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Revista Española de Cirugía Oral y Maxilofacial

On-line version ISSN 2173-9161Print version ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.31 n.3 Madrid May./Jun. 2009




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

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



G. Laissle Casas del Valle1, P. Aparicio Molares1, F. Uribe Fenner1, D. Alcocer Carvajal2

1 Cirujano Dentista
2 Cirujano Maxilofacial
Facultad de Odontología Universidad Mayor. Cátedra de Cirugía y Traumatología. Santiago, Chile





One of the most common procedures in the field of Oral and Maxillofacial Surgery is third molar surgery. From prophylactic measures to large osteolytic lesions, there are various indications. Some of the consequences of this procedure are; edema, trismus and postoperative pain. Flap design is an important feature of surgical technique that plays a vital role in minimizing these consequences. The objective of this study is a post operative evaluation of included third molar jaw surgery using a linear flap on one side and a triangular flap on the other side of the same patient.
A prospective study of 15 patients from the Dentistry College at the Major University was carried out. Before surgery standard photos were taken and maximum oral opening was measured for each patient. The edema, maximum oral opening and pain were measured 48 hours and 7 days after surgery. All of the data were analyzed statistically. There are no significant differences in the edema, ability to open the mouth or the level of pain using the two types of flap. There also is no correlation between the operation time and the three variables studied.
The postoperative edema, pain and trismus after included third molar surgery are similar when using linear or triangular flap designs. The surgeon can choose one or the other indistinctly, according to his/her preference.

Key words: Third Molars; Linear Flap; Triangular Flap; Edema; Trismus; Pain.


La cirugía de terceros molares constituye en la práctica de la cirugía oral y maxilofacial, una de las intervenciones más realizadas. Las indicaciones son variadas, desde medidas profilácticas hasta grandes lesiones osteolíticas. Algunas de las consecuencias después de dicha intervención son; edema, trismus y dolor postoperatorio. En la técnica quirúrgica, el colgajo cobra gran importancia a la hora de minimizar estas consecuencias. El objetivo del presente estudio es evaluar el postoperatorio de la cirugía de terceros molares mandibulares incluidos, utilizando un colgajo lineal en un lado y un colgajo triangular en el otro lado del mismo paciente.
Se realizó un estudio prospectivo en 15 pacientes de la Facultad de Odontología de la Universidad Mayor. Se tomaron registros fotográficos estandarizados y se midió la apertura bucal máxima pre-quirúrgica de cada paciente. Se registró el edema, la limitación de apertura bucal y el dolor a las 48 horas y a los 7 días, además del tiempo intraoperatorio. Todos los datos fueron analizados estadísticamente. No existen diferencias significativas en el edema, limitación de la apertura ni dolor al utilizar ambos colgajos. Tampoco existe correlación entre el tiempo operatorio y las tres variables estudiadas.
El postoperatorio de la cirugía de terceros molares mandibulares incluidos es similar al utilizar un colgajo lineal o un colgajo triangular. El cirujano puede optar por uno o el otro indistintamente, según su preferencia.

Palabras clave: Terceros molares; Colgajo lineal; Colgajo triangular; Edema; Trismus; Dolor.



The third molar is one of the most practiced surgeries in the Oral and Maxillofacial Surgical field. As a consequence this topic has been thoroughly documented throughout history. 1-4 The indications for surgery range from prophylactic measures, to patients that present large osteolytic lesions related to third molars, mainly mandibular.1,3,4,6 Like all surgeries, there are complications. These include everything from episodes of post surgical hemorrhage to, in some cases, large maxillofacial infections that require more complex treatments. 2,3,5,6 As a result multiple forms of reducing these complications have been researched. Whether it be the improving the measures of asepsis, the use of antibiotics, or the use distinct technical maneuvers and procedures in the actual surgical technique.3,4, 7-12

Some of the postoperative characteristics looked at in patients are edema (initiated mainly because of the osteotomy that is carried out), maximum mouth opening (trismus) and postoperative pain. The flap design plays an important role in surgical technique in terms of minimizing these consequences.7,8,10 Studies have been published that compare scarring and postoperative status when using distinct flap designs.7,8,10,12

The objective of this study was postoperative evaluation of Impacted Third Molar surgery, in patients with signs of exodontia in both molars, using two different flap designs (one on each side) on the same patient.


Materials and method

In this prospective clinical study the two flap designs used in Impacted Third Molar surgery were evaluated and later compared. The patients studied attended the Oral Surgery Clinic at the Universidad Mayor and the Spanish Army's Central Odontological Surgery Center for two months in July and September of 2004. They included only ASA I patients who had both mandible third molars in symmetrical positions (no more that 15 degrees of difference) and who were A-symptomatic. Patients with local pathologies such as pericoronaritis or abscesses were excluded from the study.

The study group consisted of 15 patients. The position of each molar was determined radio graphically and classified according to Pell and Gregory.

A clinical photo was taken of the front of the face using a Nikon Coolpix 4500 digital camera. This picture was then attached to a cephaloslate, made for this purpose, which was later used to determine the condition of each patient. After surgery an identical picture would be taken and compared to the original (Fig. 1).

The maximum mouth opening was also measured (the maximum amount the patient could open their mouth by themselves) with a ruler (Mauser brand). This measurement was taken between the edges of the incisions of teeth 1.1 and 4.1, using the mean of three measurements. This value was converted from millimeters into the percentage of maximum mouth opening. The team of researchers consisted of two operators and one investigator, who took the measurements and photographs before and after surgery (48 hours and 7 days).

Surgical Protocol

Two surgeries were performed at an interval of 2 weeks on each patient. During the first surgery tooth 3.8 was operated on was using the linear flap design. During the second surgery the tooth 4.8 was removed using the triangular flap design. Both operations were part of the previous protocol. The following medications were used: Amoxicillin 2 g 1 hour before, Betametasone 3 mg 1 hour before and 1.5 mg 6 hours after, and Ibuprofen 400 mg, 1 hour before and every 8 hours for 3 days. Clindamycin 600 mg was administered 1 hour before in patients who were allergic to Penicillin.

Both extractions were administered under local anesthetic with vasoconstrictor. The triangular flap consists of one incision that starts along the ramus rising up the mandible to the distal vestibular of the second molar, from there an incision is made going forward and down 45 degrees, forming a triangle. This offers maximum visibility and does not harm neighboring teeth. Since it doesn't go over the dental groove, it allows for good reposition of the flap which improves scarring of the surgical site (Fig. 2). Contrarily, the linear flap consists of an incision that starts running along the ramus rising up the mandible until the distal vestibular of the second molar, passing over the center of the kept third molar. From there it is extended with a circular incision until, in most cases, the distal of the first molar. This allows for proper visibility and is suitable for sloped mesials and surfaced third molars 3 (Fig. 3).

Once a flap design has been decided the incision is made, necessary osteotomy and-or tooth section, irrigating with physiological serum. The luxation and exodontia of the third molar are carried out with elevators and luxators. The pericoronary sack is removed and irregular boney spicles removed. When repositioning the flap it is sutured with 3/0 silk. Post surgical instructions were given to the patient verbally and in writing. The surgery was timed from the point of the initial incision until the last stitch was made.

Post-operative Measurements

Measurements were taken 48 hours and 7 days after surgery. These measurements include the maximum mouth opening and post operative pain. The pain is measured using the EVA method (visual scale method) in which the patient is given a sheet with a straight line numbered 1-10 with the legends "No pain" and "Unbearable Pain" on each side. The patient was asked how much pain they were in at that time.

In order to calculate the post operative edema a second photograph was taken using cephalostate.

The presence of certain complications was also clinically evaluated. These complications include alveolitis, infection, hemorrhaging.

Measurement of Postoperative Edema

Pre and post surgery photographs were compared for each patient, taken using a cephalostat with 3 cephalometric points as reference points (both external auditive conducts and Nasion) The three clinical photographs( pre operation, 48 hours after and 7 days after) were converted into black and white using Adobe Photoshop 8.0 in order to get better contrast of the facial perimeter. The photographs were analyzed using AutoCAD 2004 software marking the contour of the face from one earlobe to the other. It created a grid that used the nose as a center point to measure the perimeters. Then using Systat 11 software, the data obtained were converted into a percentage for posterior statistical analysis.



Test t was used in the statistical analysis for the variables of edema, maximum mouth opening and pain. Pearson Correlation was used in order to determine if there was a relationship between operation time and the other variables already mentioned.

Patient age ranged from16 to 24, with an average age of 18.93. At 60% the predominant sex was male. Applying the Pell and Gregory Classification, the class 2 position was the most prevalent at 70%. In turn, class B was observed in most cases with 53.33%. The most frequent angle of the third molars was the mesial which occurred in 93.33% of cases. The results delivered by the statistical analysis, between the linear flap design and the triangular flap design were p =0.078 after 48 hours and p =0.803 after 7 days. This demonstrates that, in terms of edema there is no significant difference between the two flap designs (Fig. 4).

For maximum mouth opening post surgery, the results were p =0.172 after 48 hours and p =0.102 after 7 days. This demonstrates that for this variable there is also no significant statistical difference between flap designs (Fig. 5).

The Visual Scale Method (EVA) was to measure pain, 48 hours after surgery p = 0.334 and 7 days after p = 0.173. For this variable there were no significant differences between the two flap designs (Fig. 6).

Table 1 shows the number of cases of alveolitis and infection, and their incidence in relation to all of the extracted molars. A low percentage of these complications are observed. Alveolitis occurred where the triangular flap design was used while infection occurred when the linear flap design was used.

There is no correlation between the operation time and edema in either design after 48 hours and 7 days.



There are not many studies that perform post operative evaluations of flap design. The majority of the studies that exist analyze specific medications13,14 or evaluate post surgical second molar periodontal scarring.8,10,11

Our study revealed that there are no significant differences between flap design and edema, mouth opening or post operative pain. Suarez- Cunqueiro et al.12 found similar results when they compared the marginal flap and the para-marginal flap in impacted third molars. They found that there were no significant differences between edema, mouth opening or post operative pain. They concluded that either design can be used interchangeably. According to Jakse et al.7 the flap design considerably influences the first stages of scarring. The triangular flap resulted in a lower percentage of dehisency. Although the objective of our study wasn't to evaluate scarring, we agree with this finding. With regard to edema, pain and maximum mouth opening, Jakse et al.7 did not find differences between the two flap designs.

Post operative pain is mainly related to the amount of direct trauma to the tissue during extraction. The percentage of edema in this study was about 1% in both flap designs. This is fairly low when compared to other studies. This could be the result of medication, mainly the use of oral Beta metasona before and after surgery. Shultze-Mosgau et al.,15 point out that the use of metilprednisolone and Ibuprophen together works as a good anti-inflammatory and analgesic, preventing post operative edema. Although the measurement of edema with photographs is much more exact than the other methods described in the literature, the use of 3D16 cameras makes these measurements more credible.

It might be considered that longer operation time would mean more traumas on the tissue and therefore more edema. However, we have concluded that there is no correlation between these variables. According to García et al.,17 edema is more closely related to the difficulty of the surgery than to the time the surgery takes.

In reference to the mouth opening we didn't find any significant difference between the two flap designs. We confirm that for the two flap designs the peak of maximum mouth opening was measured after 48 hours. We also observed that for both groups when a patient experienced more maximum oral opening after 48 hours they also experienced a more maximum opening after 7 days.

Suarez-Cunqueria et al.12 determined that there were no differences in terms of mouth opening when using the two flap designs. They measured this variable 5 days, 10 days and 3 months after surgery. In our study there is no correlation between operation time and mouth opening, which would confirm that because of an antialgical effect this variable depends more on the magnitude of pain experienced by the patient.

There are various studies analyzing the presence of pain and its intensity after surgery but there are very few studies that compare flap design and post operative pain. Suarez- Cunqueiro et al.12 show that there is no relation between the flap design used and the intensity of pain experienced. In this study reports of post operative pain were low, which could be explained by the use of pharmacological protocol pre and post operation with a base of antibiotics, corticoids and non-steroid anti-inflammatories. According to other reports the presence of pain is equal to edema and mouth opening is more closely related to surgical trauma than to the flap design used. The infection and alveolitis are complications that are found after surgeries of this type. In our there was only one case of infection related to a vestibular abscess located near the linear flap. Another patient had wet alveolitis when the triangular flap was used. The number of patients in our study is low, however the presence of these complications corresponds with the literature.19,20

We can conclude that the flap design is not related to post operative status of the patient, but is rather determined by other factors be they specific to the patient or the actual surgery itself.



The post operative status of the patient after included third molar surgery which includes: edema, pain and mouth opening are similar when using either a linear or triangular flap design. The surgeon can choose one or the other according to his/her preference.



Germán Laissle Casas del Valle
La Castellana Norte 100, Departamento 132
Bucomáxilofacial. Santiago, Chile

Recibido: 13.02.2008
Aceptado: 28.05.2009



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