- Email: [email protected]
Review of flap design influence on the health of the periodontium after mandibular third molar surgery
Review of flap design influence on the health of the periodontium after mandibular third molar surgery ˙Inci Karaca, DDS, PhD,a S¸ebnem S¸ims¸ek, DDS, PhD,b Dilek Ug˘ar, DDS, PhD,a and Süleyman Bozkaya, DDS, PhD,b Ankara, Turkey UNIVERSITY OF GAZI
The purpose of this study is to review the effect of flap design in terms of periodontal status of the preceding second molar after lower third molar surgery. Impacted lower third molar surgery may result in periodontal complications on the distal surface of the adjacent second molar. Flap design that is used during impacted third molar surgery is important to prevent those complications. Several different flap techniques, mainly envelope, triangular (vertical) flaps, and their modifications have been developed to minimize those complications. Each technique has some advantages as well as disadvantages. It is also reported that the selection of a flap design does not seem to have a lasting effect on the health of periodontal tissue. The effect of the type of flap used for lower third molar surgery on the periodontal status of the second molar, as well as the factors that may influence this outcome, has been uncertain. The decision to use on one or the other of the flaps should be based on surgeon’s preference. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:18-23)
Third molars are the teeth that are most commonly impacted.1 They are present in 90% of the population, with 33% having at least 1 impacted third molar.2,3 These impactions are probably the result of both genetic and environmental factors.1,4,5 The removal of impacted third molars is often advocated for a variety of reasons6-10; however, absolute indications and contraindications for the removal of these teeth have not been established.11,12 While there is little controversy over removal of the impacted third molars associated with pathologic lesions, questions still remain about the prophylactic removal of these teeth. At the recent National Institutes of Health Consensus Development Conference on Removal of Third Molars it was agreed that impaction or malposition of a third molar was an abnormal state and might justify its removal. Such treatment was not considered to be “prophylactic,”7,13 and thus removal of impacted third molars is the most frequently performed surgical procedure in many oral and maxillofacial surgical practices.1,14 A large number of investigations concerning the third molar have been presented, most of them dealing with the prevalence and classification of impaction, a
Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Gazi. b Resident, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Gazi. Received for publication Jun 1, 2006; returned for revision Oct 24, 2006; accepted for publication Nov 29, 2006. 1079-2104/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2006.11.049
18
different surgical techniques for its removal, and preand postoperative symptoms.15-17 Studies have examined effects on the malocclusion, resorption, and repair of the adjacent roots, and relationship to pericoronitis and pathogens.11,18-20 Surgical removal of mandibular third molars requires that a flap be created and ostectomy be performed.2 This surgery may be associated with a variety of complications.1,14,21-25 One of the most overlooked is the compromised periodontal status of the adjacent second molar after the surgical removal of an impacted mandibular third molar.25 The influence of impacted third molar extraction on the periodontal pockets distal to the adjacent second molar was investigated by several authors6,11,15,26-30 with conflicting results. Ash et al.29 evaluated the effect of extraction of a partially or fully impacted third molar on periodontal health of the adjacent second molar; they reported deepening of periodontal pockets. Similar findings were later shown by Kugelberg et al.15 and Peng et al.11 To the contrary, Szmyd and Hester30 showed a decrease in pocket depth following third molar extraction. Similar results have been shown by Groves and Moore.28 Woolf et al.26 and Stephens et al.27 have also shown a decrease in periodontal pocket depth following third molar extractions using 2 types of distal wedge flaps. Quee et al.6 and Krausz et al.,31 however, have shown no significant changes in pocket depths following third molar extractions. Loss of attachment distal to the second molar following third molar extraction was described by Ash et al.29 Stephens et al.27 have shown similar attachment loss using 2 types of distal wedge flaps and this was
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further corroborated by Quee et al.6 Peng et al.11 showed greater attachment loss only at the distal sites of the experimental group (attachment loss: 4.10 ⫾ 0.45 mm and 5.82 ⫾ 0.26 mm for the control and experimental groups, respectively). Krausz et al.31 have shown that clinical attachment levels for the test and control sites were similar. Changes in alveolar bone height following third molar extractions have also been a subject of controversy in the literature. Groves and Moore28 reported similar bone loss on the distal aspect of the second molar, using any of 3 different flap designs. Peng et al.11 reported the increased radiographic bone loss was only found at the distal sites and not at the mesial sites on the experimental group. Conversely, Ash et al.29 and Krausz et al.31 have shown an increase of the alveolar bone height distal to the second molar in young patients. Likewise, Kugelberg et al.15 have shown similar findings— mostly in male patients, and later32 in a group of young patients (ⱕ20 years). The outcome of third molar surgery is influenced by a variety of factors including, among others, mucoperiosteal flap design1,26,33-36; however, there is relatively little information concerning the effect of impaction surgery on the periodontal health of the adjacent second molar.15,19,37,38 Periodontal evaluation after the surgical removal of impacted mandibular third molars has raised questions concerning the direct result of this surgery on the subsequent periodontal pocket formation, loss of epithelial or connective tissue attachment, or bone loss of the second molar.2,6,15,27,32,39-41 Therefore, reducing the incidence of these complications becomes imperative. FLAP DESIGN TECHNIQUES The design of flaps used to expose impacted mandibular third molars has been the subject of textbooks and various articles in recent years.6,27,28,42,43 Several different flap techniques have been developed, compared, and discussed to minimize potential periodontal complications to adjacent second molar6,27,44,45 or improve surgical access.14,42 Mucoperiosteal access flaps used for removing third molars can be broadly grouped under envelope and triangular (vertical) flaps.14 In 1971, Szmyd45 described 2 different flap designs in detail. The first was an envelope flap with the incision beginning just medial to the external oblique ridge and extending to the middle of the distal line angle of the second molar (Fig. 1).27,45 From there, a sulcular incision was made from the distofacial line angle of the second molar to the mesiofacial line angle of the first molar. This flap could be modified to provide a gingivectomy of the tissues overlying the impacted third molar by extension of a second
Karaca et al 19
Fig. 1. Envelope flap described by Szmyd.27,45 A, distal wedge of tissue to be removed; B-B, extent of sulcular incision; S, sutures.
incision from the external oblique line to the distal edge of tissue. In the second flap designed by Szmyd, the first part of the incision was similar to the first. It was continued by a vertical incision line from the distofacial line angle of the second molar apically to the mucogingival line approximately 2 to 3 mm (Fig. 2).27,45 Szmyd45 recommended the second modification for the following advantages: (1) no need to detach the facial free gingival tissue around the second and first molar; (2) decreased amount of reflected periosteum; (3) broad-based blood supply to the flap; (4) adequate exposure and visibility; (5) good bony support for the soft tissue flap; and (6) closure can be effected with a single suture and the distal aspect of the third molar socket. An envelope flap exposing the buccal bone of the adjacent second molar is the most common approach for lower third molar surgery.2,6,27,32,33,44,46 There are definite advantages of this flap design. The surgical site is adequately uncovered, providing generous visibility during the removal of the molar. The sulcular incision can be extended mesially any time, if needed. As a consequence of the extensively prepared mucoperiosteal flap, the osseous defect can be safely covered after surgery. Moreover, blood supply up to the wound margins is adequate.27,44 In the literature, however, possible disadvantages of this method are discussed. The distal extension of the incisions conventionally made to access impacted mandibular third molars comes close to or even cuts across the insertion of the temporalis tendon. It also commonly lies over the bone defect formed after removal of the tooth. This could be responsible, at least in part, for the occurrence of trismus,
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Fig. 2. Modification of the envelope flap described by Szmyd.27,45 A, distal wedge of tissue to be removed; V, vertical releasing incision to mucogingival line; B, anterior extent of horizontal releasing incision along mucogingival line; S, sutures.
pain, swelling, and periodontal damage of the preceding second molar after surgery.14 Although there are no specific data available from the literature, when using the envelope flap, wound dehiscence at the distofacial edge of the preceding second molar is frequent in the first phase of wound healing after surgical removal of impacted mandibular third molars.47 Such dehiscence potentially prolongs the time of postsurgical treatment. This may lead to a longer period of discomfort and continuous pain and could cause the development of alveolar osteitis and compromised periodontal status of the adjacent second molar.44 Every preparation of a mucoperiosteal flap is an intervention to the area of the alveolar process and may induce loss of alveolar bone causing a growing activity of osteoclasts.44,48 Every sulcular incision interferes with the periodontal ligament and may lead to compromised periodontal status.44 Every exposure of the alveolar bone to the buccal cavity, even without ostectomy or extraction, causes bone resorption.49-52 The type of flap described by Szmyd,45 which leaves the collar of gingiva intact on the buccal aspect of the second molars, could minimize this bone resorption.2 These standard incisions have been modified by several surgeons to minimize postoperative complications or improve surgical access.14,22,53,54 Berwick,55 in 1966, designed a vestibular tongue-shaped flap that extended onto the buccal shelf of the mandible with an incision line that did not lie over the bony defect created by the removal of the impacted tooth, and had its base at the distolingual aspect of the second molar to
Fig. 3. Outline of incision of the vestibular tongue-shaped flap described by Berwick.55
spare the periodontal ligament of the adjacent molar (Fig. 3). In 1972, Magnus et al.,56 with the same aim, described a paragingival flap in which the anterior releasing incision is located 0.5 cm apical to the gingival margin of the second and first molars, instead of carrying an incision anteriorly around the gingival margins of these molars. In 1962, Ash et al.29 examined periodontal status of second molars before and immediately after the removal of 75 completely impacted third molars, and 2 weeks, 6 months, and a year following. They found an increase in the incidence of periodontal pockets and/or root exposure on the distal aspect of second molars at 6 months and 1 year after surgery. Data were not sub-
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jected to statistical analysis, thus making it difficult to determine whether reported changes could have been present and unrecognized before the removal of the third molar or if they were results of the surgical technique. The authors stated that “. . . the presence and/or surgical removal of impacted third molars results in an increase in the number of periodontal pocket formation on the distal of second molars.”29, p218 Szmyd and Hester,30 in 1963, examined 75 mandibular second molars before and after the removal of the adjacent third molars. They reported that the incidence of periodontal pocket depths distal to second molars was decreased after the removal of impacted mandibular third molars with a mucoperiosteal flap incorporating a distal wedge procedure. In 1983, Stephens et al.27 reported the results of a comparative study of 2 types of flap used during impacted mandibular third molar removal on the periodontal health of adjacent second molars. The envelope flap described by Szmyd was used on one side and the modified envelope flap with a vertical releasing incision to mucogingival line was used on the other side. The 15 patients who participated in the study were examined preoperatively, and 2, 6, and 12 weeks after removal of their impacted mandibular third molars. The results showed an actual improvement in the health status around mandibular second molars at 12 weeks compared to the preoperative readings. According to experimental data, however, there was no significant difference between the 2 flap designs examined. They concluded that “. . . if a problem involving the soft tissues around the mandibular second molars occurs after the 12th week, it is apparently not due to the surgery or the technique, but is the result of some other process.”27, p724 Quee et al.,6 in a similar study in 1984, examined 30 patients who underwent bilateral surgical removal of their impacted mandibular third molars. A split-mouth experimental design was used, with one side of the mandible being randomly allocated to 1 of 2 flap design groups: the vertical flap described by Thoma57 and the envelope flap (the variation of Thoma’s vertical flap) described by Kruger.58 The authors found that although there was some loss of attachment on the distal surface of the second molar after surgery, there was no difference between the 2 flap designs at 6 months. They concluded that “. . . flap design had no influence on the subsequent change in attachment level.”6, p629 In 1988, Schofield et al.41 compared the influences of 2 types of flap used in removing bilateral impacted mandibular third molars that would not require removal of bone distal to the second molar on the health of the periodontal tissue of the second molar tooth. They chose the recall period of 1 year so that they could
Karaca et al 21
assess final osseous and soft tissue levels. Fifty patients initially entered the study; however, on recall 1 year later, only 23 remained for final assessment. Either an envelope flap or a vertical flap modified from Kruger58 was used on each side chosen by the flip of a coin. Their results supported and extended the results of Stephens et al.27 and Quee et al.6 Schofield et al. concluded that “. . . the selection of a flap design for mandibular third molar surgery does not seem to have a lasting effect on the health of the periodontium on the distal of the second molar.”41, p691 In 2003, Suarez-Cunqueiro et al.1 compared 2 different flap designs in terms of wound healing, periodontal pocket depth of second molar, pain, maximum mouth opening, and swelling after third molar surgery. The 27 healthy patients who underwent surgical removal of 4 impacted third molars, including 54 lower and 54 upper, were included. Access for removal of the impacted molar in one randomly chosen half of the jaw was accomplished by use of a marginal flap, which is the traditional technique for third molar surgery, and access in the other half by use of a paramarginal flap, which is a variation of the latter. The results, when subjected to statistical analysis, showed that the use of the marginal flap in impacted third molar surgery resulted in better primary wound healing at 5-day follow-up than the use of the paramarginal flap. No evidence existed, however, that the choice of either flap design had an influence on postoperative pain, swelling, or mouth opening at 5 days, 10 days, and 3 months after surgery. Although the paramarginal flap has less pocket depth in the initial stages, there was no difference after the early follow-ups in that both designs obtained the same positive outcome at 3 months after surgery. These authors concluded that “. . . there are no advantages of the use of a paramarginal flap instead of a traditional marginal flap for removing impacted third molars.”1, p403 CONCLUSIONS Surgical removal of impacted lower third molars may be associated with periodontal complications. Several different flap techniques are used for such a surgery. As reported in previous studies,27,41 flap design in lower third molar surgery influences primary wound healing but does not seem to have a lasting effect on the health of the periodontium on the distal of the second molar. If there is a problem involving the soft tissues around the mandibular second molars, it is apparently not a result of the surgery or the technique, but is the result of some other process. Further comparative studies are still needed for determining the best technique.
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REFERENCES 1. Suarez-Cunqueiro MM, Gutwald R, Reichman J, Otero-Cepeda XL, Schmelzeisen R. Marginal flap versus paramarginal flap in impacted third molar surgery: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95(4):403-8. 2. Rosa AL, Carneiro MG, Lavrador MA, Novaes AB Jr. Influence of flap design on periodontal healing of second molars after extraction of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93(4):404-7. 3. Scherstein E, Lysell L, Rohlin M. Prevalance of impacted third molars in dental students. Swed Dent J 1989;13(1-2):7-13. 4. Richardson M. Impacted third molars. Br Dent J 1995;178(3):92. 5. Seward GR, Haris M, McGowan DA, editors. An outline of oral surgery. Oxford, UK: Wright; 1999, p. 52. 6. Quee TA, Gosselin D, Millar EP, Stamm JW. Surgical removal of the fully impacted mandibular third molar. The influence of flap design and alveolar bone height on the periodontal status of the second molar. J Periodontol 1985;56(10):625-30. 7. Giglio JA, Gunsolley JC, Laskin DM, Short K. Effect of removing impacted third molars on plaque and gingival indices. J Oral Maxillofac Surg 1994;52(6):584-7. 8. Laskin DM. Indications and contraindications for removal of impacted third molars. Dent Clin North Am 1969;13(4):919-28. 9. Peterson LJ. Rationale for removing impacted teeth: when to extract or not to extract. J Am Dent Assoc 1992;123(7):198-204. 10. Nordenram A, Hultin M, Kjellman O, Ramstrom G. Indications for surgical removal of the mandibular third molar. Study of 2630 cases. Swed Dent J 1987;11(1-2):23-9. 11. Peng KY, Tseng YC, Shen EC, Chiu SC, Fu E, Huang YW. Mandibular second molar periodontal status after third molar extraction. J Periodontol 2001;72(12):1647-51. 12. Mercier P, Precious D. Risks and benefits of removal of impacted third molars. A critical review of the literature. Int J Oral Maxillofac Surg 1992;21(1):17-27. 13. NIH consensus development conference for removal of third molars. J Oral Surg 1980;38(3):235-6. 14. Nageshwar. Comma incision for impacted mandibular third molars. J Oral Maxillofac Surg 2002;60(12):1506-9. 15. Kugelberg CF, Ahlstrom U, Ericson S, Hugoson A. Periodontal healing after impacted lower third molar surgery. A retrospective study. Int J Oral Surg 1985;14(1):29-40. 16. Kugelberg CF, Ahlstrom U, Ericson S, Hugoson A, Thilander H. The influence of anatomical, pathophysiological and other factors on periodontal healing after impacted lower third molar surgery. A multiple regression analysis. J Clin Periodontol 1991;18(1):37-43. 17. Killey HC, Kay LW. The impacted wisdom tooth. Edinburgh, UK: Churchill Livingstone; 1975. 18. Ades AG, Joondeph DR, Little RM, Chapko MK. A long-term study of the relationship of third molars to changes in the mandibular dental arch. Am J Orthod Dentofacial Orthop 1990;97(4):323-35. 19. Nitzan D, Keren T, Marmary Y. Does an impacted tooth cause root resorption of the adjacent one? Oral Surg Oral Med Oral Pathol 1981;51(3):221-4. 20. Mombelli A, Buser D, Lang NP, Berthold H. Suspected periodontopathogens in erupting third molar sites of periodontally healthy individuals. J Clin Periodontol 1990;17(1):48-54. 21. Iizuka T, Tanner S, Berthold H. Mandibular fractures following third molar extraction. A retrospective clinical and radiological study. Int J Oral Maxillofac Surg 1997;26(5):338-43. 22. Walters H. Reducing lingual nerve damage in third molar surgery: a clinical audit of 1350 cases. Br Dent J 1995; 25;178(4):140-4. 23. Chiapasco M, De Cicco L, Marrone G. Side effects and compli-
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cations associated with third molar surgery. Oral Surg Oral Med Oral Pathol 1993;76(4):412-20. Schmelzeisen R, Frolich JC. Prevention of postoperative swelling and pain by dexamethasone after operative removal of impacted third molar teeth. Eur J Clin Pharmacol 1993;44(3):275-7. Motamedi MH. Preventing periodontal pocket formation after removal of an impacted mandibular third molar. J Am Dent Assoc 1999;130(10):1482-4. Woolf RH, Malmquist JP, Wright WH. Third molar extractions: periodontal implications of two flap designs. Gen Dent 1978;26(1):52-6. Stephens RJ, App GR, Foreman DW. Periodontal evaluation of two mucoperiosteal flaps used in removing impacted mandibular third molars. J Oral Maxillofac Surg 1983;41(11):719-24. Groves BJ, Moore JR. The periodontal implications of flap design in lower third molar extractions. Dent Pract Dent Rec 1970;20(9):297-304. Ash MM, Costich ER, Hayward JR. A study of periodontal hazards of third molars. J Periodontol 1962;33:209-19. Szmyd L, Hester WR. Crevicular depth of the second molar in impacted third molar surgery. J Oral Surg Anesth Hosp Dent Serv 1963;21:185-9. Krausz AA, Machtei EE, Peled M. Effects of lower third molar extraction on attachment level and alveolar bone height of the adjacent second molar. Int J Oral Maxillofac Surg 2005; 34(7):756-60. Kugelberg CF, Ahlstrom U, Ericson S, Hugoson A, Kvint S. Periodontal healing after impacted lower third molar surgery in adolescents and adults. A prospective study. Int J Oral Maxillofac Surg 1991;20(1):18-24. Sands T, Pynn BR, Nenniger S. Third molar surgery: current concepts and controversies. Part 2. Oral Health 1993;83(5):19, 21-2, 27-30. Garcia Garcia A, Gude Sampedro F, Gandara Rey J, Gallas Torreira M. Trismus and pain after removal of impacted lower third molars. J Oral Maxillofac Surg 1997;55(11):1223-6. Shevel E, Koepp WG, Butow KW. A subjective assessment of pain and swelling following the surgical removal of impacted third molar teeth using different surgical techniques. SADJ 2001;56(5):238-41. Clauser C, Barone R. Effect of incision and flap reflection on postoperative pain after the removal of partially impacted mandibular third molars. Quintessence Int 1994;25(12):845-9. App GR, Stephens RJ. Periodontal considerations and the impacted tooth. Dent Clin North Am 1979;23(3):359-67. Ash M. Third molars as periodontal problems. Dent Clin North Am 1964;18:51. Kugelberg CF. Periodontal healing two and four years after impacted lower third molar surgery. A comparative retrospective study. Int J Oral Maxillofac Surg 1990;19(6):341-5. Marmary Y, Brayer L, Tzukert A, Feller L. Alveolar bone repair following extraction of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol 1986;61(4):324-6. Schofield ID, Kogon SL, Donner A. Long-term comparison of two surgical flap designs for third molar surgery on the health of the periodontal tissue of the second molar tooth. J Can Dent Assoc 1988;54(9):689-91. Alling CC, Helfrick JE, Alling RD. Impacted teeth. Philadelphia, PA: Saunders; 1983. 167-170. Donlon W, Triuta M. Minimal incision third molar impaction surgery. Int J Oral Maxillofac Surg 1999:28(Suppl 1):57. Jakse N, Bankaoglu V, Wimmer G, Eskici A, Pertl C. 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(1):7-12.
OOOOE Volume 104, Number 1 45. Szmyd L. Impacted teeth. Dent Clin North Am 1971;15:299-318. 46. Pajarola GF, Jaquiery C, Lambrecht JT, Sailer HF. [The extraction of retained mandibular wisdom teeth (II). The surgical technic, follow-up and complications] Schweiz Monatsschr Zahnmed 1994; 104(12):1520-34. French, German. 47. Klatil L. Komplikationen bei der Entfernung von Weisheitszahnen [doctoral thesis]. Graz (Austria): KF-University Graz; 1998. 48. Tavtigian R. The height of the facial radicular alveolar crest following apically positioned flap operations. J Periodontol 1970;41(7):412-8. 49. Bergstrom J, Henrikson CO. Quantitative long-term determinations of the alveolar bone mineral mass in man by 125-I absorptiometry. II. Following periodontal surgery. Acta Radiol Ther Phys Biol 1974;13(6):489-500. 50. Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. Alveolar crest reduction following full and partial thickness flaps. J Periodontol 1972;43(3):141-4. 51. Yaffe A, Fine N, Binderman I. Regional accelerated phenomenon in the mandible following mucoperiosteal flap surgery. J Periodontol 1994;65(1):79-83. 52. Yaffe A, Iztkovich M, Earon Y, Alt I, Lilov R, Binderman I. Local delivery of an amino bisphosphonate prevents the resorptive phase of alveolar bone following mucoperiosteal flap surgery in rats. J Periodontol 1997;68(9):884-9.
Karaca et al 23 53. van Gool AV, Ten Bosch JJ, Boering G. Clinical consequences of complaints and complications after removal of the mandibular third molar. Int J Oral Surg 1977;6(1):29-37. 54. Schow SR. Evaluation of postoperative localized osteitis in mandibular third molar surgery. Oral Surg Oral Med Oral Pathol 1974;38(3):352-8. 55. Berwick WA. Alternative method of flap reflection. Br Dent J 1966;20;121(6):295-6. 56. Magnus WW, Castner DV Jr, Hiatt WR. An alternative method of flap reflection of mandibular third molars. Mil Med 1972;137(6):232-3. 57. Thoma KH: The management of malposed inferior third molars. J Dent Res 1932;12:175-208. 58. Kruger GO. Management of impactions. Dent Clin North Am 1959;707-722. Reprint requests: I˙nci Karaca, DDS, PhD Department of Oral and Maxillofacial Surgery Faculty of Dentistry Gazi University 06510 Emek Ankara, Turkey [email protected]
The purpose of this study is to review the effect of flap design in terms of periodontal status of the preceding second molar after lower third molar surgery. Impacted lower third molar surgery may result in periodontal complications on the distal surface of the adjacent second molar. Flap design that is used during impacted third molar surgery is important to prevent those complications. Several different flap techniques, mainly envelope, triangular (vertical) flaps, and their modifications have been developed to minimize those complications. Each technique has some advantages as well as disadvantages. It is also reported that the selection of a flap design does not seem to have a lasting effect on the health of periodontal tissue. The effect of the type of flap used for lower third molar surgery on the periodontal status of the second molar, as well as the factors that may influence this outcome, has been uncertain. The decision to use on one or the other of the flaps should be based on surgeon’s preference. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:18-23)
Third molars are the teeth that are most commonly impacted.1 They are present in 90% of the population, with 33% having at least 1 impacted third molar.2,3 These impactions are probably the result of both genetic and environmental factors.1,4,5 The removal of impacted third molars is often advocated for a variety of reasons6-10; however, absolute indications and contraindications for the removal of these teeth have not been established.11,12 While there is little controversy over removal of the impacted third molars associated with pathologic lesions, questions still remain about the prophylactic removal of these teeth. At the recent National Institutes of Health Consensus Development Conference on Removal of Third Molars it was agreed that impaction or malposition of a third molar was an abnormal state and might justify its removal. Such treatment was not considered to be “prophylactic,”7,13 and thus removal of impacted third molars is the most frequently performed surgical procedure in many oral and maxillofacial surgical practices.1,14 A large number of investigations concerning the third molar have been presented, most of them dealing with the prevalence and classification of impaction, a
Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Gazi. b Resident, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Gazi. Received for publication Jun 1, 2006; returned for revision Oct 24, 2006; accepted for publication Nov 29, 2006. 1079-2104/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2006.11.049
18
different surgical techniques for its removal, and preand postoperative symptoms.15-17 Studies have examined effects on the malocclusion, resorption, and repair of the adjacent roots, and relationship to pericoronitis and pathogens.11,18-20 Surgical removal of mandibular third molars requires that a flap be created and ostectomy be performed.2 This surgery may be associated with a variety of complications.1,14,21-25 One of the most overlooked is the compromised periodontal status of the adjacent second molar after the surgical removal of an impacted mandibular third molar.25 The influence of impacted third molar extraction on the periodontal pockets distal to the adjacent second molar was investigated by several authors6,11,15,26-30 with conflicting results. Ash et al.29 evaluated the effect of extraction of a partially or fully impacted third molar on periodontal health of the adjacent second molar; they reported deepening of periodontal pockets. Similar findings were later shown by Kugelberg et al.15 and Peng et al.11 To the contrary, Szmyd and Hester30 showed a decrease in pocket depth following third molar extraction. Similar results have been shown by Groves and Moore.28 Woolf et al.26 and Stephens et al.27 have also shown a decrease in periodontal pocket depth following third molar extractions using 2 types of distal wedge flaps. Quee et al.6 and Krausz et al.,31 however, have shown no significant changes in pocket depths following third molar extractions. Loss of attachment distal to the second molar following third molar extraction was described by Ash et al.29 Stephens et al.27 have shown similar attachment loss using 2 types of distal wedge flaps and this was
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further corroborated by Quee et al.6 Peng et al.11 showed greater attachment loss only at the distal sites of the experimental group (attachment loss: 4.10 ⫾ 0.45 mm and 5.82 ⫾ 0.26 mm for the control and experimental groups, respectively). Krausz et al.31 have shown that clinical attachment levels for the test and control sites were similar. Changes in alveolar bone height following third molar extractions have also been a subject of controversy in the literature. Groves and Moore28 reported similar bone loss on the distal aspect of the second molar, using any of 3 different flap designs. Peng et al.11 reported the increased radiographic bone loss was only found at the distal sites and not at the mesial sites on the experimental group. Conversely, Ash et al.29 and Krausz et al.31 have shown an increase of the alveolar bone height distal to the second molar in young patients. Likewise, Kugelberg et al.15 have shown similar findings— mostly in male patients, and later32 in a group of young patients (ⱕ20 years). The outcome of third molar surgery is influenced by a variety of factors including, among others, mucoperiosteal flap design1,26,33-36; however, there is relatively little information concerning the effect of impaction surgery on the periodontal health of the adjacent second molar.15,19,37,38 Periodontal evaluation after the surgical removal of impacted mandibular third molars has raised questions concerning the direct result of this surgery on the subsequent periodontal pocket formation, loss of epithelial or connective tissue attachment, or bone loss of the second molar.2,6,15,27,32,39-41 Therefore, reducing the incidence of these complications becomes imperative. FLAP DESIGN TECHNIQUES The design of flaps used to expose impacted mandibular third molars has been the subject of textbooks and various articles in recent years.6,27,28,42,43 Several different flap techniques have been developed, compared, and discussed to minimize potential periodontal complications to adjacent second molar6,27,44,45 or improve surgical access.14,42 Mucoperiosteal access flaps used for removing third molars can be broadly grouped under envelope and triangular (vertical) flaps.14 In 1971, Szmyd45 described 2 different flap designs in detail. The first was an envelope flap with the incision beginning just medial to the external oblique ridge and extending to the middle of the distal line angle of the second molar (Fig. 1).27,45 From there, a sulcular incision was made from the distofacial line angle of the second molar to the mesiofacial line angle of the first molar. This flap could be modified to provide a gingivectomy of the tissues overlying the impacted third molar by extension of a second
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Fig. 1. Envelope flap described by Szmyd.27,45 A, distal wedge of tissue to be removed; B-B, extent of sulcular incision; S, sutures.
incision from the external oblique line to the distal edge of tissue. In the second flap designed by Szmyd, the first part of the incision was similar to the first. It was continued by a vertical incision line from the distofacial line angle of the second molar apically to the mucogingival line approximately 2 to 3 mm (Fig. 2).27,45 Szmyd45 recommended the second modification for the following advantages: (1) no need to detach the facial free gingival tissue around the second and first molar; (2) decreased amount of reflected periosteum; (3) broad-based blood supply to the flap; (4) adequate exposure and visibility; (5) good bony support for the soft tissue flap; and (6) closure can be effected with a single suture and the distal aspect of the third molar socket. An envelope flap exposing the buccal bone of the adjacent second molar is the most common approach for lower third molar surgery.2,6,27,32,33,44,46 There are definite advantages of this flap design. The surgical site is adequately uncovered, providing generous visibility during the removal of the molar. The sulcular incision can be extended mesially any time, if needed. As a consequence of the extensively prepared mucoperiosteal flap, the osseous defect can be safely covered after surgery. Moreover, blood supply up to the wound margins is adequate.27,44 In the literature, however, possible disadvantages of this method are discussed. The distal extension of the incisions conventionally made to access impacted mandibular third molars comes close to or even cuts across the insertion of the temporalis tendon. It also commonly lies over the bone defect formed after removal of the tooth. This could be responsible, at least in part, for the occurrence of trismus,
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Fig. 2. Modification of the envelope flap described by Szmyd.27,45 A, distal wedge of tissue to be removed; V, vertical releasing incision to mucogingival line; B, anterior extent of horizontal releasing incision along mucogingival line; S, sutures.
pain, swelling, and periodontal damage of the preceding second molar after surgery.14 Although there are no specific data available from the literature, when using the envelope flap, wound dehiscence at the distofacial edge of the preceding second molar is frequent in the first phase of wound healing after surgical removal of impacted mandibular third molars.47 Such dehiscence potentially prolongs the time of postsurgical treatment. This may lead to a longer period of discomfort and continuous pain and could cause the development of alveolar osteitis and compromised periodontal status of the adjacent second molar.44 Every preparation of a mucoperiosteal flap is an intervention to the area of the alveolar process and may induce loss of alveolar bone causing a growing activity of osteoclasts.44,48 Every sulcular incision interferes with the periodontal ligament and may lead to compromised periodontal status.44 Every exposure of the alveolar bone to the buccal cavity, even without ostectomy or extraction, causes bone resorption.49-52 The type of flap described by Szmyd,45 which leaves the collar of gingiva intact on the buccal aspect of the second molars, could minimize this bone resorption.2 These standard incisions have been modified by several surgeons to minimize postoperative complications or improve surgical access.14,22,53,54 Berwick,55 in 1966, designed a vestibular tongue-shaped flap that extended onto the buccal shelf of the mandible with an incision line that did not lie over the bony defect created by the removal of the impacted tooth, and had its base at the distolingual aspect of the second molar to
Fig. 3. Outline of incision of the vestibular tongue-shaped flap described by Berwick.55
spare the periodontal ligament of the adjacent molar (Fig. 3). In 1972, Magnus et al.,56 with the same aim, described a paragingival flap in which the anterior releasing incision is located 0.5 cm apical to the gingival margin of the second and first molars, instead of carrying an incision anteriorly around the gingival margins of these molars. In 1962, Ash et al.29 examined periodontal status of second molars before and immediately after the removal of 75 completely impacted third molars, and 2 weeks, 6 months, and a year following. They found an increase in the incidence of periodontal pockets and/or root exposure on the distal aspect of second molars at 6 months and 1 year after surgery. Data were not sub-
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jected to statistical analysis, thus making it difficult to determine whether reported changes could have been present and unrecognized before the removal of the third molar or if they were results of the surgical technique. The authors stated that “. . . the presence and/or surgical removal of impacted third molars results in an increase in the number of periodontal pocket formation on the distal of second molars.”29, p218 Szmyd and Hester,30 in 1963, examined 75 mandibular second molars before and after the removal of the adjacent third molars. They reported that the incidence of periodontal pocket depths distal to second molars was decreased after the removal of impacted mandibular third molars with a mucoperiosteal flap incorporating a distal wedge procedure. In 1983, Stephens et al.27 reported the results of a comparative study of 2 types of flap used during impacted mandibular third molar removal on the periodontal health of adjacent second molars. The envelope flap described by Szmyd was used on one side and the modified envelope flap with a vertical releasing incision to mucogingival line was used on the other side. The 15 patients who participated in the study were examined preoperatively, and 2, 6, and 12 weeks after removal of their impacted mandibular third molars. The results showed an actual improvement in the health status around mandibular second molars at 12 weeks compared to the preoperative readings. According to experimental data, however, there was no significant difference between the 2 flap designs examined. They concluded that “. . . if a problem involving the soft tissues around the mandibular second molars occurs after the 12th week, it is apparently not due to the surgery or the technique, but is the result of some other process.”27, p724 Quee et al.,6 in a similar study in 1984, examined 30 patients who underwent bilateral surgical removal of their impacted mandibular third molars. A split-mouth experimental design was used, with one side of the mandible being randomly allocated to 1 of 2 flap design groups: the vertical flap described by Thoma57 and the envelope flap (the variation of Thoma’s vertical flap) described by Kruger.58 The authors found that although there was some loss of attachment on the distal surface of the second molar after surgery, there was no difference between the 2 flap designs at 6 months. They concluded that “. . . flap design had no influence on the subsequent change in attachment level.”6, p629 In 1988, Schofield et al.41 compared the influences of 2 types of flap used in removing bilateral impacted mandibular third molars that would not require removal of bone distal to the second molar on the health of the periodontal tissue of the second molar tooth. They chose the recall period of 1 year so that they could
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assess final osseous and soft tissue levels. Fifty patients initially entered the study; however, on recall 1 year later, only 23 remained for final assessment. Either an envelope flap or a vertical flap modified from Kruger58 was used on each side chosen by the flip of a coin. Their results supported and extended the results of Stephens et al.27 and Quee et al.6 Schofield et al. concluded that “. . . the selection of a flap design for mandibular third molar surgery does not seem to have a lasting effect on the health of the periodontium on the distal of the second molar.”41, p691 In 2003, Suarez-Cunqueiro et al.1 compared 2 different flap designs in terms of wound healing, periodontal pocket depth of second molar, pain, maximum mouth opening, and swelling after third molar surgery. The 27 healthy patients who underwent surgical removal of 4 impacted third molars, including 54 lower and 54 upper, were included. Access for removal of the impacted molar in one randomly chosen half of the jaw was accomplished by use of a marginal flap, which is the traditional technique for third molar surgery, and access in the other half by use of a paramarginal flap, which is a variation of the latter. The results, when subjected to statistical analysis, showed that the use of the marginal flap in impacted third molar surgery resulted in better primary wound healing at 5-day follow-up than the use of the paramarginal flap. No evidence existed, however, that the choice of either flap design had an influence on postoperative pain, swelling, or mouth opening at 5 days, 10 days, and 3 months after surgery. Although the paramarginal flap has less pocket depth in the initial stages, there was no difference after the early follow-ups in that both designs obtained the same positive outcome at 3 months after surgery. These authors concluded that “. . . there are no advantages of the use of a paramarginal flap instead of a traditional marginal flap for removing impacted third molars.”1, p403 CONCLUSIONS Surgical removal of impacted lower third molars may be associated with periodontal complications. Several different flap techniques are used for such a surgery. As reported in previous studies,27,41 flap design in lower third molar surgery influences primary wound healing but does not seem to have a lasting effect on the health of the periodontium on the distal of the second molar. If there is a problem involving the soft tissues around the mandibular second molars, it is apparently not a result of the surgery or the technique, but is the result of some other process. Further comparative studies are still needed for determining the best technique.
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OOOOE Volume 104, Number 1 45. Szmyd L. Impacted teeth. Dent Clin North Am 1971;15:299-318. 46. Pajarola GF, Jaquiery C, Lambrecht JT, Sailer HF. [The extraction of retained mandibular wisdom teeth (II). The surgical technic, follow-up and complications] Schweiz Monatsschr Zahnmed 1994; 104(12):1520-34. French, German. 47. Klatil L. Komplikationen bei der Entfernung von Weisheitszahnen [doctoral thesis]. Graz (Austria): KF-University Graz; 1998. 48. Tavtigian R. The height of the facial radicular alveolar crest following apically positioned flap operations. J Periodontol 1970;41(7):412-8. 49. Bergstrom J, Henrikson CO. Quantitative long-term determinations of the alveolar bone mineral mass in man by 125-I absorptiometry. II. Following periodontal surgery. Acta Radiol Ther Phys Biol 1974;13(6):489-500. 50. Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. Alveolar crest reduction following full and partial thickness flaps. J Periodontol 1972;43(3):141-4. 51. Yaffe A, Fine N, Binderman I. Regional accelerated phenomenon in the mandible following mucoperiosteal flap surgery. J Periodontol 1994;65(1):79-83. 52. Yaffe A, Iztkovich M, Earon Y, Alt I, Lilov R, Binderman I. Local delivery of an amino bisphosphonate prevents the resorptive phase of alveolar bone following mucoperiosteal flap surgery in rats. J Periodontol 1997;68(9):884-9.
Karaca et al 23 53. van Gool AV, Ten Bosch JJ, Boering G. Clinical consequences of complaints and complications after removal of the mandibular third molar. Int J Oral Surg 1977;6(1):29-37. 54. Schow SR. Evaluation of postoperative localized osteitis in mandibular third molar surgery. Oral Surg Oral Med Oral Pathol 1974;38(3):352-8. 55. Berwick WA. Alternative method of flap reflection. Br Dent J 1966;20;121(6):295-6. 56. Magnus WW, Castner DV Jr, Hiatt WR. An alternative method of flap reflection of mandibular third molars. Mil Med 1972;137(6):232-3. 57. Thoma KH: The management of malposed inferior third molars. J Dent Res 1932;12:175-208. 58. Kruger GO. Management of impactions. Dent Clin North Am 1959;707-722. Reprint requests: I˙nci Karaca, DDS, PhD Department of Oral and Maxillofacial Surgery Faculty of Dentistry Gazi University 06510 Emek Ankara, Turkey [email protected]