Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
1 January 2002
ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY
ORAL AND MAXILLOFACIAL SURGERY
Objectives. Wound dehiscences after lower third molar surgery potentially extend the time of postsurgical treatment and may
cause long-lasting pain. It was the aim of this prospective study to evaluate the primary wound healing of 2 different flap
designs.
Methods. Sixty completely covered lower third molars were removed. In 30 cases, the classic envelope flap with a sulcular
incision from the first to the second molar and a distal relieving incision to the mandibular ramus was used, whereas the other
30 third molars were extracted after preparation of a modified triangular flap first similarly described by Szmyd. Wound
healing was controlled on the first postoperative day, as well as 1 and 2 weeks after surgery.
Results. The overall result was a total of 33% wound dehiscence. In the envelope-flap group, wound dehiscences developed
in 57% of the cases. This represents a relative risk ratio of 5.67, with a 95% CI from 1.852 to 12.336. With the modified triangular-flap technique, only 10% of the wounds gaped during wound healing.
Conclusion. This study confirms evidence that the flap design in lower third molar surgery considerably influences primary
wound healing. The modified triangular flap is significantly less conducive to the development of wound dehiscence.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:7-12)
8 Jakse et al
B
Fig 1. A, B, Illustration and clinical view of a dehiscence after
third molar surgery using the envelope flap technique.
Flap designs
Technique I: envelope flap with a sulcular incision
from the first to the second molar and a distal
relieving incision to the mandibular ramus. The incision was done from the mandibular ramus to the distobuccal crown edge of the second molar, cutting in one
move through all layers of the soft tissue to the bone.
From there, a sulcular buccal incision was made to the
middle of the first molar (Fig 2). The mucoperiosteal
flap was elevated entirely down to the buccal surface of
the mandible. Distal to the second molar a periosteal
elevator was used to prepare subperiosteally to the
lingual area, to protect the lingual nerve.
Technique IImodified triangular flap. The first
part of the incision was similar to technique I. The incision was done from the mandibular ramus to the distobuccal crown edge of the second molar, continued by a
perpendicular incision line, obliquely into the
mandibular vestibulum, with a length of about 10 mm.
In contrast to the incision line originally described by
Szmyd,2 the modified incision extends over the
mucogingival borderline. The periodontium of the
second molar was only touched at the distofacial edge
(Fig 3). By preparing the buccal mucoperiosteum, a
triangular flap was formed (vestibular triangular flap).
The lingual preparation was the same as for technique I.
After mobilizing the mucoperiosteal flap and uncovering the surgical site, the proceedings were always the
Jakse et al 9
RESULTS
Out of the 60 surgical sites, 20 dehiscences (33%)
were found. Although on the first day after surgery, all
wounds were well closed without any sign of a beginning rupture, after 1 week, 20 cases showed gaping
wound margins distobuccal to the second molar. No
additional dehiscence developed between day 7 and
10 Jakse et al
DISCUSSION
An envelope flap with a sulcular incision from the
first to the second molar and a distal relieving incision
to the mandibular ramus is a widely used technique for
lower third molar surgery.3-7 There are definite advantages of this flap design. The surgical site is generously
uncovered, ensuring a good overview during surgery.
The sulcular incision can be prolonged mesially any
time, in case cystic lesions should extend mesially or if
additional endosurgery of the adjacent molars is
requested. As a consequence of the extensively
prepared mucoperiosteal flap, the osseous defect can
always be safely covered after the removal of the
molar. Moreover, a large flap with a broad base guarantees good vascularity up to the wound margins.
In the literature, possible disadvantages of this
method are discussed. Every preparation of a mucoperiosteal flap leads to a growing activity of osteoclasts in
the area of the alveolar process, inducing loss of alveolar bone.17 Every sulcular incision is an intervention
to the periodontal ligament and may lead to periodontal
damage. Alternatively, paragingival13 and vestibular
tongue-shaped11 flap designs, which aim at sparing the
periodontal ligament of the adjacent molar, have been
described. Especially in cases of thin keratinized
gingiva in the area of the second molar, the conventional flap design may lead to a total loss of the
attached gingiva in this area after the operation. This,
again, can cause pocket formation and loss of attachment in the area of the second molar.18
In addition, the frequent occurrence of dehiscences
distofacial to the second molar seems to be another
disadvantage of the envelope-flap design.8 To our
knowledge, such primary wound healing disorders
have not been studiedparticularly in lower third
molar surgery.
These gapings are usually located at the distobuccal
gingival rim of the adjacent second molar, where the
distal relieving incision leads into the sulcular incision.
In this area, soft tissue tensions resulting from postoperative hematoma and masticatory movements may
induce a rupture of the wound margins during the first
few postoperative days. This is particularly true for the
envelope flap because it is fixed anteriorly with intersulcular sutures. Such dehiscences can take place
inconspicuously and unnoticed by the patient and may
heal secondarily. Thus, secondary wound healing can
cause wedge-shaped defects of the gingiva distal to the
second molar, or it can favor a loss of attachment distal
Jakse et al 11
12 Jakse et al