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Modified Flap Design for Lower Third Molar Surgery: A Short Patient-based Outcome Comparative Study

*Faaiz Y. Alhamdani, **Athil A.Raheem & **Basma Kamal

*College of Dentistry, Al- Mustansiriay University, Baghdad- Iraq.

**Alkaramah Secondary Dental Care Centre,Baghdad- Iraq.



Objectives: to compare the influence of a newly suggest modified flap design on pain and swelling with the traditional two sided flap.

Materials and Methods:
Patients were divided into two groups: conventional approach (control) group (n=42) and modified approach (experimental) group (n=41). Pain and swelling were evaluated for the first three postoperative days using 10 cm visual analogue scales. Presence of dry socket was documented in the 7th postoperative day.

There was statistically significant difference on the third  postoperative day (p <0.05) in the mean pain score between the two surgical groups. The mean score of swelling in conventional group
was slightly higher than the modified approach (p<0.05) in the first and the third post operative days. The incidence of dry socket in the modified approach was significantly less than conventional approach group (p <0.001).

The modified flap design has a relative advantage over the conventional two sided buccal approach in terms of postoperative pain, swelling and dry socket incidence.

Keywords: modified approach, lower third molar surgery, pain, swelling, dry socket.


1.    Arta, S.A., Pourabbas Kheyradin, R. Mesgarzadeh, A. H. Hassanbaglu, B. Comparison of the influence of two flap designs on periodontal healing after surgical extraction of impacted third molars. J Dent Res Dent Clin Dent Prospects, 2011. 5(1): p. 1-4.

2.    Dunne, C.M., Goodall, C. A. Leitch, J. A. Russell, D. I., Removal of third molars in Scottish oral and maxillofacial surgery units: a review of practice in 1995 and 2002. Br J Oral Maxillofac Surg, 2006. 44(4): p. 313-6.

3.    Farish, S.E. and G.F. Bouloux, General technique of third molar removal. Oral Maxillofac Surg Clin North Am, 2007. 19(1): p. 23-43, v-vi.

4.    Koyuncu, B.O. and E. Cetingul, Short-term clinical outcomes of two different flap techniques in impacted mandibular third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol, 2012. 116(3): p. e179-84.

5.    Contar, C.-M.-M., Priscila de Oliveira          Karina

Kanegusuku  Rosana-da Silva Berticelli  Luciana-Reis

Azevedo-Alanis  Maria-Angela-Naval Machado, Complications in third molar removal: A retrospective study of 588 patients. Med Oral Patol Oral Cir Bucal. 2010 Jan 1;15 (1):e74-8, 2010. 15(1): p. 74-78.

6.    Sisk, A., WB. Hammer  DW. Shelton  ED Jr. Joy, Complications following removal of impacted third molars: the role of the experience of the surgeon. J Oral Maxillofac Surg., 1986. 44: p. 855-9.

7.    Sandhu, A., S. Sandhu, and T. Kaur, Comparison of two different flap designs in the surgical removal of bilateral impacted mandibular third molars. Int. J. Oral Maxillofac. Surg., 2010. 39: p. 1091–1096.

8.    Mitchell, D. and A. Kanatas, eds. Third molar surgery. An Introduction to Oral and Maxillofacial Surgery, ed. D. Mitchell and A. Kanatas. 2015, CRC Press: New York.

9.    Winter, G., Principles of exodontia as applied to the impacted third molar: a complete treatise on the operative technic with clinical diagnoses and radiographic interpretations. St. Louis: American Medical Book, 1926: p. 21-58.

10.  Pell, G. and B. Gregory, Impacted mandibular third molar: classification and modified technique for removal. Dent Digest 1993. 39: p. 330-338.

11.  Mitchell, D.A., ed. Third molar surgery. First Indian Edition ed. An Introduction to Oral and Maxillofacial Surgery, ed. D.A. Mitchell. 2007, Oxford University Press: New Delhi.

12.  Tulloch, J.F., A.A. Antczak-Bouckoms, and N. Ung, Evaluation of the costs and relative effectiveness of alternative strategies for the removal of mandibular third molars. Int J Technol Assess Health Care, 1990. 6(4): p. 505-15.

13.  Osunde, O.D., B.D. Saheeb, and R.A. Adebola,

Comparative study of effect of single and multiple suture techniques on inflammatory complications after third molar surgery. J Oral Maxillofac Surg, 2011. 69(4): p. 971-6.

14.  Campbell, W.I. and C.C. Patterson, Quantifying meaningful changes in pain. Anaesthesia, 1998. 53(2): p. 121-5.

15.  Aznar-Arasa, L., Harutunian, K. Figueiredo, R. Valmaseda-Castellon, E. Gay-Escoda, C., Effect of preoperative ibuprofen on pain and swelling after lower third molar removal: a randomized controlled trial. Int J Oral Maxillofac Surg, 2012. 41(8): p. 1005-9.

16.  Roode, G.J. and K. Butow, An alternative surgical flap design for impacted third molars: a comparison of two different surgical techniques. SADJ, 2010. 65(6): p. 246, 248-51.

17.  Petikova, L., I. Satko, and D. Novotnakova, Complications after Third Molar Surgery. Bratisl Lek Listy, 2010. 111(5): p. 296-298.

18.  Juodzbalys, G. and P. Daugela, Mandibular third molar impaction: review of literature and a proposal of a classification. J Oral Maxillofac Res, 2013. 4(2): p. e1.

19.  Bryant, C., ed. Tooth extraction. Operative Oral and Maxillofacial Surgery, ed. J. Langdon, et al. 2011, Hodder & Stoughton Limited.

20.  Carvalho, R.W. and B.C. do Egito Vasconcelos,

Assessment of factors associated with surgical difficulty during removal of impacted lower third molars. J Oral Maxillofac Surg, 2011. 69(11): p. 2714-21.

21.  Bello, S.A., Adeyemo, W. L. Bamgbose, B. O. Obi, E. V. Adeyinka, A. A., Effect of age, impaction types and operative time on inflammatory tissue reactions following lower third molar surgery. Head Face Med, 2011. 7: p. 8.

22.  Meechan, J.G., ed. Extraction of Unerupted or Partly

Erupted Teeth. Principles of Oral and Maxillofacial Surgery, ed. U.J. Moore. 2011, Blackwell Publishing Ltd.

23.  Sortino, F. and M. Cicciu, Strategies used to inhibit postoperative swelling following removal of impacted lower third molar. Dent Res J (Isfahan), 2011. 8(4): p. 162-71.

24.  Osunde, O.D., R.A. Adebola, and U.K. Omeje, Management of inflammatory complications in third molar surgery: a review of the literature. Afr Health Sci, 2011. 11(3): p. 530-7.

25.  Baqain, Z.H., Al-Shafii, A. Hamdan, A. A. Sawair, F. A., Flap design and mandibular third molar surgery: a split mouth randomized clinical study. Int J Oral Maxillofac Surg, 2012. 41(8): p. 1020-4.

26.  Erdogan, O., Tatli, U. Ustun, Y. Damlar, I., Influence of two different flap designs on the sequelae of mandibular third molar surgery. Oral Maxillofac Surg, 2011. 15(3): p. 147-52.

27.  Sulieman, M.S., Clinical evaluation of the effect of four flap designs on the post–operative sequel (pain, swelling and trismus) following lower third molar surgery. Al– Rafidain Dent J., 2005. 5(1): p. 24-32.

28.  Dolanmaz, D., Esen, A. Isik, K. Candirli, C., Effect of 2 flap designs on postoperative pain and swelling after impacted third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol, 2012. 116(4): p. e244-6.

29.  Goldsmith, S.M., Rohana Kumara De Silva Darryl C. Tong Robert M. Love, Influence of a pedicle flap design on acute postoperative sequelae after lower third molar removal. Int. J. Oral Maxillofac. Surg., 2012. 41: p. 371–375.

30.  Nageshwar, Comma incision for impacted mandibular third molars. J Oral Maxillofac Surg, 2002. 60(12): p. 1506-9.

31.  Ogden, G.R., Outcomes after lower 3rd molar surgery:

what about quality of life? OS, 2014(7): p. 1-2.

32.  Rakprasitkul, S. and V. Pairuchvej, Mandibular third molar surgery with primary closure and tube drain. Int J Oral Maxillofac Surg, 1997. 26(3): p. 187-90.

33.  Mitchell, D.A. and A.N. Kanatas, eds. Exodontia and its sequelae. Second Edition ed. An Introduction to Oral and Maxillofacial Surgery, Second ed. D.A. Mitchell and A.N. Kanatas. 2015, CRC Press.

34.  Abu Younis, M.H. and R.O. Abu Hantash, Dry socket: frequency, clinical picture, and risk factors in a palestinian dental teaching center. Open Dent J, 2011. 5: p. 7-12.

35.  Eshghpour, M., A. Moradi, and A.H. Nejat, Dry socket following tooth extraction in an Iranian Dental Center: incidence and risk factors. Journal of Dental Materials and Techniques, 2013. 2(3): p. 86-91.

36.  Karnure, M.H., Review on conventional and novel techniques for treatment of alveolar osteitis. Asian Journal of Pharmaceutical and Clinical Research, 2013. 6(3).