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

Comparison of Buccal and Lingual-Based Triangular Flap During Mandibular Third Molar Extraction for Reducing Postoperative Complications: A Randomized Controlled Trial

Background

Surgical removal of the mandibular third molar requires reflection of the mucoperiosteal flap. Several studies have suggested different varieties and innovative designs for flap reflection. We have designed a randomized controlled trial (RCT) to check the feasibility of two flap designs: lingual-based triangular flap (LBTF) and buccal-based triangular flap (BBTF) by calculating the duration of surgery and evaluating postoperative complications such as pain, swelling, and trismus.

Materials and Method

It was a non-inferiority parallel-group RCT. The trial was registered in the Control Trial Register of India (CTRI/2021/10/037182) and was performed according to Consolidated Standards of Registered Trial (CONSORT) guidelines. Intraoperative surgery time and postoperative pain, swelling, and trismus were measured and analyzed by a two-sample t test. The Chi-square test was used to measure gender distribution in the study.

Result

Of the total of 88 required subjects, gender distribution and performed surgical time were statistically insignificant with a p-value of 0.76 and 0.48, respectively. The pain was significantly higher in the LBTF group in the 5th and 7th postoperative days with a p-value of 0.02 and 0.028. The swelling was statistically higher during all the follow-ups except for the 28th day in the LBTF group with values of 0.006, 0.002 and 0.003, respectively. There was no significant difference in inter-incisional distance (IID) between the groups during postoperative check-ups.

Conclusion

LBTF shows no edge over BBTF during mandibular third molar disimpaction.

In Vitro Study of Tensile Strength Comparison of Selected Nonabsorbable and Absorbable Suture Materials after Immersion in 0.12% Chlorhexidine Gluconate

Aim

To compare the tensile strength (TS) of absorbable and nonabsorbable suture materials after immersion in 0.12% chlorhexidine gluconate.

Materials and Methods

Six 4-0-gauge suture materials were used, namely silk (S), polypropylene (PP), polyamide 6 (PA6), polyglactin 910 (PG910), poliglecaprone 25 (PL25), and polydioxanone (PDX). A total of 540 suture materials were divided equally (90) into six groups and tested. These materials were divided into a nonimmersed condition (10) and two thermostatically controlled immersion media (40 each), using artificial saliva for the control group (CG) and 0.12% chlorhexidine gluconate for the test group (TG). The specimens were tied to prefabricated rubber rods before immersion and removed at the testing timepoint. By using a universal testing machine (Instron 5566) with hooks attached, a hook-mounted specimen TS testing was performed on days 0, 1, 3, 7, and 14 at a 10 mm/min crosshead speed until the material was stretched to failure, and the maximum TS was recorded in Newtons (N). The continuous variables were taken as the mean and standard deviation across the six study groups to assess the significance at α = 0.05. A two-factor analysis of variance (ANOVA) was performed to assess the TSs over time in different media. A Bonferroni correction was performed when the data were statistically significant according to a two-factor ANOVA. Intragroup statistical comparisons were performed by repeated ANOVA for each study group. All data were analyzed using SPSS 26.

Results

The suture material TS analysis showed that nonabsorbable suture materials maintained their TS throughout the study; silk exhibited different behaviors, decreasing in TS from baseline to day 1 and maintaining its TS until day 14. All absorbable suture materials decreased in TSs by day 14. The silk and PG910 samples in the TG performed significantly better than those in the CG.

Conclusions

Prescribing 0.12% chlorhexidine gluconate as a postsurgical mouth rinse is safest when silk and PG910 are the optimal suture materials.

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.

The Role of Antibiotic Use in Third Molar Tooth Extractions: A Systematic Review and Meta-Analysis

Background and Objectives: Anecdotal evidence suggested variation in practices for antibiotic prescribing around dental procedures including route of administration of antibiotics, timing of the course prescribed (before, after or both), length of course prescribed, narrow vs. broad spectrum agents prescribed, use of single or combination of antibiotics, and the use of loading doses. This review aims to investigate this disparity of practices and the absence of global and local recent consensus on the most appropriate antibiotic interventions around invasive dental procedures. Material and methods: Following PRISMA-P© methodology, a systematic review of randomised controlled clinical trials was designed, reviewed, and entered on the PROSPERO© website prior to commencement. Ethics approval was gained from the University of Wolverhampton Committee. Searches were performed using PubMed©, Science Direct™, and the Cochrane Database, plus the bibliographies of studies identified. They investigated studies examining the efficacy and safety of any antibiotic regimen tested, independent of regimen used, versus a placebo, control, or no therapy, on outcomes in post third molar extraction. Results: The primary outcome of interest was postoperative infection and secondary outcomes were other post-surgical related complications of infectious nature and antibiotic adverse events. Sixteen RCTs were identified that met the selection criteria. Antibiotic use was reported to be safe, causing few adverse events. Meta-analysis of infection events showed antibiotics reduced the risk of an infection by 69%, but routine use for prophylaxis in uncomplicated procedures was not supported, and their role in patients with comorbidities or impaired immunity remains controversial. The effect on the incidence of dry socket showed no difference based upon regimen used. No significant benefit was found with respect to reduction of intraoral inflammation, wound dehiscence, haematoma, and lymphadenopathy. Conclusion: The effect on postoperative pain reduction was inconclusive. Routine use of antibiotics around M3 extraction procedures is not supported, but their use in the presence of co-morbidities and or immunosuppression remains controversial to be confirmed by future studies.

Effectiveness of a Brief Hypnotic Induction in Third Molar Extraction: A Randomized Controlled Trial (HypMol)

Third molar extraction is a painful treatment for patients, and thus, it can be used to investigate the effects of analgesics on pain. Hypnosis can help to reduce pain and to decrease the intake of postoperative systemic analgesics. In this study, the effectiveness of a brief hypnotic induction for patients undergoing third molar extractions was investigated. Data were collected from 33 patients with third molar extractions on the right and left sides. Patients received 2 different types of pain interventions in this monocentric randomized crossover trial. Third molar extraction was conducted on 1 side with reduced preoperative local anesthetics and an additional brief hypnotic induction (Dave Elman technique). The other side was conducted with regular preoperative local anesthetics without a brief hypnotic induction (standard care). Intake of postoperative systemic analgesics was allowed in both treatments. Patients' expectations about hypnosis were assessed at baseline. The primary outcome was the area under the curve with respect to ground of pain intensity after the treatment. Secondary outcomes were the amount of postoperative analgesics consumed and the preferred treatment. There was no evidence that the area under the curve with respect to ground of pain differed between the 2 interventions (controlling for gender), but the patients' expectations affected the effectiveness of the brief hypnotic induction. This means that patients with high expectations about hypnosis benefit more from treatment with reduced preoperative local anesthetics and additional brief hypnotic induction. PERSPECTIVE: Hypnosis is used as a treatment to reduce pain in general and dental settings. In this study, additional a brief hypnotic induction with reduced preoperative local anesthetic use did not generally reduce posttreatment pain after third molar extraction more than regular local anesthetics. The expectation of the patients about the effectiveness of hypnosis affected the effectiveness of the brief hypnotic induction so that patients with high expectations had a larger benefit from a brief hypnotic induction than patients with low expectations.

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.

Pain in Oral and Maxillofacial Surgery and Implant Dentistry: Types and Management

Over the years, the pain has been defined numerous times in several ways. In oral and maxillofacial surgery, the occurrence of pain, especially postoperatively, is anticipated. Pain arises as a combination of various processes after tissue damage. Distinct pain experiences in oral surgery were depicted in several previous studies, adding knowledge to the field. The management of these encounters has been suggested over time, improving treatment approaches in the clinical setting. This review aims to understand the pain and its types and intervention in the field of oral and maxillofacial surgery.

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.

Classification of postoperative edema based on the anatomic division with mandibular third molar extraction

Purpose

Several investigations have been performed for a postoperative edema after extraction, but the results have been controversial due to low objectivity or poorly reproducible assessments of the edema. The aim of this study was to suggest a classification and patterns of postoperative edema according to the anatomical division associated with extraction of mandibular third molar as a qualitative evaluation method.

Methods

This study was conducted forty-four mandibular third molars extracted and MRI was taken within 48 h after extraction. The postoperative edema space was classified by MRI (one anatomic component—buccinator muscle—and four fascial spaces—supra-periosteum space, buccal space, parapharyngeal space, and lingual space), and evaluated independently by two examiners. The inter-examiner reliability was calculated using Kappa statistics.

Results

The evaluation of buccinator muscle edema showed good agreement and the fascial spaces showed constant high agreement. The incidence of postoperative edema was high in the following order: supra-periosteum space (75.00%), buccinator muscle (68.18%), parapharyngeal space (54.55%), buccal space (40.91%), and lingual space (25.00%).

Conclusion

Postoperative edema could be assessed clearly by each space, which showed a different tendency between the anatomic and fascial spaces.

A Noval Method for Surgical Removal of the Impacted Mandibular Third Molar: Sartawi Technique

Background

The goal of this article is to present and evaluate the clinical effectiveness of a new surgical approach using a triangular flap with slight modification and a 3-0 black braided silk surgical suture as flap retractor which is later used after the surgical procedure as a normal suture, aiming to decrease procedure time, soft tissue retraction, and tools for removal of impacted mandibular third molar.

Methods

Patients requiring removal of fully impacted or semi-impacted lower third molars are treated with a new approach using minimal steps and tools, a simple triangular flap, slight mucoperiosteum elevation, as the flap sides are secured and reflected with a silk suture by an assistant holding both sides of the suture from behind the patient.

Results

The surgical area at the procedure was efficiently exposed, and the separation of the crown from the roots was easily done using a surgical handpiece, separation and removal of the crown, removal of the roots with a straight elevator, without the need of flap retractor or overexposure of the surgical side with a conventional triangular flap or others. After the treatment, the two sides of suture are tied together with double overhand knots, and the surgical site was fully repositioned and closed without any complications. 5- and 7-day follow-up was done on the patients, and no complications were reported.

Conclusions

This preliminary study presents a new surgical approach (Sartawi technique) which can be used during extraction of impacted and semi-impacted lower third molars, the results showed that the operation time was noticeably reduced, the size of exposed mucoperiosteum tissue was minimized compared to the conventional method, the use of the mucoperiosteum elevator was eliminated, and number of suture knots and suture used to close the surgical site reduced to a single stitch.

Effect of lingual-based flap design on postoperative pain of impacted mandibular third molar surgery: Split-mouth randomized clinical trial

Background

The extraction of third molars is one of the most common procedures in oral and maxillofacial surgery clinic. Surgical extraction involves the manipulation of both soft and hard tissues, so the patient usually experiences pain, swelling, and trismus in the immediate post-operative period. Several studies have been conducted using different types of surgical flaps to provide access with the least possible damage of soft tissues. Designing and implementing an optimum flap, which provides easier technique, better visibility, minimal post-operative complications, and best healing, is an aspired goal of every oral surgeon. This study aimed to compare lingual-based four-cornered flap with conventional triangular flap, and to evaluate its effect on post-operative pain after surgical extraction of impacted lower third molars.

Material and Methods

Seventeen patients (age ranged from 19 to 26 years) with bilateral, symmetrical impacted lower third molars (n=34) were included in the study. This was a randomized clinical trial with a split-mouth design. The impacted molars were assigned randomly, by coin flipping, to two groups: Case side with lingual-based four-cornered flap (Group A), and control side with conventional triangular flap (Group B). Away from the incision, the prognosis, surgical intervention, and postoperative procedures were exactly the same for the two groups. Postsurgical pain was assessed for 5 days using visual analogue scale (VAS) and by recording patients need for analgesics on a daily basis. Patients were also evaluated via a self-reporting questionnaire, i.e. Postoperative Symptoms Severity (PoSSe) scale, administered on the seventh postoperative day.

Results

Pain scores recorded in Group A were found to be significantly lower as compared to pain scores in Group B in the 5 postoperative days (P<0.05). Total analgesic intake in Group B was significantly higher (P<0.05). PoSSe scores were lower in Group A, however, this difference was insignificant (P>0.05).

Conclusions

According to the data of the current study and within its limits, it appeared that lingual-based four-cornered flap design was superior to the conventional triangular flap regarding the postsurgical discomfort and pain.

Key words:Impaction, third molar surgery, flap design, pain, PoSSe scale, split-mouth, RCT.

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.

The influence of flap design on sequelae and quality of life following surgical removal of impacted mandibular third molars: A split-mouth randomised clinical trial

BACKGROUND

Surgical removal of impacted mandibular third molar is one of the most frequently performed interventions in oral and maxillofacial surgery.

OBJECTIVES

To compare two different flap designs in terms of sequelae and quality of life following surgical removal of impacted third molars.

METHODS

This prospective, randomised, split-mouth clinical study involved patients referred for surgical removal of bilateral symmetrical impacted mandibular third molars. Envelope flap and modified triangular flap techniques were used. The effects of flap design on trismus, swelling, wound dehiscence, alveolar osteitis, haematoma, infection and quality of life were evaluated on post-operative days 3 and 7. Pain levels were assessed on post-operative days 1, 3 and 7.

RESULTS

Significant differences were determined between the two groups in terms of trismus, pain and wound dehiscence scores on post-operative day 3. However, on post-operative day 7, this difference was observed only in trismus. Statistically significant differences were also determined between the two groups on post-operative day 3 for social isolation and eating subscale scores as well as total quality of life score.

CONCLUSION

Based on the study findings, the modified triangular flap may be superior to the envelope flap in terms of pain, trismus, and wound dehiscence in the first 3 days after impacted third molar surgery and may have a better impact on quality of life during this process.

Apical surgery failures: Extraction or re-surgery? Report of five cases

Apical surgery (AS) is considered as the last attempt to save teeth which cannot be treated with conventional endodontic approach. The main goal of apical surgery is to create a barrier between the root-canal system and the peri-radicular tissues by means of a tight root-end filling after resection. However, failures in this treatment is usually result with tooth loss. In such cases surgical re-treatment would take into consideration as viable alternative. In this case series, successful ARs that performed in ten teeth of five patients who applied for extraction after an unsuccessful apical surgery, were presented. It is pointed that if appropriate surgical and endodontic intervention is performed and adequate apical obturation is provided with retrograde filling, teeth can be treat without extraction.

The Impact of the Use of Kinesio Taping Method on the Reduction of Swelling in Patients After Orthognathic Surgery: A Pilot Study

BACKGROUND Orthognathic surgery (OGS) is associated with extensive surgical intervention within the soft and hard tissues of the facial region of the skull leading to inflammatory reactions. The presence of postoperative swelling indicates the accumulation of exudate or transudate; both these fluids occur in surgery. Massive swelling is a significant problem, because the tension of tissues intensifies pain sensations. The aim of the study was to evaluate the effectiveness of the kinesio taping method (KT) in patients after orthognathic surgery in the area of the facial skull in terms of eliminating postoperative swelling. MATERIAL AND METHODS The study of the impact of kinesiology tape applied after orthognathic surgery to the craniofacial area on the elimination of swelling was performed in sixteen patients who suffered from this complication after bilateral sagittal split osteotomy. RESULTS The swelling was shown to be reduced after KT; within the same study the differences were statistically significant between the left and right sides and for the same side (p<0.05). The application of the lymphatic kinesio taping method led to the reduction of tension in the affected area and restoration of proper lymphatic circulation in the region covered by swelling. This allows for the improvement of the blood and lymph microcirculation and activation of self-healing processes. CONCLUSIONS The analysis of the impact of the practical use of the lymphatic KT on complications after orthognathic surgery revealed that it had a beneficial effect on the reduction of swelling. The use of the KT method seems promising because it is simple to carry out, not traumatic, economical and rarely causes undesirable allergies.