DISCUSIÓN

Post operative comparison of two flap designs in inferior third molar surgery

Comparación del postoperatorio de dos colgajos en cirugía de terceros molares inferiores

Pedro Infante-Cossío

Profesor Titular Vinculado. Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario Virgen del Rocío, Sevilla, España

In this article the authors discuss an interesting topic that continues to be the subject of great controversy. It is well known that the inferior third molar surgery is one of the main procedures carried out in the field of Oral and Maxillofacial Surgery. This surgery's post surgical symptoms include: pain, swelling and trismus.¹ The factors related to post surgical recovery are varied and considered proportionate to the surgical act.² Generally these factors are related to the difficulty of the surgery, the operative trauma, the age of the patient, the index of difficulty of the molar and the time needed to operate.³ It has also been shown that the amount of information a patient receives before surgery has a positive effect on their recuperation, pain control and level of satisfaction with treatment.⁴

A range of studies have been published that assess the different variables that have an influence on patients after Third molar surgery. However just like the authors indicate in this article, there are not as many studies that investigate the influence that flap design has on recuperation after surgery. Garcia y cols.⁵ show that when compared to third molar extractions where the flap is not elevated, elevating a mucoperiosteal flap causes significantly greater levels of pain and trismus.

The main advantage of using a linear flap is that it is easy to suture and it adjusts well. However, the fundamental disadvantage consists of defining a smaller operating area which makes osteotomy more difficult, because of this it is used in more favorable third molar extractions.⁶ The triangular flap, probably more commonly used, is the most versatile flap design because it allows better access and visibility. ⁷ Monaco and Cols.⁶ support the idea that that the triangular flap decreases operation time, and they utilize it with less cooperative patients and those who have difficulties with oral opening. There are various published studies that have evaluated which flap design could cause more periodontal scarring problems with the second molar.⁸ It has been shown that the linear flap design results in better short term periodontal scarring, but in the long term (3 and 6 months) there are no clinically relevant differences between the two flap designs.^6,9,10

From reading this interesting article and the other works that have recently been published in the literature, it is determined that when comparing the use of a linear or triangular flap there are no differences in the incidence of postoperative pain and trismus. Baqain and cols.¹¹ have recently published a study about the sample of 245 third molar extractions. This study found an incidence of pain in 37.2% and trismus in 17.6% of cases. These authors found a slightly higher incidence of pain and trismus when using the triangular flap design, but not enough to merit statistical significance. Similarly, in their study of 35 patients, Kirk and cols.¹² did not find differences related to post operative pain or trismus with one flap or the other. However, when using the triangular flap they did report higher values of swelling. In conclusion, we believe that the objective of this commentary is to encourage a new study, very rigorous from a methodological stand point, that evaluates how the two flap designs influence recuperation after the extraction of a compacted third molar. Taking into account the results of this and other studies it can be concluded that each professional can use whichever flap design he is trained to use. It is clear that there are no differences in the main characteristics of postoperative recuperation. The selection of one design or the other may be based on their personal preferences and what will be the most efficient and safe for the patient. It seems clear that the intensity post surgical pain is related to other variables related to the magnitude of the operation. Regardless of the flap design used, post operative pain can also be related to the severity of trismus when contracting chewing muscles when elevating the mucoperiosteal flap.

References

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