International Journal of Medical and Health Research

ISSN: 2454-9142
www.medicalsjournals.com
Volume 1; Issue 3; October 2015; Page No. 32-35

The flap design of third molar surgery: An overview

1
Ranjeet Bodh MDS, 2 Anshul Jain
1
Senior Resident Dept of oral and maxillofacial surgery Maulana azad institute of dental sciences, New Delhi, India.
2
Senior Resident Dept of oral and maxillofacial surgery Maulana Azad Institute of Dental Sciences, New Delhi, India.

Abstract
Purpose of the study:- Purpose of present study is to review the update in various flap designs and their influence on outcome in
third molar surgery.
Material and Methods:- Literature was selected through a search of electronic databases. The keywords used for search were
mandibular third molar, impacted mandibular third molar, mandibular third molar flap design, mandibular 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.
Results:-In total 29 literature sources were obtained and reviewed.
Conclusion:- Review states that considering various flaps, triangular flap and envelop flap were mainstay for third molar surgery,
triangular flaps have significance over envelop flap in term of wound healing, postoperative pain, trismus and swelling but not
significant statistically. These two flaps do not seem to have a long lasting difference in term of primary wound healing and status
of periodontium.

Keywords: Third molar, flap design, incision, impacted tooth.

Introduction Outcome of third molar surgery is influenced by variety of

It is theoretically possible for any tooth to follow an aborted factors, including mucoperiosteal flap design.
eruption path and become impacted within the dentoalveolar Purpose of present study is to review the update in various flap
process or in remote heterotrophic anatomic sites [13]. designs and their influence on outcome in third molar surgery
At the recent National institute of health consensus
development conference on removal of third molar, it was Sequencing and comparison of flap design techniques-
agreed that impaction or malposition of third molar was an Mucoperiosteal access flaps used for removing third molar are
abnormal state and might justify its removal; such treatment broadly grouped under triangular (vertical flap) and envelop
was not considered to be prophylactic. And thus removal of flap and few other variables.
impacted third molars is the most frequently performed surgical In 1932 Thoma19 described the vertical flap for removal of third
procedure in many oral and maxillofacial surgical practices [1, 4, molar surgery [5, 8].
8]
. Howe described a mucoperiosteal flap in which the anterior
Accessibility significantly influences the degree of difficulty of incision curved forward from distobuccal corner of crown of
removal of a third molar. The ease with which the tooth can be second molar and ended along side of mesiobuccal cusp of that
removed is also influenced by the degree of surgical exposure, tooth. The distal incision was then extended along the buccal
the ability to create a pathway for tooth delivery and ability to gingival to external oblique ridge [1, 16]. Ward (Fig 1)
gain purchase (natural or surgically prepared) on the tooth [4]. recommended a larger but similar mucoperiosteal flap for
Surgical removal of lower third molar is a common procedure improved access in 1956 [1, 23]
and is associated with potential postoperative complication
which includes pain, swelling, trismus, and alveolar osteitis. To
minimize these complications clinicians have sought an optimal
surgical approach and have investigated the use of various flaps
[2, 12, 17]
.
Principle of surgical flap design is to provide access with the
least possible ensuring soft tissue damage. Incisions should be
designed so as to provide good and adequate blood
supply(broad base), good access to allow adequate vision and
space for instrumentation, protect the soft tissue in term of
influencing minimal trauma, and permitting anatomical Fig 1: Ward Incision
repositioning and reattachment of the flap. The incision must
permit elevation and reflection of soft tissue without damaging In 1959 Kruger [20] (Fig 2) described envelop flap (a variation
the adjacent structure and it must be a full thickness flap of Thomas vertical flap) in which first part of incision was
(overlying gingival, mucosa, submucosa, periosteum) [2, 6, 14]
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similar to vertical incision i.e begins medial to external oblique In 1979 Killy and Kay [24] (Fig 5) advocatd flaps starting along
ridge and extending to distal lower angle of second molar the gingival crevices of second molar tooth. Healing of gingival
followed by sulcular incision which was made from distofacial crevices from incision has been unsatisfactory and now rarely
angle of second molar to mesiofacial angle of first molar [8]. used [1, 24].

Fig 5: Killy and Kay Incision

Fig 2: Kruger Envelop Flap
In 2002 Nageshwar [15] (Fig 6) gave the comma shaped flap for
impacted mandibular third molar surgery. The incision is made
In 1966 Berwick [21] (Fig 3) described vestibular tongue shaped
to a point below second molar from where it is smoothly curved
flap. This tongue shaped flap extended on to the buccal shelves
up to meet the gingival crest at the distobuccal line angle of
of mandible with an incision line that did not lie over bony
second molar. The incision is continued as a crevicular incision
defect, created by removal of impacted tooth, and had its base
around the distal aspect of second molar. The incision is
at the distolingual aspect of second molar to spare the
designed to overcome the problem with conventional incisions
periodontal ligament of adjacent tooth [5, 8, 15]
as cut across the insertion of temporalis tendon and flap
commonly lie over the bone defect formed after removal of
impacted tooth [2, 14, 15].

Fig 3: Berwick Tougue Shape Flap

In 1969 Henry [22] (Fig 4) described lateral trepanation Fig 6: Nageshwar Comma Shaped Flap
technique for excision of developing mandibular third molar
and was reported by Kaj and Klamfeldt as having no late Though variable flap techniques are designed to overcome the
postoperative complications. This technique is based on the shortcoming of triangular (Fig 7) and envelop flaps but in our
assumption after evaluation, that the third molar would be review we found the later flaps (triangular flap and envelop
impacted. This technique does not appear to be popular [1]. flap) as mainstay for third molar surgery [2, 12, 3, 4, 9, 10, 11].

Fig 4: Henry Incision Fig 7: Triangular Flap

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Pain, trismus, and facial swelling after a surgical removal of third lingual, ensuring a wound closure that is almost tension-free.
molar tooth are routine sequel due to inflammation as a result of The mesial vestibular relieving incision, which is only adapted
surgery. A major cause of third molar surgical trauma occurs coronally by a single suture, allows depletion of the
when raising a mucoperiosteal flap to gain access to the tooth [2, 3, postoperative hematoma during masticatory movements. On
6]
. the very first postoperative day, hematoma is easy to relieve by
Envelop flap allows good exposure of surgical site, incision can spreading and compression. Also the release area has bone
be extended anteriorly if required. Owing to broad base, blood support. This study has shown that the conventional sulcular
supply is excellent, and the design facilitates easy closure and flap design has a nearly 6-times-higher risk of rupture of the
reapproximation. Potential problem of envelop flap have been primary wound closure than the modified triangular flap. The
discussed in the literature and include damage to the periodontal modified triangular flap design, when compared with the
ligaments when creating sulcular incision around a tooth, conventional sulcular incision, definitely makes primary wound
increased osteoclastic activity when raising mucoperiosteal flap healing easier. Factors such as the degree of impaction, the
with potential local bone loss and a higher risk of wound duration of the surgery, and nicotine habits have less influence
dehiscence in postoperative period compared with modified on primary wound healing [12].
triangular flap [2]. Modified triangular flap is regarded as more Trismus after third molar surgery is usually caused by
conservative owing to a lesser degree of tissue reflection inflammation of the muscles of mastication leading to spasm
because it avoids the raising of soft tissue from the buccal secondary to the raising of a mucoperiosteal flap. There is no
aspect of second molar. It is simple to close and allows for advantage in choosing either of these flap designs over the other
relatively tension free closure. However unlike the envelop to reduce the severity of trismus. Nageshewar [15] has proposed
flap, it cannot be readily extended [2, 3, 8, 9-11]. that this may be due to the distal incision path of all commonly
Every preparation of a mucoperiosteal flap leads to a growing used flap designs being the same. There is insufficient research
activity of osteoclasts in the area of the alveolar process, comparing flap designs with different distal incision courses to
inducing loss of alveolar bone [25]. Every sulcular incision is an objectively evaluate this statement, but it would appear
intervention to the periodontal ligament and may lead to reasonable to attribute to the same distal incision path the
periodontal damage. Alternatively, paragingival and vestibular similarity of trismus severity in the 2 flap designs.
tongue-shaped [21] flap designs, which aim at sparing the Postoperative pain on the other hand is not directly influenced
periodontal ligament of the adjacent molar, have been by flap design. However VAS score was found elevated in
described. Especially in cases of thin keratinized gingiva in the patients who developed alveolar osteitis. Difference may have
area of the second molar, the conventional flap design may lead been seen owing to the increased incidence of alveolar osteitis
to a total loss of the attached gingiva in this area after the associated with the use of the envelope flap, but the difference
operation. This again can cause pocket formation and loss of in incidence of alveolar osteitis between this two flaps was not
attachment in the area of the second molar [26]. The frequent statistically significant [2, 6, 10].
occurrence of dehiscences distofacial to the second molar The periodontal status of second molar is another area of
seems to be another disadvantage of the envelope-flap design. interest. Schofield et al reported that flap design was not
These gaping are usually located at the distobuccal gingival rim important on periodontal health of second molar, and when
of the adjacent second molar, where the distal relieving incision bone was not removed distal to second molar, flap design did
leads into the sulcular incision. In this area, soft tissue tensions not have permanent effect. Thus the effect of flap design have
resulting from postoperative hematoma and masticatory more relevance to the immediate postsurgical period rather then
movements may induce a rupture of the wound margins during as a long term concern [3].
the first few postoperative days. This is particularly true for the The envelope flap is easier to perform and suture than the
envelope flap because it is fixed anteriorly with intersulcular triangular flap, but it does not facilitate access to the
sutures. Such dehiscence can take place inconspicuously and surrounding structures, making osteotomy more difficult, and
unnoticed by the patient and may heal secondarily. Thus, more distal dehiscence of sutured incision. Whereas the
secondary wound healing can cause wedge-shaped defects of triangular flap allows easier access to the surrounding
the gingiva distal to the second molar, or it can favor a loss of structures, facilitating the osteotomy needed to extract the
attachment distal to the second molar. The triangular flap tooth. Conversely, suturing is more involved, and the exposure
allows easy relief of the hematoma during the first of a larger bone area tends to activate osteoclastic bone
postoperative day. A dehiscence does make hygiene more resorption [28, 29]. At the postoperative examination after 7 days,
difficult and requires intense follow-up treatment (ie, frequent the probing depth was statistically greater in the first and second
irrigation and possible local medication). There is also a chance molars on the side on which an envelope flap was used. These
for longer-lasting discomfort caused by hypersensitivity in the findings could be related to the deficient initial regeneration of
area of the distally exposed root surface of the second molar. the connective-tissue attachment, which was formed perfectly
Alveolar osteitis and soft tissue abscess are more severe 3 months postoperatively, as demonstrated on postextraction
complications that are possible. Jakse et al in his comparison probing [5, 8, 9, 11].
study found that, 56% of the patients develop a disorder in
primary wound healing, when conventional sulcular flap design Conclusion
was used. With the modified triangular flap design, primary Review states that considering various flaps, triangular flap and
wound healing was significantly improved, dehiscence envelop flap were mainstay for third molar surgery, triangular
occurred only in 10% of cases. He suggests that this was flaps have significance over envelop flap in term of wound
because of a tension decrease in the area of the distal wound healing, postoperative pain, trismus and swelling but not
closure compared with the situation of the envelope flap significant statistically. These two flaps do not seem to have a
technique. The vestibular triangular flap can be easily moved to
34 
 
long lasting difference in term of primary wound healing and 19. Thoma KH. The management of malposed inferior third
status of periodontium. molars. J Dent Res 1932; 12:175-208.
20. Kruger GO. Management of impactions. Dent Clin North
References Am 1959; 707-722.
1. Obiechina AE: Update in the technique of third molar 21. Berwick WA. Alternative method of flap reflection. Br
surgery. Annals of Ibadan postgraduate medicine 2003; Dent J. 1966; 20; 121(6):295-6.
1:40-44. 22. Henry CB. Excision of developing mandibular third molar
2. Kirk DG, Tong DC, Love RM. Influence of two different by lateral trepanation. Brit Dental J. 1969; 127:111-118.
flap design on incidence of pain, swelling, trismus, and 23. Ward TG. Split bone technique for removal lower third
alveolar osteitis in the week following third molar surgery. molar.Brit Dent J. 1956; 101:297-301.
Oral surg Oral med Oral pathol Oral radiol Endod, 2007; 24. Killy HC, Kay LW. The impacted wisdom tooth. Published
104:e1-e6. E &S Livingston Ltd. London, 1979.
3. Dolanmaz D, Candirli Celal. Effect of two flap designs on 25. Tavtigian R. The height of facial radicular alveolar crest
postoperative pain and swelling after impacted third molar following apically positioned flap operations. J
surgery. Oral surg Oral med Oral pathol Oral radiol,2012 Periodontol. 1970; 41:412-8.
4. Ferish SE, Bouloux GF. General technique of third molar 26. Motamedi MH. A technique to manage gingival
removal. Oral maxillofacial surg clin n Am, 2007; 19:23-43 complications of third molar surgery. Oral Surg Oral Med
5. Monaco G, Doprile G, Tavernese L. Mandibular third molar Oral Pathol Oral Radiol Endod 2000; 90:140-3.
removal in young patients: An evaluation of 2 different flap 27. Dhanrajani PJ, Jonaidel O. Trismus: aetiology, differential
designs. J Oral maxillofac surg, 2009; 67:15-21. diagnosis and treatment. Dent Update 2002; 29:88-94.
6. Roode GJ, Butow K. An alternative surgical flap design for 28. Wood DL, Hoag PM, Donnenfeld W. Alveolar crest
impacted third molars: A comparison of two different reduction following full and partial thickness flaps. J
surgical techniques. SAJD, 2010; 65:246-251. Periodontol. 1972; 43:141.
7. Naaj IAE, Braun R. Surgical approach to impacted 29. Yaffe A, Fine N, Binderman I. Regional accelerated
mandibular third molars-Operative classification. J oral phenomenon in the mandible following mucoperiosteal
maxillofac surg. 2010; 68:628-633. flap surgery. J Periodontol. 1994; 65:79.
8. Karaka I, Simsek S, Uger D. Review of flap design
influence on the health of the periodontium after
mandibular third molar surgery. Oral surg Oral med Oral
pathol Oral radiol, 2007; 104:18-23.
9. Baqain ZH, Shaffi AA, Hamdan AA. Flap design and
mandibular third molar surgery: a split mouth randomized
clinical study. International journal of oral and
maxillofacial surgery, 2012; 41:1020-1024.
10. Sandhu A, Sandhu S. Comparison of two different flap
designs in the surgical removal of bilateral impacted
mandibular third molars. International journal of oral and
maxillofacial surgery. 2010; 39:1091-1096.
11. Stephens R, George R, Dennis W. Periodontal evaluation
of two mucoperiodontal flaps used in removing impacted
mandibular third molars. International journal of oral and
maxillofacial surgery. 1986; 41:719-724.
12. Jakse Nobert, Bankaoglu V, Wimmor G. Primary wound
healing after lower third molar surgery: Evaluation of 2
different flap designs. Oral surg Oral med Oral pathol Oral
radiol Endod, 2002; 93:7-12.
13. Alling CC, Catone GY. Management of impacted teeth.J
oral maxillofac surg, 1993; 51:3-6.
14. Rafetto LK, Synan W. Surgical management of third
molars.Atlas Oral Maxillofacial Surg clin N Am, 2012;
20:197-223.
15. Nageshwar. Comma incision for impacted mandibular
third molars. J oral maxillofac surg. 2002; 60:1506-1509.
16. Obimakinde O.S:Impacted mandibular third molar
surgery; an overview. Dentoscope, 2009;16
17. Szmyd L. Impacted teeth. Dent Clin North Am 1971;
15:299-318.
18. Suarez-Cunqueiro MM, Gutwald R, Reichman J, Otero-
Cepeda XL, Schmezeisen R. Marginal vs paramarginal
flap in impacted third molar surgery: a prospective study.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;
95:403-8.
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