J Oral Maxillofac Surg 67:15-21, 2009

Mandibular Third Molar Removal in Young Patients: An Evaluation of 2 Different Flap Designs
Giuseppe Monaco, DMD,* Giuseppe Daprile, DMD, Loredana Tavernese, DMD, Giuseppe Corinaldesi, MD, DMD, and Claudio Marchetti, MD, DDS
Purpose: To evaluate the inuence of 2 different ap designs on periodontal healing and postoperative

complications, after inferior third molar removal in young patients.

Patients and Methods: Twenty-four mandibular third molars were extracted from 12 patients with an

average age of 16 years. Patients were included in the study when radiographs at the time of surgery showed that only the crown of the germ was formed. Each patient underwent 2 extractions, using a triangular ap on one side and an envelope ap on the other. Periodontal probing was recorded at the preoperative visit, and 7 days, 3 months, and 6 months after extraction. Postoperative complications were recorded using a questionnaire completed by the patient for the week after the extraction. Results: The examination performed 7 days after the extraction demonstrated a deeper probing depth in all teeth examined. This increase was statistically greater (P .05) for the rst and second molars when an envelope ap was used. After 3 months, the probing depths returned to preoperative values. No signicant differences were seen between the 2 ap designs when postoperative complications were considered. The average operating time was 30.66 minutes with the triangular ap, versus 35.66 minutes with the envelope ap. This difference was not signicant. After 6 months, the 2 ap designs resulted in no difference in periodontal healing or complications, but 30% of the surgical extractions resulted in a debilitating postoperative period for the patients treated. Conclusions: Although we observed statistically signicant differences in probing depth between triangular and envelope aps 7 days after the extraction of third molars with no root development, this was not important from a clinical perspective, because periodontal healing at 3 and 6 months was comparable. We believe that this is also the case with the extraction of third molars with fully formed roots. Another important nding was the presence of a debilitating postoperative period in most of the patients who underwent extraction, contrary to the beliefs of many surgeons. 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:15-21, 2009 The extraction of an impacted third molar is a surgical procedure that can cause periodontal damage to the adjacent tooth.1 The healing process depends not only on the surgical technique and experience of the surgeon, but also on the age of the patient and whether periodontal pathology is present.2 The surgical technique includes variables such as ap design, bone removal, and the tooth sectioning necessary to extract the tooth, and must be performed without
Received from the School of Dentistry, University of Bologna, Bologna, Italy. *Visiting Professor, Department of Oral and Maxillofacial Surgery. Visiting Professor, Department of Periodontology. Clinical Fellow, Department of Oral and Maxillofacial Surgery. Associate Professor, Department of Oral and Maxillofacial Surgery.

damaging the surrounding anatomical structures. An experienced surgeon better manages the surgical problems and subsequently reduces the patients postoperative pain.2 Different variables can inuence the periodontal healing process. Studies to evaluate the effects of different ap designs on the periodontium of the rst and second molars after extraction of the third molar tried to standardize the surgical protocol, to reduce
Professor and Chief, Department of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Marchetti: Department of Oral Surgery, School of Dentistry, Via S Vitale 59, 40125 Bologna, Italy; e-mail: claudio.marchetti@bo.nettuno.it
2009 American Association of Oral and Maxillofacial Surgeons

0278-2391/09/6701-0004$34.00/0 doi:10.1016/j.joms.2007.05.032

15

16 the effects of these variables on the nal results.3-5 The ap designs proposed by various authors can essentially be grouped into envelope and triangular aps.3-8 Envelope aps have no release incisions, and the ease of access to the tooth to be extracted depends on the length of the mesial extension of the sulcular incision, which can, if necessary, extend to the second premolar. Triangular aps involve a buccal releasing incision, which can be positioned mesially or distally to the second molar beside the papilla.9 This prospective study compared triangular and envelope ap designs in inferior third molar extractions, and evaluated how they affect periodontal healing, the operating time, and the occurrence of postoperative complications such as fever, swelling, pain, and wound infection. The removal of an incompletely formed third molar in such patients allows for better standardization of the surgical protocol, because the variables linked to root shape, patient age, and periodontal disease are lacking. Moreover, given that the average age of the patient samples used in previous studies was over 20 years,3-8 the postoperative complications of germectomy have largely been overlooked in the literature.

MANDIBULAR THIRD MOLAR REMOVAL

Patients and Methods

PATIENTS

This study enrolled 12 medically healthy patients (5 females and 7 males) between the ages of 15 and 19 years (mean age, 16 years) who had not taken any antibiotics or anti-inammatory drugs in the 14 days before surgery. All patients had been referred to the Department of Oral and Maxillofacial Surgery at the Bologna Dental Clinic (Bologna, Italy) by dentists who recommended bilateral extraction of the inferior third molars for orthodontic reasons. The criterion for inclusion in this study was that the third molar showed no root development on radiographic examination 1 to 2 months before surgery (Fig 1).
OPERATION

FIGURE 1. A, Panoramic radiograph of a patient in the study. B, Magnication of the tooth ( 4). Monaco et al. Mandibular Third Molar Removal. J Oral Maxillofac Surg 2009.

During intraoral examinations, we found no evidence of periodontal inammation. The molars were extracted if the plaque index score was lower than 20%,10 and the right and left third molars were extracted at 2 different times about 1 month apart. Preoperative probing was recorded buccally at mesial, medial, and distal points on the adjacent molars and second premolar. The probing depth, attachment level, and presence of eventual recession were recorded for each tooth. All measures were performed twice to the nearest millimeter by 2 surgeons with more than 10 years of experience in periodontology. If the 2 results did not match, the greater value was used. The

examination was conducted with a William periodontal probe (with millimeter markings), and was repeated 7 days, 3 months, and 6 months after extraction. The left and right mandibular third molars were extracted using an envelope ap (Fig 2A) on one side and a triangular ap (Fig 2B) on the other. For the rst extraction, the ap design used was a casual choice, whereas the second extraction was performed using the design not used in the rst extraction. In each case, the third molar with the less favorable ratio between the space available and space required for normal eruption was extracted rst. Before extraction, all the patients rinsed for 1 minute with a 0.2% chlorhexidine mouthwash.11 All

MONACO ET AL

17 surgical procedures were performed under local anesthesia (2% mepivacaine with adrenalin 1:100,000), and when the selected incision was performed, the surgical technique was standardized as much as possible. The osteotomy necessary to visualize the tooth was performed using a rounded burr mounted on a high-speed or low-speed handpiece (Fig 3A). To minimize the quantity of bone removed, the tooth was minimally exposed and then sectioned into 4 parts with a carbide ssure burr mounted on a highspeed handpiece. After sectioning, the 4 fragments were removed (Fig 3B), and the socket was rinsed with physiological saline and lled with a collagen sponge. Primary closure of the ap was attempted in all cases using 4-0 silk sutures. No dressing was used. Beginning the day after surgery, patients rinsed twice daily with 0.20% chlorhexidine solution for 10 days.12 The length of surgery was taken as the time elapsed between the initial ap incision and nal suturing. The surgeon scored operative bleeding clinically as: 1, very low; 2, low; 3, normal; 4, high; and 5, very high. After extraction, the patient quantied the degree of surgical pain and discomfort experienced during surgery on a 10-cm horizontal visual analog scale (VAS) in which the endpoints indicated no pain and unbearable pain.2 All patients were prescribed the nonsteroidal anti-inammatory nimesulide as 100 mg of soluble powder (Aulin; Boehringer Mannheim, Mannheim, Germany), with instructions to take it only if they experienced pain. All patients also received a questionnaire in which they reported the degree and intensity of pain, using the same 10-cm horizontal VAS 6 hours postoperatively, in the evening between 10:00 and 11:00 PM, and the next 6 days in the morning (7:00 to 9:00 AM) and evening (8:00 to 9:00 PM). Upon analysis of the VAS, extractions were considered painful when scored at greater than or equal to 4 cm on the 10-cm scale. On a word scale that described pain intensity as 1) slight, 2) some, 3) mild, 4) moderate, 5) severe, and 6) agonizing, a score greater than or equal to 4 cm corresponded to moderate pain. The presence of this value for 3 or more days in the week after the extraction was the parameter used to dene pain as a postoperative complication.2 Patients were also required to report fever, swelling, trismus, and the daily use of anti-inammatory drugs. Fever was considered a postoperative complication when present for at least 2 days in the week after the

4
FIGURE 2. A, Envelope ap. B, Triangular ap. Monaco et al. Mandibular Third Molar Removal. J Oral Maxillofac Surg 2009.

18

MANDIBULAR THIRD MOLAR REMOVAL

extraction.2 The patient measured his or her temperature with a thermometer placed under the armpit for 5 minutes at 8:00 PM every day for the rst 7 days. The patients reported swelling in the questionnaire, and it was rated on a scale from 1 to 3 as: 1, swelling visible but not sufcient to alter the patients face; 2, swelling sufcient to alter the patients face, but not enough to limit mouth opening; and 3, swelling associated with trismus that limited mouth opening and phonation. Swelling was considered a complication when present for at least 2 days.2 This scale was essentially an indicator of the esthetic and functional discomfort suffered by the patient. Once the patient was instructed on how to use the scale, the surgeons did not evaluate swelling, because self-evaluation is as valid as clinical evaluation for dening swelling.13,14 Moreover, the scale used to score swelling was extremely simple, consisting of a box to check, so that our younger patients could easily complete it. The surgeon observed and reported wound infections in the questionnaire 1 week postoperatively at suture removal. All extractions were performed by 2 surgeons, each with more that 10 years of surgical experience. The surgeon who had not operated on the patient conducted the postoperative examinations and collected the questionnaire, reporting all information about the postoperative week to avoid any underestimation of complications.
STATISTICAL ANALYSIS

The difference in healing between the 2 techniques was evaluated using 3-way analysis of variance, with the factors ap design (triangular ap or envelope ap), time (7 days, 3 months, and 6 months), and probing depth position (distal, medial, and mesial). Post hoc analyses of simple effects and individual comparisons were assessed using the modied t test and Bonferronis method.15 The nonparametric Mann-Whitney test was used to analyze postoperative complications.16 Differences were considered signicant if P values were less than .05.

Results
RELATIONSHIP BETWEEN FLAP DESIGN AND PERIODONTAL HEALING

Postoperative examinations 7 days after the extractions showed an increase in probing depth in all teeth examined. Greater values were recorded for the rst

4
FIGURE 3. A, Exposure of the tooth. B, Sectioning the tooth into 4 parts. Monaco et al. Mandibular Third Molar Removal. J Oral Maxillofac Surg 2009.

MONACO ET AL

19 Pain was present in 5 extractions performed with a triangular ap, and in 3 performed with an envelope ap (30% of all extractions). Pain as a complication persisted for the rst 3 days in 3 patients, for the rst 4 days in 2 patients, for the entire postextraction week in 2 patients, and from the third to the fth day in 1 patient. In no case was pain reported on alternate days. In all other patients, pain was present for 1 or 2 days, generally during the rst 4 postextraction days, and thus was not considered a complication. In 5 patients, pain and swelling were both present as complications. Specically, pain was associated with swelling levels of 1, 2, and 3 in 1 patient, 3 patients, and 1 patient, respectively. The 2 ap designs did not differ statistically in terms of the use of analgesics. In this study, fever complicated one case with each type of ap (P .05). With the triangular ap, fever was associated with pain and swelling at level 2. With the envelope ap, fever was associated with pain and swelling at level 1. The wound became infected in 3 patients using a triangular ap, and in 1 patient using an envelope ap (P .05). Of these cases, one infection became evident 19 days after extraction; an envelope ap had been used, and in the week after the extraction, swelling at level 1 was reported. Two other cases of wound infection occurred in the same patient, and were associated with pain and swelling at level 2 when an envelope ap was used, and with pain and swelling at level 3 on the other side. The remaining case of infection involved an extraction performed with a triangular ap, and it was associated with pain and swelling at level 2.

and second molars when an envelope ap was used compared with a triangular ap (P .05). In all cases, the probing depth tended to return to the preoperative value as early as 3 months after the extraction. Recovery was complete at 6 months, and no difference between the 2 aps was found. In 2 cases each of envelope and triangular aps, a recession of 1 mm was recorded in the teeth involved with the aps.
RELATIONSHIP BETWEEN FLAP DESIGN AND OPERATING TIME

The triangular ap required an average operating time of 30.66 minutes, compared with 35.66 minutes using the envelope ap. The difference was not statistically signicant. Nevertheless, in 3 patients, the operating time with the triangular ap was half of that compared with the opposite-side extraction performed using an envelope ap.
RELATIONSHIP BETWEEN FLAP DESIGN AND POSTOPERATIVE COMPLICATIONS

The postoperative complications considered were pain, swelling, fever, and wound infection. These complications were distributed evenly between the 2 different types of ap, and no statistically signicant differences were observed. In this study, postoperative swelling was present after all 24 extractions. Swelling was present in each case during the rst 3 days after extraction, increasing especially on the second and third days. Only 1 patient experienced swelling associated with trismus. Swelling was scored as 2 in 14 cases, and as 1 in 9 cases.

Table 1. MEAN PROBING DEPTH WITH ENVELOPE AND TRIANGULAR FLAPS, VALUES AND STANDARD DEVIATIONS

Tooth Second molar Second molar Second molar Second molar Second molar Second molar First molar First molar First molar First molar First molar First molar Second premolar Second premolar Second premolar Second premolar Second premolar Second premolar

Flap Triangular Envelope Triangular Envelope Triangular Envelope Triangular Envelope Triangular Envelope Triangular Envelope Triangular Envelope Triangular Envelope Triangular Envelope

Site Distal Distal Medial Medial Mesial Mesial Distal Distal Medial Medial Mesial Mesial Distal Distal Medial Medial Mesial Mesial

Preoperative 2.7 2.9 2.1 2.4 2.5 2.6 2.3 2.0 1.8 1.8 2.4 2.3 2.5 2.3 1.4 1.3 2.0 2.4 0.2 0.2 0.2 0.2 0.2 0.3 0.4 0.1 0.1 0.1 0.2 0.1 0.2 0.2 0.1 0.1 0.2 0.2

7 Days 4.7 5.4 3.9 4.5 3.3 4.4 2.8 3.7 2.2 3.5 2.6 3.5 2.8 3.2 1.8 2.1 2.3 2.7 0.5 0.5 0.2 0.3 0.4 0.2 0.3 0.3 0.3 0.2 0.3 0.2 0.2 0.3 0.3 0.4 0.3 0.3

3 Months 3.2 2.8 2.5 2.4 2.5 2.6 2.5 2.3 2.2 1.9 2.6 2.7 2.7 2.6 1.8 1.8 2.3 2.8 0.3 0.3 0.3 0.3 0.3 0.2 0.3 0.2 0.3 0.3 0.3 0.2 0.2 0.3 0.3 0.3 0.3 0.3

6 Months 2.7 2.8 1.9 2.4 2.1 2.5 2.3 1.9 1.4 1.7 2.2 2.3 2.3 2.3 1.4 1.5 2.3 2.3 0.3 0.2 0.1 0.3 0.2 0.2 0.1 0.2 0.1 0.2 0.2 0.2 0.1 0.2 0.2 0.2 0.2 0.2

Monaco et al. Mandibular Third Molar Removal. J Oral Maxillofac Surg 2009.

20 No statistically signicant differences were noted between the 2 ap designs when pain during surgery and operative bleeding were considered. Table 1 summarizes the mean probing depth for each tooth for the envelope aps and triangular aps. Figure 4 graphically shows the periodontal healing progress of the 2 kinds of aps.

MANDIBULAR THIRD MOLAR REMOVAL

Discussion
The envelope ap is easier to perform and suture than the triangular ap, but does not facilitate access to the surrounding structures, making osteotomy more difcult. In this study, a bigger envelope ap was chosen, to try to reduce the operative differences with the triangular ap. A recent study noted more distal dehiscences of the sutured incision with envelope aps.6 In our study, however, the envelope ap

FIGURE 4. Time course of healing after surgery with triangular (open circles) and envelope (solid squares) ap techniques. Probing depths (average of distal, mesial, and medial positions; difference from control values) 7 days, 3 months, and 6 months after surgery are shown for the second premolar (top), rst molar (middle), and second molar (bottom). Error bars represent standard error of the mean. *P .05. **P .01. Monaco et al. Mandibular Third Molar Removal. J Oral Maxillofac Surg 2009.

did not result in more distal dehiscences than the triangular ap. This is probably because the bigger mesial sulcular incision allowed suturing without excessive tension, even with marked tissue edema, which always occurred following extraction. The triangular ap allows easier access to the surrounding structures, facilitating the osteotomy needed to extract the tooth. Conversely, suturing is more involved, and the exposure of a larger bone area tends to activate osteoclastic bone resorption.17-19 At the postoperative examination after 7 days, the probing depth was statistically greater in the rst and second molars on the side on which an envelope ap was used. These ndings could be related to the decient initial regeneration of the connective-tissue attachment, which was formed perfectly 3 months postoperatively, as demonstrated on postextraction probing. The postoperative examinations 3 and 6 months after extraction showed perfect healing with both aps. We believe that this follow-up period was adequate, and was similar to the follow-up periods in most studies of this type. A longer duration runs the risk of losing some patients to follow-up.4,7,20 With regard to operating times, a triangular ap facilitated extractions compared with an envelope ap, although the difference was not statistically signicant. However, this might be an important factor with less cooperative patients or with those who cannot open their mouths fully for anatomical reasons. Difculty in opening the mouth (distance between the mandibular and maxillary incisors of 30 mm)9 can hinder the use of burrs, complicating the surgical procedure. In such cases, the use of a triangular ap might be advisable. Another important nding of this study was the higher percentage of pain and swelling compared with that in adults using the same type of questionnaire (30% vs 10.7% of surgical extractions).2 Pain was considered a complication when present for 3 or more days, and in these cases, the use of analgesics was high compared with the study on adults.2 In 4 cases, pain was not a sequelae, but the patients took more than 10 sachets of nimesulide in the postoperative week. In 6 envelope ap cases and 5 triangular ap cases, the consumption of analgesics exceeded 10 sachets of nimesulide 100 mg in 1 week. This corroborates the idea that postoperative pain cannot be neglected as a complication in patients less than 19 years of age. Based on these observations, one might postulate that subjects less than 19 years of age have a lower pain threshold, and a greater need for pharmaceutical pain relief than adult patients (25 years of age or older), who had a low incidence of postoperative complications and a minimal impact on quality of life after third molar surgery.21 This nding is im-

MONACO ET AL

21
5. Schoeld IDF, Kogon SL, Donner A: Long-term comparison of two surgical ap designs. J Can Dent Assoc 54:689, 1988 6. Jakse N, Bankaoglu V, Wimmer G, et al: Primary wound healing after lower third molar surgery: Evaluation of two different ap designs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 93:7, 2002 7. Rosa AL, Carneiro MG, Lavrador MA, et al: Inuence of ap design on periodontal healing of second molars after extraction of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 93:404, 2002 8. Suarez-Cunqueiro MM, Gutwald R, Reichman J, et al: Marginal ap versus paramarginal ap in impacted third molar surgery: A prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 95:403, 2003 9. Checchi L, Monaco G: Terzi Molari Inclusi: Soluzioni Terapeutiche. Bologna, Ed. Martina, 2001 10. Silness P, Le H: Periodontal disease in pregnancy. Acta Odontol Scand 22:121, 1964 11. Poeschl PW, Eckel D, Poeschl E: Postoperative prophylactic antibiotic treatment in third molar surgeryA necessity? J Oral Maxillofac Surg 62:3, 2004 12. Delibasi C, Saracoglu U, Keskin A: Effects of 0.2% chlorhexidine gluconate and amoxicillin plus clavulanic acid on the prevention of alveolar osteitis following mandibular third molar extractions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94:301, 2002 13. Berge TI: The use of a visual analogue scale in observer assessment of postoperative swelling subsequent to third molar surgery. Acta Odontol Scand 47:167, 1989 14. Pasqualini D, Cocero N, Castella A, et al: Primary and secondary closure of the surgical wound after removal of impacted mandibular third molars: A comparative study. Int J Oral Maxillofac Surg 34:52, 2005 15. Wallenstein S, Zucker CL, Fleiss JL: Some statistical methods useful in circulation research. Circ Res 47:1, 1980 16. Parker RE: Introductory Statistics for Biology. London, Edward Arnold, 1973 17. Wood DL, Hoag PM, Donnenfeld W, et al: Alveolar crest reduction following full and partial thickness aps. J Periodontol 43:141, 1972 18. Yaffe A, Fine N, Binderman I: Regional accelerated phenomenon in the mandible following mucoperiosteal ap surgery. J Periodontol 65:79, 1994 19. Yaffe A, Iztkovich M, Earon Y, et al: Local delivery of an amino bisphosphonate prevents the resorptive phase of alveolar bone following mucoperiosteal ap surgery in rats. J Periodontol 68:884, 1997 20. Dodson TB: Management of mandibular third molar extraction sites to prevent periodontal defects. J Oral Maxillofac Surg 62:1213, 2004 21. Haug RH, Perrot DH, Gonzales ML, et al: The American Association of Oral and Maxillofacial Surgeons age-related third molar study. J Oral Maxillofac Surg 63:1106, 2005 22. Ricketts RM: Studies leading to practice of abortion of lower third molars. Dent Clin North Am 23:393, 1979 23. Schwarze CW: The inuence of third molar germectomyA comparative long-term study. Trans Eur Orthod Soc 51:551, 1975 24. Ogden GR, Bissias E, Ruta DA, et al: Quality of life following third molar removal: A patient versus professional perspective. Br Dent J 185:407, 1998

portant, because the extraction of a third molar without root development is often described as having fewer postoperative complications than the extraction of a third molar with formed roots, and is consequentially recommended for very young patients (aged 8 to 9 years)22 without considering the psychological impact.23,24 The surgeons prescribed antibiotics (amoxicillin 1 g every 12 hours for 5 days) in 4 triangular ap cases and 1 envelope ap case when suppuration from the wound occurred. In these patients, when the sutures were removed after 7 days, imperfect healing with distal buccal dehiscence at the second molar was noted. The incomplete seal between the tooth and gingival tissues was probably associated with an alveolus infection. Although the difference was not significant, other studies did not report the formation of a distal dehiscence when triangular aps were used.8 In conclusion, although we observed statistically signicant differences in probing depth between triangular and envelope aps 7 days after the extraction of third molars with no root development, this was not important from a clinical perspective, because the periodontal healing at 3 and 6 months was comparable. We believe that this is also the case with the extraction of third molars with fully formed roots. Another important nding was the presence of a debilitating postoperative period in most of the patients who underwent extraction, contrary to the beliefs of many surgeons. The use of our very detailed questionnaire to document the daily postoperative progress of patients allowed us to readdress some aspects of this surgery in young patients that were previously taken for granted in the literature.

References
1. Kugelberg CF: Periodontal healing two and four years after impacted lower third molar surgery: A comparative retrospective study. Int J Oral Maxillofac Surg 19:341, 1990 2. Monaco G, Staffolani C, Gatto MR, et al: Antibiotic therapy in impacted third molar surgery. Eur J Oral Sci 107:437, 1999 3. Stephens JR, App GR, Foreman DW: Periodontal evaluation of two mucoperiosteal aps used in removing impacted mandibular third molars. J Oral Maxillofac Surg 41:719, 1983 4. Chin Quee TA, Gosselin D, Millar EP, et al: Surgical removal of the fully impacted mandibular third molar. The inuence of ap design and alveolar bone height on the periodontal status of the second molar. J Periodontol 10:625, 1985