FLAP DESIGN IN IMPACTED THIRD MOLAR SURGERY

4-cornered flap: the bases and apex of the flap are located 4–5 cm anterior to the lingual cortical
plate and buccal vestibule, respectively

Comma-shaped flap: the incision extends from the point distobuccal to the second molar upward
and forward to the gingival sulcus of the distal surface with a smooth curve

Lingually-based triangular flap: the incision line is composed of an oblique vestibular incision, a
sulcus incision in the distal surface and vertical incision from the distobuccal corner of the second
molar
The history of flap designsi

George B. Winter (1926)—describes 3 flap designs depending on the axial orientation of the teeth

Kurt H. Thoma (1932)—stated that the incision should be made along the
post molar triangle, starting on the ramus and keeping nearer the lingual
side than the buccal. The incision should terminate 2mm behind the 2 nd
molar, from this point, it is extended over the alveolar ridge and down on
the buccal side.

Terrence George Ward (1956)—described 3 incisions that are widely used

today. The incision starts on the retromolar pad distobuccally to the third
molar, continues through the sulcus, and finishes with a vertical incision
buccal to the 3rd molar.

Gustav Otto Kruger (1959)—describes an

envelope flap, in which a distal-buccal incision is
made and continued into a crevicular incision. A
modified version with a mesial vertical incision
was also described for better visibility.

Alistair Berwick (1966)—described a flap that he stated provided a

good blood supply, good vision for instrumentation, and minimum
trauma when reflecting it. The first incision started on the distal
point but laterally and downwards, and then a second incision was
made following he external oblique ridge to meet the first incision
with the intention of forming a curved angle.

Lucian Szmyd (1971)—described an incision starting at the distal

surface of the second molar, with a buccal continuation 5mm below
the gingival margin of the second molar that ended in a vertical
fashion.
 Walt W. Magnus (1972)—the incision mimicked the envelope flap;
however, it was made 5mm below the gingival margin. He explained
that such an approach required no sutures and the faster healing. It is
sometimes chosen when the patient is under orthodontic treatment at
the time of surgery.

Donlon and Triuta (1999)—incision is made on the distal mid-crest approach of the 2 nd molar and
extended buccally and distally towards the external oblique ridge.

Iyer Nageshwar (2002)—proposed comma flap, which an incision made

on distobuccal point below the 2nd molar that smoothly curves up to
meet the gingival crest at the distobuccal angle line of the 2nd molar.

Factors influence different types of Flap Design:

1. Surgeon preferences or experiences

2. Impacted tooth position and orientation

The fundamental principle in flap designii:

• Provide adequate access, visibility, and instrumentation

• The base of the flap should be broader that the free end to ensure adequate blood supply
• The incision should be performed at the right angle to the underlying bone with a smooth
stroke of the scalpel, which is kept in contact with bone throughout the entire incision so
that the mucosa and periosteum are completely incised, while avoiding any anatomical
structures.
• The incision should be designed such that it can be closed over solid bone and delicately
handled without tension.
• Vertical releasing incision should start from the buccal vestibule and end up mesial or distal
to the interdental papilla.

Effect of flap design on periodontal healing after surgical removal of an impacted third molariii:

Chen et. al stated that there are no significant differences in the probing depth reduction and clinical
attachment level gain at the distal surface of the second molar between different flap designs.
However, a subgroup analysis revealed that the Szmyd and paramarginal flap designs may be the
most effective in reducing the probing depth in impacted third molar extraction, and the envelope
flap may be the least effective.

Surgical outcomes of triangular vs envelope design:

According to Bailey et. al iv, there is insufficient evidence to determine whether envelope or
triangular flap designs led to more alveolar osteitis, wound infection, or permanent altered tongue
sensation. In terms of other adverse effects, two studies reported wound dehiscence at up to 30
days after surgery but found no difference in risk between interventions.
According to Lopes et. al v, the flap design did not influence pain, edema, trismus, dehiscence, or
osteitis. The triangular flap was associated with a greater occurrence of postoperative ecchymosis
and lower periodontal probing depth on day 7 postoperative when compared to the envelope flap in
mandibular third molar surgeries.

The influence of flap design on patients’ experiencing pain, swelling, and trismus after mandibular
third molar surgeryvi:

Marco et. al stated that there was no clear consensus among the reviewed studies that a particular
flap design for third mandibular molar surgery could have advantages regarding patients perceived
postoperative clinical morbidities. Cumulative evidence suggests that flap selection association with
surgical difficulties is mainly determined by impacted tooth position. In fact, the tissue manipulation
performed during flaps, which leads to patient discomfort, aims to increase surgical visibility area
and further reduce surgical time. Thus, a flap design is chosen based on the surgeon’s experience,
molar position, and orientation, and, finally, these characteristics along with the duration of the
surgical procedure, directly affect patients’ postoperative experience.

Lingual-based flap vs buccal-based flapvii:

The study done by Yuan et. al, suggested that compared with buccal-based flaps, lingual-based flaps
are superior in preventing postoperative early wound dehiscence in mandibular impacted third
molar extraction. As a desirable distolingual-based flap, the comma flap could be regarded as an
alternative considering its potential to reduce postoperative discomfort, especially for mid-bony or
intermediary bony impactions. For full bony impacted teeth, traditional buccal-based flaps are more
commonly recommended. In clinical practice, surgeons should select an optimal flap design based
on the position of the impacted teeth and the difficulty of the operation to provide patients with a
better treatment experience.

i
Sifuentes-Cervantes, J. S., Carrillo-Morales, F., Castro-Núñez, J., Cunningham, L. L., & Van Sickels, J. E. (2021).
Third molar surgery: Past, present, and the future. Oral surgery, oral medicine, oral pathology and oral
radiology, 132(5), 523–531. https://doi.org/10.1016/j.oooo.2021.03.004
ii
AlFotawi, R. A. (2020). Flap Techniques in Dentoalveolar Surgery. In G. Sridharan, A. Sukumaran, & A. E. O. A.
Ostwani (Eds.), Oral Diseases. IntechOpen. https://doi.org/10.5772/intechopen.91165
iii
Chen, Y. W., Lee, C. T., Hum, L., & Chuang, S. K. (2017). Effect of flap design on periodontal healing after
impacted third molar extraction: a systematic review and meta-analysis. International journal of oral and
maxillofacial surgery, 46(3), 363–372. https://doi.org/10.1016/j.ijom.2016.08.005
iv
Bailey, E., Kashbour, W., Shah, N., Worthington, H. V., Renton, T. F., & Coulthard, P. (2020). Surgical
techniques for the removal of mandibular wisdom teeth. The Cochrane database of systematic reviews, 7(7),
CD004345. https://doi.org/10.1002/14651858.CD004345.pub3
v
Lopes da Silva, B. C., Machado, G. F., Primo Miranda, E. F., Galvão, E. L., & Falci, S. G. M. (2020). Envelope or
triangular flap for surgical removal of third molars? A systematic review and meta-analysis. International
journal of oral and maxillofacial surgery, 49(8), 1073–1086. https://doi.org/10.1016/j.ijom.2020.01.001
vi
DE Marco, G., Lanza, A., Cristache, C. M., Capcha, E. B., Espinoza, K. I., Rullo, R., Vernal, R., Cafferata, E. A., &
DI Francesco, F. (2021). The influence of flap design on patients' experiencing pain, swelling, and trismus after
mandibular third molar surgery: a scoping systematic review. Journal of applied oral science : revista FOB, 29,
e20200932. https://doi.org/10.1590/1678-7757-2020-0932
vii
Yuan, L., Gao, J., Liu, S., & Zhao, H. (2021). Does the Lingual-Based Mucoperiosteal Flap Reduce
Postoperative Morbidity Compared With the Buccal-Based Mucoperiosteal Flap After the Surgical Removal of
Impacted Third Molars? A Meta-analysis Review. Journal of oral and maxillofacial surgery : official journal of
the American Association of Oral and Maxillofacial Surgeons, 79(7), 1409–1421.e3.
https://doi.org/10.1016/j.joms.2021.02.023