PPD, and CAL, pre-operatively (T0), after 15 days (T1), after 1 month (T2), and after 2 months (T3) from extraction. Techniques performed were trapezoidal flap (TRAP), marginal flap (MARG), flap with papilla detachment (DETP), and flap with papilla decapitation (DEC). No significant differences were found between the four flaps at each observation time and considering the interval between T0 and T3, for VPI, PPD at first molar site, PPD at second molar site, and CAL at second molar site. Significant variations for CAL were registered, for each flap, between T0 and T3, in all cases for buccal site, in three cases for buccal-distal site. After 2 months of follow-up, no strong evidence can be assumed for or against the use of a particular flap design for the extraction of lower 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.

Effects of Impacted Lower Third Molar Extraction on Periodontal Tissue of the Adjacent Second Molar

The extraction of impacted lower third molars (ILTM) is one of the most common procedures in oral-maxillofacial surgery. Being adjacent to lower second molars, most impacted lower third molars often lead to distal periodontal defects of adjacent second molars. Several symptoms may occur after extraction, such as periodontal pocket formation, loss of attachment, alveolar bone loss and even looseness of second molar resulting in extraction. The distal periodontal defects of second molars are affected by many factors, including periodontal conditions, age, impacted type of third molars, and intraoperative operations. At present, several studies have suggested that dentists can reduce the risk of periodontal defects of the second molar after ILTM extraction through preoperative evaluation, reasonable selection of flap design, extraction instruments and suture type, and necessary postoperative interventions. This review summarizes the research progress on the influence factors, interventions methods and some limitations of distal periodontal defects of adjacent second molar after extraction of impacted mandibular third molars, with the aim of opening up future directions for studying effects of ILTM extraction on periodontal tissue of the adjacent second molar.

Flapless Surgical Approach to Extract Impacted Inferior Third Molars: A Retrospective Clinical Study

This study aimed to compare a flapless surgical approach (FSA) with a traditional envelope flap (traditional approach (TA)). Every patient was treated with two approaches: TA and FSA. The primary outcome variables were both the discomfort during the post-operative convalescence and the correct final recovery of the impacted area. The secondary outcome variable was the average duration of the surgery. Post-operative pain and oedema were recorded. The measurements of soft tissue interface toward the distobuccal edge of the second molar were taken by periodontal probe before surgery (baseline) and 8 weeks after surgery. Statistical software was used to evaluate the data; a p-value < 0.05 was considered statistically significant. Twenty-four teeth of 12 patients (six Caucasian males and six Caucasian females, aged 23 ± 4 (17-30) years) with both lower impacted third molars (Ms3) were analysed. Considering an alpha error 0.05 that sample size allows power from 0.80 to 0.90, depending on the variable evaluated. Concerning attached gingiva, oedema and pain, the linear mixed model resulted in a statistically significant difference between the TA and FSA (p = 0.003; p < 0.01; and p = 0.018, respectively). Conversely, the model did not show a difference (p = 0.322) if pocket probing depth was considered. The FSA procedure was faster (p < 0.05) than the TA procedure (17 min and 8 s (±6 s) vs. 28 min and 6 s (±4 s), respectively). The results suggest that the FSA could be a suitable option for improving the surgical removal of lower Ms3. However, additional randomized controlled trial studies are necessary to confirm the reliability of our procedure and to verify its suitability in more complex Ms3 classifications.

Evidence-based clinical decision making for the management of patients with periodontal osseous defect after impacted third molar extraction: A systematic review and meta-analysis

Background/purpose

Extraction of impacted mandibular third molar (MTM) is one of the most common procedures in clinical dental treatment; building a decision tree to perform MTM extraction can be prudent in alleviating periodontal diseases. This study is to review the latest research on the management of periodontal osseous defect (POD) after MTM extraction and rebuild a new clinical decision tree.

Materials and methods

Current study was conducted according to PRISMA statement. Medline, Embase, Scopus, and Google Scholar were searched concerning treatment of MTM extraction up to Oct.2019. Three focused questions revolving around asymptomatic versus disease site, age, and necessity of ridge preservation after >6 months follow up will be answered.

Results

A total of 7 studies were included for meta-analysis. Evidences were inadequate in regards to asymptomatic vs disease site of MTM extraction in the long-term follow-up. For patients with age <25 years, postoperative probing depth (PD) always remained at < 4 mm. However, for patients with age >25 years with initial PD > 7 mm, residual pockets still remained at 5 mm. For ridge preservation, significant positive effect in reduction of second molar distal site PD was observed, regardless of different biomaterials being placed (z = 4.69, p < 0.00001).

Conclusion

Age is of utmost importance in preoperative evaluation during impacted MTM extraction. The timing for ridge preservation is essential determinant for achieving optimal treatment outcome. The clinical decision tree as proposed could serve as guidance when dealing with POD after impacted MTM extraction.

The effect of triangular and reversed triangular flap designs to post third molar odontectomy complications (a pilot study)

Background

Odontectomy is one of the most common surgical procedures in oral and maxillofacial surgery. Flap design influences the post operative complications. Triangular flap is the most widely used flap design but it has many shortages such as dehiscence, alveolar osteitis, reactionary bleeding, and periodontal disruption distal of second molar. The aim of this study is to introduce an alternative flap design in the surgical removal of impacted mandibular third molars – reversed triangular flap – and to compare this flap design with the triangular flap in case of dehiscence, reactionary bleeding, and clinical attachment loss.

Material and Methods

This prospective, split-mouth study involved 15 patients with bilateral partially impacted mandibular third molars with similar impaction classification. One impacted tooth was removed using a triangular flap and the other using a reversed triangular flap. Post operative complications such as dehiscence, reactionary bleeding, and clinical attachment loss were recorded 1, 3, 7, 14, and 30 days post odontectomy.

Results

Chi square test result shows that there were fewer incidences of dehiscence seven days post surgery using the reversed triangular flap (p=0.032). Mann Whitney-U test result shows that the reversed triangular flap exhibited less bleeding score on day 1 (p=0.002) and day 2 (p=0.035) post surgery. There were no statistically significant differences according to Mann Whitney-U test between the flap designs for the clinical attachment loss on distal of second molar on day 14 (p=0.512) and day 30 (p=0.902) post surgery.

Conclusions

The reversed triangular flap design is preferable to triangular flap for impacted third molar surgery, escpecially in terms of wound dehisence and reactionary bleeding.

Key words:Flap design, third molar impaction, odontectomy, post odontectomy complications.

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 Different Kinesio Taping Techniques After Third Molar Surgery

PURPOSE

Elastic therapeutic taping method has been shown to reduce pain and edema after surgery. The purpose of the present study was to compare the effects of 2 different Kinesio taping (KT) techniques on swelling, pain, and trismus after third molar surgery.

PATIENTS AND METHODS

The study was designed as a split-mouth, single-blinded, and controlled randomized clinical trial. Patients undergoing lower impacted third molar extraction at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, İzmir Katip Çelebi University, were included in the present study. Group I included 30 patients and was used to compare the classic KT technique (technique A) and the new KT technique (technique B). Group II included 15 patients and was used to compare the classic KT technique (technique A) and no KT (No-KT [control]). Group III included 15 patients and was used to compare the new KT technique (technique B) and No-KT (control). Swelling was assessed using the 3dMD Face System (3dMD, Atlanta, GA). The maximum interincisal distance was recorded using a digital caliper preoperatively (T0) and at postoperative days 2 (T1) and 7 (T2). The visual analog scale for pain scores were recorded postoperatively at 30 minutes, 1, 2, 3, 4, 5, 6, 8, 10, 12, and 24 hours, and 1, 2, 3, 4, 5, 6, and 7 days. The effects of operative time, patient age, and patient gender were also evaluated.

RESULTS

The data from 60 patients (27 men and 33 women) with a mean age of 22.28 years (range, 18 to 31 years) were analyzed in the present study. The amount of swelling and the interincisal distance were less with technique B than with technique A and no KT (control group).

CONCLUSIONS

KT is a useful method for reducing postoperative morbidity after impacted third molar extraction. In particular, the application of KT using the new technique described in the present study could be more effective than the classic methods.

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.

Effect of flap design and duration of surgery on acute postoperative symptoms and signs after extraction of lower third molars: A randomized prospective study

Background. Different surgical variables are assumed to play a role in postoperative course after lower third molar extraction. The aim of study was to assess whether flap design and duration of surgery can influence acute postoperative symptoms and signs after lower third molar extraction.

Methods. Twenty-five patients scheduled for lower third molar extraction were included in this study and randomly assigned to two groups in terms of flap design: group A (envelope flap) and group B (triangular flap). Swelling and trismus were assessed before and after surgery on days 0, 2 and 7. Pain was assessed for seven days after surgery. Maximum postoperative pain was chosen as the main outcome variable. ANOVA was used to assess differences between the groups regarding maximum postoperative pain, trismus and swelling at 2- and 7-day intervals. Pearson's correlation coefficient was used to assess correlation between duration of surgery and postoperative symptoms and signs.

Results. No significant difference was found between the two flap designs for any postoperative symptoms and signs. The duration of surgery was found to be correlated with both trismus (r = -0.44, P = 0.04) and swelling (r = 0.59, P = 0.004) as assessed 2 days after surgery. No associations were found between duration of surgery and maximum postoperative pain and trismus and swelling at 7-day interval.

Conclusion. Within the limits of the present study, the duration of surgery, and not the flap design, affected the acute postoperative symptoms and signs after lower third molar extraction.

[Consequences of impacted wisdom teeth extraction on the periodontal environment of second molars. A pilot study]

INTRODUCTION

Wisdom teeth extraction is a common procedure, generally considered as safe by patients. However, complications are possible, especially periodontal ones. The aim of this study was to evaluate the frequency and the consequences of periodontal complications at the level the 2nd molars after extraction of the wisdom teeth.

MATERIAL AND METHODS

A single-center retrospective observational multi-operator study was conducted at the university hospital of Besançon - France. The files of all the adult patients who underwent extraction of four impacted wisdom teeth by mean of a standardized surgical technique between November 2012 and November 2014 and who could be followed 1 year postoperatively at least and that precisely mentioned the periodontal status of the surgical sites were included. Postoperative complications, gingival and plaque indexes according to Loë and Silness, periodontal attachment level and periodontal second molar probing were recorded. The main judgment criterion was the occurrence of a periodontal complication in the second molar areas.

RESULTS

The files of 20 patients (15 women - 5 men), operated on by five different surgeons, met the inclusion criteria. Two patients suffered from dry socket at one of the avulsion sites. No patient had a gingival or plaque index greater than 2. No gingival recession or periodontal pocket over 4mm was found.

DISCUSSION

Extraction of impacted third molars in young healthy adults didn't have any impact on the second molars periodontal environment in our study. Literature suggests that surgical technique greatly influences the occurrence and the extent of periodontal sequelae.

Evaluation of two flap designs on the mandibular second molar after third molar extractions

BACKGROUND

The extraction of third molars is associated with some clinical outcomes and periodontal problems. It is imperative to note that the type of incision used in the surgery for the removal of the impacted third molar is critical. The design of the flap influences the healing of the surgically created defect and damage to the distal periodontal area of the adjacent second molar. However, till date, there have been conflicting reports on the influence of different flap designs used for the surgical removal of impacted third molars.

AIM

The present study aimed to comparatively evaluate the clinical outcomes and periodontal status of the adjacent second molar, when two different flap designs, namely, the envelope and the modified triangular flap designs were used.

MATERIALS AND METHODS

Sixty female patients with bilateral impacted third molars completed the study with envelope flap on one side and modified triangular flap design on the other side of the mandible for third molar removal. Clinical parameters including pain, dehiscence and swelling were assessed postoperatively and periodontal probing depth (PPD) on the distal aspect of adjacent second molar were assessed both pre- and post-operatively.

RESULTS

The results were assessed on 1, 3 and 8 days for pain using visual analog scale. The subjective perception of swelling was evaluated on 3, 7 and 15 days postoperatively in a similar manner. The results of the periodontal parameters were evaluated both preoperatively and 3 months postoperatively, with cautious exploration using a University of North Carolina (UNC)-15 periodontal probe. The statistically significant results for swelling and PPD were noted for the two flap groups using the Chi-square test (P < 0.05).

CONCLUSION

The study revealed that the modified triangular flap had lesser postoperative PPDs and dehiscence. The envelope flap was better when swelling was analyzed. The pain scores, though slightly higher for the modified triangular flap group, were not statistically significant.

Effect of flap design on periodontal healing after impacted third molar extraction: a systematic review and meta-analysis

The extraction of an impacted third molar violates the surrounding soft and bony tissues. The surgeon's access to the tooth, for which there are various surgical approaches, has an important impact on the periodontium of the adjacent second molar. The aim of this review was to analyze the relationships between the different flap techniques and postoperative periodontal outcomes for the mandibular second molars (LM2) adjacent to the impacted mandibular third molars (LM3). An electronic search of MEDLINE and other databases was conducted to identify randomized controlled trials fulfilling the eligibility criteria. To assess the impact of flap design on the periodontal condition, the weighted mean difference of the probing depth reduction (WDPDR) and the weighted mean difference of the clinical attachment level gain (WDCAG) at the distal surface of LM2 were used as the primary outcomes. The results showed that, overall, the different flap techniques had no significant impact on the probing depth reduction (WDPDR -0.14mm, 95% confidence interval -0.44 to 0.17), or on the clinical attachment level gain (WDCAG 0.05mm, 95% confidence interval -0.84 to 0.94). However, a subgroup analysis revealed that the Szmyd and paramarginal flap designs may be the most effective in reducing the probing depth in impacted LM3 extraction, and the envelope flap may be the least effective.

Surgical removal of third molars and periodontal tissues of adjacent second molars

OBJECTIVES

The aim of this study was to investigate the effect of mandibular third-molar (M3) removal on periodontal health of adjacent second molars (M2). Probing pocket depths (PPD) and probing attachment levels (PAL) have been described for primary outcome. As cofactors involved, gender, complications, two suture materials and two types of impaction were chosen as secondary outcomes.

MATERIALS AND METHODS

Seventy-eight patients (49 female; mean age: 16.0 ± 2.0 years) with 78 asymptomatic impacted mandibular M3 were included in this study. Plaque and gingival indices, PPD and PAL were recorded prior and 6 months after surgery. Impacted teeth were classified as either fully impacted (completely within in the bone) or submucosal (fully covered by oral mucosa).

RESULTS

Average baseline PPD was reduced from 3.3 mm to 2.6 mm after 6 months (p < 0.05). Average PAL was reduced from 3.0 to 2.5 mm (p < 0.05). Preoperative PPD ≥ 4 mm at the distolingual and distobuccal sites was positively correlated with clinical improvement (PPD: p < 0.05; PAL: p < 0.05). The impaction class was also identified as positive cofactor for PPD (p = 0.039), but not for PAL.

CONCLUSIONS

Young patients may benefit from an early removal of mandibular M3, especially in the presence of certain cofactors.

Does laterally rotated flap design influence the short-term periodontal status of second molars and postoperative discomfort after partially impacted third molar surgery?

PURPOSE

To assess the influence of the surgical removal of partially impacted third molars (3Ms) and compare the effects of a 3-cornered laterally rotated flap (LRF) with primary closure (flap 1) and an envelope flap with secondary closure (flap 2) on the short-term periodontal status of the adjacent second molars (2Ms). We also assessed the postoperative complications after removal of the partially impacted 3M.

MATERIALS AND METHODS

A split mouth, randomized clinical study was designed. The study sample included patients with bilateral partially impacted 3Ms. The primary predictor variable was the type of flap design (flaps 1 and 2). The primary outcome variable was periodontal status (gingival recession [GR], probing depth [PD], plaque index [PI], and gingival index) of the 2Ms measured preoperatively and 90 days postoperatively. The secondary outcome variables were postoperative complications, including pain, facial swelling, alveolitis, and local wound infection. The other variables included gender, position of the 3Ms, and surgical difficulty. We performed descriptive, comparative, correlation, and multivariate analyses.

RESULTS

The sample included 28 patients aged 18 to 28 years. The GR, PD, and PI values with the flap 2 design were greater than those with the flap 1 design (P < .05). Facial swelling with the flap 1 design was significantly greater than with the flap 2 design on the second postoperative day (P < .05). The pain levels with the flap 1 design were significantly greater than those with the flap 2 design on the first and second postoperative days (P < .05). According to the multivariate regression analyses, flap design was closely related to the periodontal status of the 2Ms and postoperative discomfort.

CONCLUSION

The results of the present clinical study have shown that the flap design in partially impacted 3M surgery considerably influences the early periodontal health of the 2Ms and postoperative discomfort. However, although the 3-cornered LRF design might cause more pain and swelling, it could be the method of choice for partially impacted 3M surgery because of the early periodontal healing.

Expandable Micro-motor Bur, design of a new device for least invasive extraction of broken teeth roots

Background

Extraction of a broken tooth root is often a traumatic experience for both the practitioner and the patient. To extract broken roots, generally invasive approaches as open window surgeries or mucoperiosteal flap and/or removal of buccal bone are performed.

Presentation of the hypothesis

Expandable micro-motor bur (EMB) is a hypothetical design of a dental instrument proposed for removal of broken teeth roots that cannot be extracted by the routine closed methods and in which common instrumentations cannot afford to accomplish. Implication of EMB would introduce a new technique in removal of broken teeth roots in which surgical trauma is minimized and so post-extraction disorders. It would eliminate surgical invasion to the surrounding tissues; and also it would eliminate profound hand forces by the practitioner, consequently reduces stress for both the practitioner and the patient. It would eliminate high risk aftermaths such as operative morbidity (due to bone loss), maxillary sinus exposure and probable need for additional surgery as are indicative of some conventional open access approaches.

Testing the hypothesis

Further studies are needed to confirm its effect in clinical cases. The effectiveness of EMB should be verified firstly by animal experiments. The likelihood of its negative influence on nearby vascular and nerve system should be well evaluated.

Implications of the hypothesis

Implication of EMB would be of interest to both patients and the surgeon due to the following main achievements: a) no need for mucoperiosteal flap, hence preservation of soft tissue, b) no need for osteotomy, hence retention of buccal bone, c) less risk of sinus exposure, d) minimum chance of post operative infections due to eliminated surgeries in soft tissues and bones and e) in terms of esthetics, it will have a special meaning for immediate placement of dental implants. EMB’s structural components include Bur head, Spacers and Bur base. A micro motor would power its spin. In contrast to conventional surgical approaches, EMB procedure is conservative. It is anticipated that EMB would provide less traumatic and least post-operative complications in extraction of broken teeth roots.

Strategies used to inhibit postoperative swelling following removal of impacted lower third molar

Postoperative swelling following different surgical strategies is an area of great interest. The main part of literature on the topic deals with swelling after extraction of low impacted third molar. In this review, we have analyzed publications of the last 20 years with a pubmed search using the following key words: impacted third molar, swelling third molar, wisdom tooth, edema jaw, corticosteroids and extraction third molar, antibiotic prophylaxis and tooth extraction. Attention has often been focused on corticosteroid therapy administered by diverse routes (orally, IV, IM, topically) and at different time schedules (before or after surgery or both). This investigation revealed how the use of different molecules and dosages makes the obtained results hardly comparable. Similar conclusions can be drawn from studies aimed at evaluating the efficacy of antibiotic therapy administered either before or after surgery. A complete review has also to take into account different surgical strategies used including various flaps, no traumatic osteothomy, and primary or secondary closure. The use of pharmacological therapy and application of an ice pack is critical in the postoperative period and has always provided positive results. However, even if it is difficult to come to definite conclusions, due to the variability of the design of studies analyzed, the postoperative discomfort identified with edema, pain and trismus following wisdom tooth removal is influenced by various factors such as the difficulty of the surgical procedure involved, age and gender of the patient, and experience of the surgeon. The pharmacological therapy when performed with corticosteroids seems to improve control of the postoperative swelling related with this kind of surgeries.

Mandibular second molar periodontal healing after impacted third molar extraction in young adults

PURPOSE

To estimate the prevalence of preoperative periodontal defects and analyze 12-month spontaneous healing on the distal aspect of the mandibular second molar (M2) after impacted mandibular third molar (M3) extraction.

MATERIALS AND METHODS

This prospective clinical study was conducted in 25 healthy young patients (21.03 ± 4.38 yr old) with 40 extractions of higher-risk periodontal impacted M3s. Plaque and gingival indexes, recession, bleeding on probing, probing depth (PD), and attachment level were recorded before surgery and at 3, 6, and 12 months after surgery at 5 sites on the distal aspect of the M2.

RESULTS

The initial mean PD was 5.70 ± 3.80 mm, with the deepest mean PD at the lingual side. At 12 months, a mean PD average of 3.77 ± 2.86 mm was recorded, with a total average recovery of 1.93 ± 2.46 mm (P < .001), that was higher at 3 months (-1.62 mm, P < .001). The PD and attachment level improvements were statistically significant (P < .001) and nearly clinically significant from baseline to 12-month follow-up and from the buccal to the lingual side of the distal aspect of the M2.

CONCLUSIONS

Impacted M3s adjacent to M2s lead to periodontal defects that are deepest at the lingual side and almost recover at 12 months after extraction. The first 3 months is considered the cutoff for periodontal healing. Young adults with high-risk periodontal M3 impactions may benefit from early extraction, which increases spontaneous periodontal healing.

Effect of 2 flap designs on postoperative pain and swelling after impacted third molar surgery

OBJECTIVE

The aim of this study was to evaluate 2 flap designs (envelope and modified triangular flap) for postoperative pain and swelling after mandibular impacted third molar surgery.

STUDY DESIGN

Thirty patients who had symmetric bilateral fully impacted mandibular third molars were selected. Left teeth were approached with an envelope flap, and right teeth were removed using a modified triangular flap. Postoperative pain and swelling were evaluated until the seventh day by using 2 verbal rating scales.

RESULTS

Statistical analyses showed that there were no significant differences between the 2 incision techniques regarding postoperative pain and swelling (P > .05).

CONCLUSIONS

There is no significant difference between the envelope and modified triangular flap regarding postoperative pain and swelling after impacted third molar surgery.

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

PURPOSE

The aim of this study was to compare the influence of triangular and envelope flaps on trismus, pain, and facial swelling after mandibular third molar surgery.

METHODS

Twenty healthy patients with bilateral, symmetrically impacted mandibular third molars were included in this double-blinded, prospective, cross-over, randomized study. The patients were operated with envelope flap on one side and triangular flap on the other side. Trismus was determined by measuring maximum interincisal opening, and facial swelling was evaluated using a tape measuring method. Pain was determined using visual analog scale (VAS) and recording the number of pain pills taken.

RESULTS

The facial swelling measurements and VAS scores were lower in the envelope flap group compared to the triangular flap group. There was no significant difference between the two flap designs in operation time, maximum interincisal opening, and the number of analgesics taken.

CONCLUSION

Envelope flap yields to less facial swelling and reduced VAS scores in comparison to triangular flap. There is no clinical difference in trismus between the two flap designs. Despite the higher VAS scores with triangular flap, no additional doses of analgesics were required in triangular flap.

Evaluation of antibiotic prophylaxis in reducing postoperative infection after mandibular third molar extraction in young patients

PURPOSE

This study evaluated the influence of antibiotic prophylaxis on postoperative complications after inferior third molar removal in young patients.

PATIENTS AND METHODS

We extracted 59 mandibular third molars from 59 patients with a mean age of 15 years (range, 12-19 years). The patients were included in the study when radiographs at the time of surgery showed that only the crown of the tooth germ was formed. Patients were randomized into 2 groups, the test group and the control group. The test group received 2-g amoxicillin tablets 1 hour before surgery, and the control group received no antibiotic therapy. The test group included 32 patients, 20 of whom were female and 12 were male; the mean age was 15 years. The control group included 27 patients, 12 of whom were female and 15 were male; the mean age was 15 years. Postoperative complications such as pain, swelling, wound infection, and fever were recorded by use of a questionnaire completed by the patient for the week after the extraction. Suture removal and questionnaire evaluation were performed by a surgeon who did not know the preoperative regimen.

RESULTS

The mean operating time was 34 minutes in the control group and 31 minutes in the test group. This difference was not significant. In the test group there was a statistically significant reduction of postoperative pain in the 7 days after the extraction, and the patients had a consistent minor consumption of analgesics. Swelling was always present in the control and test groups in the postoperative week, but in the test group it was a minor sequela and was absent in 2 patients. Wound infection was a sequela reported in 4 patients in the control group and in 1 patient in the test group; this difference was statistically significant (P < .01). Fever was present in 2 patients in the control group and in 1 patient in the test group; this difference was not statistically significant.

CONCLUSIONS

A statistically significant difference was found between patients receiving preoperative amoxicillin and the control group in the incidence of postoperative pain, fever, and wound infection. Another important finding was the statistically minor consumption of analgesics in the test group in the postoperative week.