Clinical Paper

Oral Surgery

Int. J. Oral Maxillofac. Surg. 2010; 39: 1091–1096doi:10.1016/j.ijom.2010.07.003, available online at http://www.sciencedirect.com

Comparison of two different flapdesigns in the surgical removalof bilateral impacted mandibularthird molarsA. Sandhu, S. Sandhu, T. Kaur: Comparison of two different flap designs in thesurgical removal of bilateral impacted mandibular third molars. Int. J. OralMaxillofac. Surg. 2010; 39: 1091–1096.# 2010 International Association of Oral andMaxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The purpose of this study was to compare the effects of flap design on thepostoperative sequelae of pain, swelling, trismus and wound dehiscence aftersurgical removal of bilateral impacted mandibular third molars (M3). 20 patientsaged 20–30 years who required removal of bilateral impacted M3 were included inthe study. Maximum interincisal opening and facial measurements were recordedpreoperatively. Bayonet flap was used on one side and envelope flap on the otherside for the removal of impacted M3. The effect of flap design on pain, swelling,trismus and wound dehiscence was evaluated postoperatively. Pain and wounddehiscence were significantly greater in the envelope flap group compared with thebayonet flap group (P < 0.05). No significant difference in postoperative swellingand trismus was found in either group (P > 0.05). The bayonet flap was superior tothe envelope flap for postoperative pain and wound dehiscence. There was nodifference in postoperative swelling and trismus between the two groups.

0901-5027/1101091 + 06 $36.00/0 # 2010 International Association of Oral and Maxillofacial Surge

A. Sandhu, S. Sandhu, T. KaurDepartment of Oral and Maxillofacial Surgery,SGRD Institute of Dental Sciences andResearch, Mall Mandi, G.T. Road, Amritsar,Punjab – 143006, India

Keywords: impacted mandibular third molar;flap design; postoperative sequelae.

Accepted for publication 7 July 2010Available online 19 August 2010

The surgical removal of an impactedmandibular third molar (M3) is a commonprocedure associated with various tech-niques and anecdotal opinion. The tech-niques used for incision in the mucosaand reflection of the mucoperiosteal flapaffect the intensity and frequency of post-operative complications in M3 surgery10.This study compares two flap designs, thebayonet flap and the envelope flap, andtheir effect on the postoperative sequelaeof pain, swelling, trismus and wounddehiscence after surgical removal ofbilateral M3.

Materials and methods

20 patients (3 male and 17 female), aged20–30 years (mean 25 years), wereselected for this study. Inclusion criteriaconsisted of: patients with no history ofmedical illness or medication that couldinfluence the course of postoperativewound healing; and healthy dental andperiodontal status with no local inflamma-tion or pathology at the time of toothremoval.

An attempt was made to include onlythose bilateral M3s that were of compar-

able technical difficulty, positioning andangulation as seen on panoramic radio-graphs.

Preoperatively, intraoral periapical,panoramic radiographs and informedconsent were obtained and the followingparameters were evaluated. The maxi-mum interincisal mouth opening wasrecorded using Vernier calipers as thedistance between the upper and lowercentral incisors. The facial measurementswere recorded by a thread, which wastransferred to a standardized calibratedscale. The horizontal facial measurement

ons. Published by Elsevier Ltd. All rights reserved.

1092 Sandhu et al.[(Fig._1)TD$FIG]

Fig. 1. Incision used for the envelope flap.

[(Fig._2)TD$FIG]

Fig. 2. Incision used for the bayonet flap.[(Fig._3)TD$FIG]

Fig. 3. To facilitate the use of VAS by the patients legends were placed over different parts ofthe scale.

Table 1. Mean duration of surgery in both envelope flap and bayonet flap groups.

Total no. of patients Env BntMean duration of surgery (min) Mean duration of surgery (min)

20 37.50 28.85

Env = envelope flap.Bnt = bayonet flap.

was taken as the distance from the cornerof the mouth to the attachment of theearlobe. The vertical measurement wastaken as the distance from the outercanthus of the eye to the angle of themandible by palpating and marking theinferior border1. The facial measurementwas calculated as1:

Horizontal measurementþ vertical measurement

2

A standard surgical protocol was fol-lowed. One surgeon, experienced in theuse of both the flap designs, performed thesurgery while another carried out the eva-luation. Prophylactic intravenous antibio-tic, amoxycillin 1 g and clavulanic acid200 mg (Augmentin 1.2 g; GlaxoSmithK-line Pharmaceuticals Limited, Mumbai,India) and tablet ibuprofen (Brufen600 mg; Abbott Group of Companies,India) was given 1 h before surgery.0.2% chlorhexidine rinses were given toall patients for 30 s before the procedure.The local anaesthetic used was 2% lido-caine with 1:200,000 adrenaline (Xylo-

caine1; Astra Zeneca Pharma IndiaLimited, Bangalore, India). A bayonet flapwas made on one side and an envelope flapon the other. Side selection was rando-mized by systematic allocation and boththe patients and evaluator were blinded tothe flap groups. The minimum time inter-val between the two sides was 1 month.The envelope flap incision started on theascending ramus, following the centre ofthe M3 shelf to the distobuccal surface ofthe second molar and then extended as asulcular incision to the mesiobuccal cornerof the first molar (Fig. 1)2,14.

The bayonet flap incision started on theascending ramus, following the centre ofthe M3 shelf to the distobuccal surface ofsecond molar and then extended as asulcular incision up to the midpoint ofthe buccal sulcus of the second molar,

followed by an oblique vestibular exten-sion (Fig. 2)2,14. After exposing the surgi-cal site, ostectomy was carried out using abur technique and the tooth was sectionedas necessary. The flap was approximatedwith 3-0 mersilk (Ethicon). The durationof surgery was noted from the time ofincision until the insertion of the lastsuture (Table 1). In case of the bayonetflap, a suture was also placed on thevertical limb. All patients were prescribedibuprofen 600 mg tds for 5 days and 0.2%chlorhexidine mouth rinses for 7 dayspostoperatively. Pain, swelling, trismusand wound dehiscence were noted on post-operative days 1, 3, 7, 14 and 30. Pain wasevaluated by the patient on a daily basisfor 7 postoperative days or until the patientwas pain free using a visual analogue scale(VAS) calibrated from 0 to 10,with 0 as nopain, 1–3 as mild pain, 4–6 as moderatepain, 7–9 as severe pain and 10 as worstpain. To facilitate the use of VAS by thepatients, the end points were marked as‘no pain’ and ‘worst pain’. Legends wereplaced over different parts of the scale asshown in Fig. 3.

Facial swelling (%) was calculated as1:

Postoperative measurement� preoperative measurement

Preoperative measurement

� 100

Trismus (%) was calculated as1:

Preoperative measurement� postoperative measurement

Preoperative measurement

� 100

The relationship of tooth angulation,eruption status and duration of surgerywith postoperative sequelae (pain, swel-ling and trismus) was evaluated on post-operative days 1 and 7. Wound dehiscencewas noted on the seventh postoperativeday. The wound was considered to bedehisced if there was gaping along theentire incision line11. If found to be posi-tive, the wound was not re-sutured and thetime taken for complete wound healingwas noted. Postoperative complications inany of the groups were noted and treated.

Comparison of two different flap designs in the surgical removal of bilateral impacted mandibular third molars 1093

Table 2. Comparison of pain scores in the envelope and bayonet flap group.

Post op. days Type of flapNo. of patients in pain category (n)

x2 PNone Mild Moderate Severe

1 Env 1 1 4 14 11.050* <0.05Bnt 1 6 9 4

2 Env 1 4 7 8 3.202ns >0.05Bnt 1 6 10 3

3 Env 2 4 10 4 1.537ns >0.05Bnt 2 7 9 2

4 Env 3 6 8 3 4.429ns >0.05Bnt 4 10 6 0

5 Env 3 10 6 1 3.600ns >0.05Bnt 7 10 3 0

6 Env 4 14 2 0 2.620ns >0.05Bnt 8 9 3 0

7 Env 5 13 2 0 10.556* <0.05Bnt 15 5 0 0

Env = envelope flap group.Bnt = bayonet flap group.x2 computed at three degrees of freedom.NS – non significant.P – probability value.

* Statistically significant.

Statistical analysis

Data were subjected to different types ofstatistical analyses such as x2, Karl Pear-son test (KP), analysis of varianceapproach (ANOVA) and Student’s t-test.Statistical analysis was carried out bycomputer-developed software on MSDOS and windows based R language.

Results

Pain

Statistical analysis using the x2 testrevealed significant difference (P< 0.05)in the number of patients reporting severepain in the envelope flap (n = 14; 70%)and the bayonet flap (n = 4; 20%) group onthe first postoperative day. In the envelopeflap group, pain subsided completely infive patients (25%) by day 7 and in the[(Fig._4)TD$FIG]

Fig. 4. Comparison of mean pain scores in env

remaining 15 patients (75%) in 7–14 days.In the bayonet flap group, pain subsided in15 patients (75%) by day 7 and in theremaining five patients (25%) in 7–14days. This difference was statistically sig-nificant (P < 0.05) (Table 2 and Fig. 4).On postoperative days 14 and 30, 100% ofpatients reported no pain in both the flapdesign groups.

ANOVA applied to x2 showed that,although the two attributes (type of flapand degree of pain) were highly signifi-cantly associated (x2 = 17.663; df = 3)with respect to the pooled data, therewas no heterogeneity (x2 = 19.331;df = 18) among the x2 values computedfor the 7 days.

A significant amount of correlationbetween the degree of pain and durationof surgery was found only at the seventhpostoperative day {correlation coefficient

elope and bayonet flap groups.

(r) = +0.4655, P = 0.038 for envelope flapgroup and r = 0.4695, P = 0.036 for bay-onet flap group}.

Application of the KP test revealed asignificant association between the type offlap and extent of pain. The associationwas to the level of 0.4652 (KP) on the first,and 0.4569 (KP) on the seventh postopera-tive day.

Comparison of the degree of pain in thepartially erupted and full bony impactionshowed no statistical difference (P> 0.05)on both days 1 and 7. Similar results wereobtained on comparing the degree of painand the angulation of M3 on days 1 and 7.

Swelling

Student’s unpaired t-test was applied forcomparing the mean swelling (Table 3) inboth the groups. No significant differencewas observed on any postoperative day, butusing Student’s paired t-test, a highly sig-nificant (P < 0.01) decrease in swellingwas observed from the 1st to the 3rd post-operative day (T-statistic value = 5.770 forenvelope and 3.865 for bayonet flap), fromthe 3rd to the 7th postoperative day (T-statistic value = 6.608 for envelope flapand 5.045 for bayonet flap) and the 7th tothe 14th postoperative day (T-statisticvalue = 3.645 for envelope flap and 4.461for bayonet flap) in both the groups. Nosignificant relation (P > 0.05) was foundbetween duration of surgery and post-operative swelling on postoperative days1 and 7 for both the groups. The relation-ship between degree of swelling anderuption status was not significant on post-operative days 1 and 7. On average, thedegree of swelling between verticallyimpacted teeth was significantly lower(P = 0.0161) on day 1. The relationbetween degree of swelling and angulationwas not significant for all other categorieson days 1 and 7.

Trismus

Student’s unpaired t-test was applied forcomparing the mean trismus (Table 4) inboth the groups. No significant differencewas observed on all postoperative days.Using Student’s paired t-test, a highly sig-nificant (P < 0.01) decrease in trismus wasobserved from the 1st to 3rd postoperativeday (T-statistic value = 4.510 for envelopeand 4.043 for bayonet flap), from the 3rd to7th postoperative day (T-statistic value =6.973 for envelope flap and 5.335 for bay-onet flap) and from the 7th to 14th post-operative day (T-statistic value = 6.401 forenvelope flap and 5.878 for bayonet flap)and from the 14th to 30th postoperative day

1094 Sandhu et al.

Table 4. Comparison of mean trismus (%) in the envelope flap and the bayonet flap designs atdifferent postoperative days.

Post op. days Flap design N Mean (SD) (%) P value

1 Env 20 50.884 (13.995) >0.05Bnt 20 48.220 (13.282)

3 Env 20 41.470 (15.998) >0.05Bnt 20 35.313 (14.591)

7 Env 20 30.025 (16.027) >0.05Bnt 20 24.303 (14.716)

14 Env 20 9.256 (8.992) >0.05Bnt 20 8.939 (13.935)

30 Env 20 0.345 (1.504) >0.05Bnt 20 0.000

Env = envelope flapBnt = bayonet flap.N = total number of patients in respective flaps.SD = standard deviation.P = probability value.

Table 3. Comparison of mean swelling (%) in envelope flap and bayonet flap designs atdifferent postoperative days.

Post op. days Flap design N Mean (SD) (%) P value

1 Env 20 3.767 (1.737) >0.05Bnt 20 5.237 (3.058)

3 Env 20 2.514 (1.648) >0.05Bnt 20 3.948 (2.744)

7 Env 20 0.670 (0.801) >0.05Bnt 20 1.376 (1.322)

14 Env 20 0.000 (0.00) >0.05Bnt 20 0.074 (0.320)

30 Env 20 0.071 (0.309) >0.05Bnt 20 0.000

Env = envelope flap.Bnt = bayonet flap.N = total number of patients in respective flaps.SD = standard deviation.P = probability value.

Table 5. Comparison of the incidence of wound dehiscence and time taken for wound healing inboth the flap design groups.

Wound dehiscence Env (n = 20) Bnt (n = 20)

Present 07 01Average time taken for wound healing (days) 23.86 23.00Absent 13 19

x2 at 1 df = 05.625.Central x2 = 03.84 at P = 0.05 and 06.63 at P = 0.01.

(T-statistic value = 4.483 for envelope and2.796 for bayonet flap) in both groups. Thedecrease continued to be highly significant(P < 0.01) from postoperative days 14to 30 in the envelope flap group and sig-nificant (P < 0.05) in the bayonet flapgroup. Trismus and duration of surgerywere significantly related (P = 0.038,r = 0.4649) on the first postoperative dayand highly significantly related (P = 0.004,r = 0.6032) on the seventh postoperativeday in the envelope flap group, but therelationship was not significant (P >0.05) in the bayonet flap group on thesedays. The relationship of trismus with stateof eruption and with angulation was notsignificant on days 1 and 7.

Wound dehiscence

There was significantly more wounddehiscence in the envelope flap group

compared with the bayonet flap group.The average time taken for healing wascomparable in both the groups (Table 5).

Postoperative complications

In the envelope flap group, two patientsdeveloped infection, which manifested assuppuration and was treated with antibio-tic therapy. In one patient, a small cystdeveloped postoperatively, which prob-ably developed from incomplete removal

of the tooth follicle at the time of initialsurgery. In the bayonet flap group, onepatient had swelling and bleeding from theextraction site on the second postoperativeday.

Discussion

The effect of different flap designs onpostoperative sequelae has been reported5,10,11,13,21. GOOL et al.10 and SUAREZ-CUN-

QUEIRO et al.21 attributed pain followingM3 surgery to the incision and reflectionof mucoperiosteum rather than the flapdesign. In this study, pain was signifi-cantly greater in the envelope flap groupthan the bayonet flap group. Contrary tothis, KIRK et al.13 did not find any influenceof flap design on postoperative pain. Bothgroups showed a reduction in the severityof pain from postoperative days 1 to 7.GARCIA et al.9 reported that the severity ofpain following M3 surgery declinedbetween days 1 and 5.

In the present study, the relationshipbetween eruption status of M3 and post-operative pain was not significant, whichis supported by YUASA and SUGIURA

22.BENEDIKTSDOTTIR et al.4 found higher painscores for partially erupted M3 than forfully impacted M3. MACGREGOR andHART

16 reported more pain after theremoval of unerupted teeth.

The effect of angulation of M3 on post-operative pain has been studied. The pre-sent authors have found no significantrelationship between these two attributes,but GOOL et al.10 reported least pain afterthe removal of vertically impacted M3,which increased sequentially in mesioan-gular, distoangular, horizontal and aber-rant M3.

Duration of surgery was evaluated as avariable for the degree of postoperativepain and a significant correlation betweenthe two was found for both groups on day7. These results are similar to thosereported by KIM et al.12 and PEDERSEN

19

who stated that increased duration of sur-gery was associated with significantlyhigher pain scores on days 1 and 7. MEN-

DEZ et al.17 reported a significant associa-tion between the two variables, but onlyon postoperative day 1. MACGREGOR and

Comparison of two different flap designs in the surgical removal of bilateral impacted mandibular third molars 1095

HART16 stated that the duration of the

surgical procedure was not related to theseverity of pain.

Postoperative swelling after removal ofM3 has been attributed to the reflection ofmucoperiosteum10,21. In this study, com-parison of swelling between the twogroups revealed no significant differenceon all postoperative days. KIRK et al.13

found a greater degree of swelling withthe use of a modified triangular flap com-pared with an envelope flap.

Irrespective of the flap design, swellingdecreased from its maximum reading onthe first postoperative day and in mostpatients it was zero by day 14. GOOL

et al.10 reported that swelling followingM3 surgery was a function of time andmaximum swelling occurred between 24and 48 h postoperatively.

Influence of eruption status of M3 onthe degree of postoperative swelling hasbeen studied15,22. The present authorsfound no significant relationship betweenthem. This is supported by YUASA andSUGIURA

22. Contrary to this, MACGREGOR

and ADDY15 reported that partially erupted

M3 produced greater swelling than fullbony impactions. Angulation of M3 alsoinfluences the degree of postoperativeswelling. The authors observed a signifi-cantly lower swelling in vertical M3 com-pared with mesioangular M3 only on day1. GOOL et al.10 reported an increase inpostoperative swelling sequentially fromvertical, mesioangular, distoangular tohorizontal impacted M3. The degree ofpostoperative swelling was not influencedby duration of surgery in the present study,which is supported by PEDERSEN

19 andMACGREGOR and HART

16. KIM et al.12 founda significant relationship between the twovariables only on postoperative day 1.

Irrespective of flap design, there was adecrease in trismus over days, with thehighest value being on the first postopera-tive day. On average, it extended beyond 1week. BOSCH and GOOL

5 found that trismusincreased, then decreased and extendedbeyond 1 week.

CONARD et al.7 found severe trismusfollowing M3 surgery on the first post-operative day. AZAZ et al.3 found 13% ofcases of mild–moderate trismus 10 dayspostoperatively with slow regression oftrismus. CERQUEIRA et al.6 found that tris-mus was greatest at 24 h and was stillpresent 15 days postoperatively followingM3 surgery. In the present study, theseverity of trismus in the envelope flapgroup was not significantly different fromthat in the bayonet flap group during fol-low up. GOOL et al.10, KIRK et al13 andSUAREZ-CUNQUEIRO et al.21 concluded that

trismus was not affected by the type ofincision.

In the present study, the correlation ofangulation and eruption status of M3 withtrismus revealed no significant relation-ship. GOOL et al.10 found that trismus wasmaximum following surgical removal ofhorizontal M3 followed by distoangular,mesioangular and vertical impacted M3.CERQUEIRA et al.6 observed that trismusoccurred maximally following removalof distoangular M3.

The association of duration of surgeryand postoperative trismus was significanton both the first and seventh postoperativedays in the envelope flap group but it wasnot significant in the bayonet flap group.KIM et al.12 reported a significant associa-tion between the two variables but only onthe first postoperative day. PEDERSEN

19

reported a significant association on theseventh postoperative day.

The association of age, gender and useof oral contraceptives with postoperativepain, swelling and trismus has been stu-died4,8,18,20,22 but no such correlation wasestablished in the present study as thepatients were aged 20–30 years, the num-ber of male and female patients was dis-proportionate and none of the patients wasusing oral contraceptives.

Wound dehiscence was found in 35% ofpatients in the envelope flap group and 5%of patients in the bayonet flap group. JAKSE

et al.11 also found a higher incidence ofwound dehiscence with the envelope flap.They stated that because the envelope flapis fixed anteriorly with intersulcularsutures, soft tissue tension resulting inpostoperative hematoma and masticatorymovements causes a higher incidence ofwound dehiscence. SUAREZ-CUNQUEIRO

et al.21 also found that the type of incisionaffected primary wound healing. In con-clusion, it was observed that the bayonetflap had the advantage of resulting in lesspostoperative pain and wound dehiscence,while no difference regarding swellingand trismus was found between the twoflap design groups.

The shortcomings of the present study,which affected the ability to generalize thefindings, were small sample size, andunequal distribution of different angula-tions and positions of M3. The use ofVernier calipers has limitations becausethey may forcibly open the mouth, to someextent, leading to inaccurate readings.Minor differences may occur in the extentto which the patient opens their mouth.Circumferential facial measurements arenot representative of the total swellingbecause postoperative facial oedema hasthree planes of measurements. Transfer-

ring the contour is subject to errors inaccuracy and reproducibility. Additionalmulticentric studies are required to deter-mine the best flap design for third molarsurgery.

Funding

None.

Competing interests

None.

Ethical approval

Not required.

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