J Clin Exp Dent. 2020;12(4):e327-34.

The effect of triangular and reversed triangular flap designs to post third molar odontectomy complications

Journal section: Oral Surgery doi:10.4317/jced.55864

Publication Types: Research https://doi.org/10.4317/jced.55864

The effect of triangular and reversed triangular flap designs

to post third molar odontectomy complications (a pilot study)

Henri Mudjono 1, Poerwati-Soetji Rahajoe 2, Elizabeth-Riyati-Titi Astuti 3

1
Resident, Oral and Maxillofacial Surgery, Faculty of Dentistry, Gadjah Mada University
2
Consultant and Lecturer, Oral and Maxillofacial Surgery, Faculty of Dentistry, Gadjah Mada University
3
Lecturer, Oral and Maxillofacial Surgery, Faculty of Dentistry, Gadjah Mada University

Correspondence:
Department of Oral and Maxillofacial Surgery
Faculty of Dentistry, Universitas Gadjah Mada, Indonesia
Jl. Denta No.1 Sekip Utara Sleman
Yogyakarta (55281) Indonesia
[email protected] Mudjono H, Rahajoe PS, Astuti ERT. The effect of triangular and reversed
triangular flap designs to post third molar odontectomy complications (a pi-
lot study). J Clin Exp Dent. 2020;12(4):e327-34.
Received: 08/05/2019
Accepted: 27/01/2020 Article Number: 55864 http://www.medicinaoral.com/odo/indice.htm
© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: [email protected]
Indexed in:
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Pubmed Central® (PMC)
Scopus
DOI® System

Abstract
Background: Odontectomy is one of the most common surgical procedures in oral and maxillofacial surgery. Flap
design influences the post operative complications. Triangular flap is the most widely used flap design but it has
many shortages such as dehiscence, alveolar osteitis, reactionary bleeding, and periodontal disruption distal of
second molar. The aim of this study is to introduce an alternative flap design in the surgical removal of impacted
mandibular third molars – reversed triangular flap – and to compare this flap design with the triangular flap in case
of dehiscence, reactionary bleeding, and clinical attachment loss.
Material and Methods: This prospective, split-mouth study involved 15 patients with bilateral partially impacted
mandibular third molars with similar impaction classification. One impacted tooth was removed using a triangular
flap and the other using a reversed triangular flap. Post operative complications such as dehiscence, reactionary
bleeding, and clinical attachment loss were recorded 1, 3, 7, 14, and 30 days post odontectomy.
Results: Chi square test result shows that there were fewer incidences of dehiscence seven days post surgery using
the reversed triangular flap (p=0.032). Mann Whitney-U test result shows that the reversed triangular flap exhibited
less bleeding score on day 1 (p=0.002) and day 2 (p=0.035) post surgery. There were no statistically significant
differences according to Mann Whitney-U test between the flap designs for the clinical attachment loss on distal of
second molar on day 14 (p=0.512) and day 30 (p=0.902) post surgery.
Conclusions: The reversed triangular flap design is preferable to triangular flap for impacted third molar surgery,
escpecially in terms of wound dehisence and reactionary bleeding.

Key words: Flap design, third molar impaction, odontectomy, post odontectomy complications.

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J Clin Exp Dent. 2020;12(4):e327-34. The effect of triangular and reversed triangular flap designs to post third molar odontectomy complications

Introduction sion criterias were 18-30 years old, 10-60 minutes du-
Odontectomy is one of the most frequently performed ration of operation, no history of systemic disease and
procedures in many oral and maxillofacial surgery prac- drug allergy, not pregnant, not breastfeeding, or using
tices (1). Morbidites that occur after odontectomy such contraceptive drugs, and no history of periodontal di-
as pain, swelling, trismus, alveolar osteitis, dehiscence, sease. Exclusion criterias were massive bleeding during
bleeding and compromised periodontal status of the pre- the operation, drop out of the study, and the duration of
ceding second molar are still haunting both the surgeon the operation exceeded 60 minutes. Odontectomy was
and patient. Flap design to expose the impacted tooth carried out by one operator (HM) and the observation
is one of the important determining factor (2-6). Trian- of research parameters was carried out by one observer
gular flap is the most common approach used by many (LM). The patient chose the right or left side first to do
surgeons. The disadvantage is that the triangular flap has odontectomy, the operator drew the type of flap used. A
difficulty to achieve primary wound closure on healthy second odontectomy was performed at least one week
bones, making it possible for dehiscence and compli- after the first odontectomy.
cations such as alveolar osteitis. Some researchers still -Surgical Procedure
find the incidence of dehiscence in as much as 29.2 - Before odontectomy, the patient rinsed with a solution
68% of the cases and alveolar osteitis as much as 10.8% of diluted povidone iodine for 30 seconds. Lidocaine 2%
using triangular flap design (3,7). Occurrence of oozing with epinephrine 1: 80,000 (Pehacaine, PT. Kimia Far-
after odontectomy using triangular flap design is quite ma, Jakarta, Indonesia) was used as a local anesthetic
common (8). Periodontal health of the preceding second agent for mandibular and lingual nerve block and infil-
molar using triangular flap design has been studied with tration for buccal nerve.
varying results (9,10). The triangular flap was made using an incision blade
As there are still disadvantages of the triangular flap no.15 (Aesculap AG, Tuttlingen, Germany) from the
design, the authors propose an alternative flap design, mandibular ramus to disto-buccal side of the second mo-
namely the reversed triangular flap design which is a lar, followed by an incision perpendicular to the man-
modified pedicle flap design. The reversed triangular dibular vestibule approximately 10 mm (Fig. 1). Full
flap design starts with a vertical incision from the dis-
tal of the third molar towards the vestibule and rotates
the flap to the disto-lingual side of the second molar. It
is proposed that wound closure would occur primarily,
making it easier to maintain wound hygiene, facilitating
blood clotting, and would prevent dehiscence, thereby
reducing the possibility of alveolar osteitis, soft tissue
abscesses and would give benefit in patients using bis-
phosphonate, anti-coagulant, immunocompromised, and
those undergoing radiotherapy (2,7).
This study aims to introduce an alternative flap design
for odontectomy, namely a reversed triangular flap and
compare it with the commonly used flap, namely the
triangular flap. The reversed triangular flap is expected
to reduce post odontectomy dehiscence, blood oozing,
Fig. 1: Suturing of triangular flap.
and clinical attachment loss.

Material and Methods thickness flap was raised and at the end of the operation,
-Patient selection the flap was sutured to the lingual gingiva, adjacent to
This study is a prospective and split-mouth clinical the distolingual line angle of the second molar. Suturing
study. The research was conducted at the UGM Dental was continued on the distal side of the first suture and on
Hospital, Jogjakarta, Indonesia, involving 15 patients the buccal side vertical incision.
who had bilateral third molar impaction with similar The reversed triangular flap was also a full thickness flap
classification. Each subject underwent two odontecto- and made with incision from the mesio-buccal angle of
mies with different flap technique, triang and rev tri. the first molar along the gingival sulcus to the disto-buc-
Before odontectomy, each subject was informed about cal angle of the second molar. The 90o vertical incision
the research protocol and signed an agreement to take started from the distal mucosa which covers the third
part in the study. This study obtained a research appro- molar towards the vestibule approximately 10 mm (Fig.
val from the UGM dental faculty´s ethics commission 2). Before flap closure was carried out, flap dissection
(001388 / KKEP / FKG-UGM / EC / 2018). The inclu- had to be done so that the flap closure be obtained wi-

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subjects at the 1st hour, 6th hour, day 1 and day 2 post
odontectomy. Clinical attachment loss (CAL) measure-
ment was carried out on day 14 and 30 post odontectomy
using the UNC-15 periodontal probe (Osung MND Co.
Ltd., Gimpo-si, Gyeonggi-do, South Korea) at the buc-
co-distal line angle of the second molar. Measurements
were calculated from the base of the gingival sulcus to the
cemento-enamel junction in millimeters.
-Statistical Analysis
Data was analyzed using the IBM SPSS version 23.0
(IBM Corp., Armonk, NY, USA). Each parameter was
analyzed using the Shapiro-Wilk and Levene test to
determine normality and homogenity. The dehiscense
Fig. 2: a) Flap design, and b) closure of reversed triangular flap.
frequency was analyzed using the chi-square test. The
differences between overall observation were analyzed
using the Friedmann test and the differences between in-
thout tension. Flap closure was done by rotating the side
dividual observation time were analyzed using the Wil-
of the buccal flap toward the disto-lingual side of the
coxson test. Differences between groups of observations
second molar, so that it could close the socket perfectly.
were analyzed using the Mann Whitney-U test.
Suturing started from the disto-lingual side of the lower
second molar, proceeding distally until the distal end of
the flap.
Results
-Subject Characteristic
Osteotomy was done using surgery motor and straight
A total of 15 patients (9 males and 6 females) aged 19-
handpiece with maximum speed 40.000 rpm (Surgic AP,
26 became the subject of this study. Impaction classes
Nakanishi Inc., Tochigi, Japan) and round bur (91002,
were all class IA, and most of them were mesio-angular
SS White, New Jersey, USA) with 0.9% NaCl solution
as much as 53.3%. All odontectomy flap was closed pri-
irigation. When necessary, the tooth was cut using Lin-
marily.
demann bur (SS White, New Jersey, USA) and was ex-
-Dehisence
tracted using elevator and forceps (Kohler Medizintech-
Dehiscence was not found in all subjects on day 1, and
nik, Stockach, Germany). Suturing was done using 4.0
began to occur on day 3 in both groups with no signifi-
silk suture (Triton, Medihop, Jakarta, Indonesia). The
cant differences. Dehiscence occurred 100% on day 7 in
duration of the operation was calculated from the start
triangular flap group with significant differences compa-
of the incision to the completion of suturing. Post odon-
red to the reversed triangular flap group (Table 1).
tectomy oral medication was amoxicillin 500 mg 3x1
The result of the measurement of the length of dehiscen-
and ibuprofen 400 mg 2x1 for 5 days.
ce shows the average dehiscence length in the triangular
-Postoperative Assessment
flap group is longer, both on day 3 and day 7 (Fig. 3)
Dehiscence was observed on day 1, day 3, and day 7 post
with significant difference on day 7 (Table 2). The lon-
odontectomy. If dehiscence had happened, measurements
gest value is found on day 7 triangular flap group. The
were made using a caliper (Straumann, Basel, Switzer-
dehiscence width on day 7 of the triangular flap group is
land). The length of dehiscence was measured from the
lower than on day 3, with the highest dehiscence width
distal of the second molar to the most distal opened in-
is found on day 7 reversed triangular flap group (Fig. 3).
cision, while the width of the dehiscence was measured
The Friedman test results (Table 2) show that there are
from the widest incision line that opened from the buccal
significant differences in wound dehiscence both the
side to the lingual. Bleeding observations were carried
length and width of the two groups on day 1, day 3, and
out using visual analog score (VAS) according to Ghorei-
day 7 (p <0.05). The Wilcoxon test results showed sig-
shian et al. (11). Bleeding VAS was assessed by the study

Table 1: The number of dehiscence in each study group based on the observation day.
Triangular, n (%) Reversed Triangular, n (%) p (chi-square)
H+1 0 (0) 0 (0) 1
H+3 3 (20) 4 (26,7) 0.666
H+7 15 (100) 11 (73,3) 0,032*
(*) p<0,05

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Fig. 3: Average dehiscence length and width in triangular and reversed triangular flap design
based on observation time.

Table 2: The dehiscence length in triangular flap and reversed triangular flap design.
Observation day Triangular Reversed Triangular p (Mann
Whitney-U)
n (%) ± SD n (%) ± SD
Day 1 0 (0) 0 0 (0) 0 1
Day 3 3 (20) 5,23 ± 3,91 4 (26,7) 3,50 ± 0,58 0,471
Day 7 15 (100) 5,70 ± 3,02 11 (73,3) 3,32 ± 1,69 0,04*
p (Friedman) 0,0001* 0,0001*
(*) p<0,05; n: the number of dehiscence

nificant differences (p <0.05) in the length and width 1 (46.7%) with significant difference (p = 0.002). All
of wound dehiscence between day 1 and day 7 in both research subjects in the reversed triangular flap group
groups. The results of the Mann Whitney-U test (Table at day 2 showed no bleeding (VAS = 0), while in the
2) showed significant difference only occur in the leng- triangular flap group 73.3% with significant difference
th of wound dehiscence between the reversed triangular (p = 0.035).
flap compared to the triangular flap at day 7 (p <0.05). -Clinical Attachment Loss
-Bleeding The CAL measurement results (Table 4) show that the
The measurement results for post-odontectomy bleeding highest CAL average value in the reversed triangular
VAS (Table 3) showed that the maximal bleeding sco- flap group was found at day 14, and the lowest in the
re in the reversed triangular flap group was lower than triangular flap design group found at day 30.
the triangular flap both on 1st hour, 6th hour, day 1, and The CAL value in the two flap design groups has the
day 2. The highest score for the triangular and reversed same pattern which is reduced according to the obser-
triangular flap group 1 hour post odontectomy was score vation time. The Wilcoxon test results showed that there
1, 46.7% and 40% respectively. Likewise, the observa- was a significant decrease in the average CAL from day
tion 6 hours post odontectomy was 60% in the triangular 14 to day 30 in both groups (p <0.05). There were no
group and 46.7% in the reversed triangular group. The significant differences in both groups for day 14 and day
results of the Mann Whitney-U test at 1 hour and 6 hours 30 (p> 0.05).
post odontectomy showed no significant differences be-
tween the two groups (Table 3). Discussion
Observation of day 1 post odontectomy in the triangular This study design was split mouth with similar impac-
reversed flap group showed a decrease in VAS scores, tion classification. The advantage of split mouth design
with the highest score being 0 (93.3%), while the highest is that every subject becomes control for him/herself in
score in the triangular flap design group was a score of order to avoid bias and inter subject variability. Odon-
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Table 3: Frequency of post-odontectomy bleeding VAS score in triangular and reversed triangular flap group.
Observation Time VAS Group p (Mann
score Triangular Reversed Triangular Whitney-U)
n (%) Med (m-M) n (%) Med (m-M)
1 hour 0 0 (0) 2 (1-3) 5 (33,3) 1 (0-2) 0,053
1 7 (46,7) 4 (26,7)
2 4 (26,7) 6 (40)
3 4 (26,7) 0 (0)
4 0 (0) 0 (0)
6 hours 0 1 (6,7) 1 (0-4) 5 (33,3) 1 (0-2) 0,093
1 9 (60) 7 (46,7)
2 3 (20) 3 (20)
3 1 (6,7) 0 (0)
4 1 (6,7) 0 (0)
Day 1 0 6 (40) 1 (0-3) 14 (93,3) 0 (0-1) 0,002*
1 7 (46,7) 1 (6,7)
2 1 (6,7) 0 (0)
3 1 (6,7) 0 (0)
4 0 (0) 0 (0)
Day 2 0 11 (73,3) 0 (0-1) 15 (100) 0 (0-0) 0,035*
1 4 (26,7) 0 (0)
(*) p<0,05

Table 4: CAL value in triangular flap and reversed triangular flap groups.
Group H+14 H+30 p (Wilcoxon)
( ± SD) ( ± SD)
Triangular 4,07 ± 1,61 2,33 ± 0,89 0,001*
Reversed Triangular 4,57 ± 1,93 2,67 ± 1,67 0,001*
p (Mann Whitney-U) 0,512 0,902
(*) p<0,05

tectomy is carried out by one operator and observation on day 3 in both groups with no difference between the
of research parameters is carried out by another observer triangular and reversed triangular flap groups at the in-
(LM). Many clinical trials were done using split mouth cidence (p = 0.666), length (p = 0.471) and width of de-
design (3,5-7,10). hiscence (p = 0.271).
Triangular and envelope flaps were the most studied flap The dehiscence incidence on day 7 occurred as much
design with various variables such as pain, swelling, as 100% in the triangular flap group, while the reversed
trismus, dehiscence, and periodontal health (2,9,10,12- triangular flap design group also had a 46.7% incidence
18). Reversed triangular flap was an alternative flap and (p = 0.032). Various results happened when observing
differs from triangular flap in the position of its vertical dehiscence using triangular flap on day 7. Jakse et al. (2)
incision which was located on distal of third molar. Flap found that wound dehiscence developed in only 10% of
closure was done by rotating the side of the buccal flap cases in which the modified triangular flap dibandingkan
toward the disto-lingual side of the second molar, so that dgn envelope was used. Desai et al. (16) reported 60%
it could close the socket completely. dehiscence using triangular flap compared with envelo-
Post odontectomy dehiscence mostly happens because pe flap. The same result was also stated by Monaco et
of inadequate mucosa for tension free approximation al. (14) Comparing triangular flap with lingually based
of buccal and lingual mucosa for primary closure of flap, Yolcu and Acar (7) also reported 68% dehiscence
the surgical wound (17). Dehiscence began to happen using triangular flap. Rakprasitkul and Pairuchvej (19)

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found that 73% of the dehiscence occured in triangular cause there is a disruption in the edges of the wound
flap with primary closure on day 7 post-odontectomy, due to jaw movement and mastication. Bleeding can be
but odontectomy was performed on all impaction classi- minimized by using a good surgical technique and by
fications and was not compared with reversed triangular avoiding the tearing of flaps or excessive trauma to bone
flap design. In contrast to this study is that all research and the overlying soft tissue (23)
subjects had IA impaction classification which has big- The difference between the two flap designs began to
ger gap between third and second molar. be observed at day 1 which showed that 60% of the
All subject of the triangular flap group experienced de- research subjects still felt blood oozing (VAS = 1) in
hiscence could be due to lack of mucosa used to close the triangular flap design group. This result consistents
the extraction socket so that there was tension when su- with the report from Joshi et al., in 33.3% of the study
turing the buccal flap with the lingual part of partially subjects (22). In contrast, in the reversed triangular flap
impacted third molar (3,20). Several other studies (2,17) group, only one study subject (6.67%) assessed blood
found that dehiscence in triangular flap design was less oozing in day 1, with a significant difference between
than envelope flap design, but we found no studies com- the two groups (p = 0.002). The hemostasis process oc-
paring triangular flap with reversed triangular flap de- curs faster in reversed triangular flap design than trian-
sign. gular flap design because primary closure facilitates the
The reversed triangular flap gave less dehiscence results formation of coagulum.
than the triangular flap with a significant difference in Periodontal disruption is a common complication post
the average dehiscence length at day 7 (p = 0.04) be- odontectomy. Various research comparing the effect of
tween the two groups (Table 2). Other researchers found different flaps to periodontal health using various pa-
the same thing, there were still 27% dehiscence using rameters with various results (6,9,10,15). This study
pedicle flap, which is almost similar with reversed trian- showed that the value of CAL decreased with the time
gular, compared with envelope flap on day 7 because of observation, with the value in the triangular reversed
there was still tension on the flap (21). Reversed triangu- flap design group higher than the triangular flap design
lar flap could reduce tension and dehiscence from wider group, both at day 14 and day 30, and there were signi-
dissection of the flap to the distal and inferior. Another ficant differences (p = 0.001) between the two groups
type of pedicle flap, the mesial papilla-sparing marginal (Table 4). The reduced value of CAL observed up to 6
incision, was also considered as a desirable surgical te- months after odontectomy using the triangular flap de-
chnique that gave less dehiscence compared with trian- sign was also encountered by Chang et al. (24) and Le-
gular and envelope flap (3). ung et al. (25). The limitation of this study was that no
Bleeding observed in this study was local bleeding CAL measurements had been taken before odontectomy
(oozing) which caused from local factor such as flap so that the condition of periodontal tissue before odon-
design. Systemic factor had been excluded from this tectomy was unknown. The CAL value in the reversed
study. There had been few study that observed post triangular flap group was higher because the gingival
odontectomy bleeding. This study used visual analog sulcus incision was longer and the more bone surface
score according to Ghoreishian et al. (11) Other study was reduced during osteotomy than the triangular flap
on post odontectomy bleeding was also using the same design, causing disruption to the periodontal tissue and
scoring system but excluded score 4 (massive bleeding) increasing bone resorption due to increased osteoclast
(22). Limitation of the subjective assessment is the di- activity (26). Therefore the triangular flap is preferable
fference in judgement between individuals. Therefore it for deeper impaction.
is necessary to make an objective measurement to assess The average value of CAL day 30 in both groups was
post-odontectomy bleeding. still above the normal value of the gingival sulcus (> 2
Flap closure in the reversed triangular flap design oc- mm) which means that the process of healing periodon-
curred primarily, which was seen in the observation of tal tissue is still ongoing. The remodeling phase starts
the 1st and 6th hour post odontectomy in the reversed 21 days after the trauma and the strength of the collagen
triangular flap group, there were 33.3% of all study sub- matrix reaches 20% within 30 days after trauma (27).
jects who did not experience bleeding (VAS=0). Setiya The average value of CAL did not show a significant
et al. stated that all of the study subjects still experienced difference between the two types of flap design both on
oozing on the 1st day with triangular flap (8). Oozing the observations on day 14 (p = 0.865) and day 30 (p =
events at the 1st and 6th hours observations of the trian- 0.676). Kiritoglu et al. (10) also stated that there was no
gular reversed flap group were less than the triangular difference in probing depth between modified triangular
flap design group (Table 3), and there were no signi- and 3-cornered flap on four weeks observation. Other
ficant differences between the two groups (p> 0.05). study, comparing the design of triangular and bayonet
Oozing is mostly observed where vertical incisions are flaps, suggests that there is no difference in CAL va-
located in the triangular flap design, which happens be- lues of 6 months and 12 months post-odontectomy (9).

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Another meta-analysis study shows that surgical extrac- luation of efficacy of tissue glue and sutures after surgical removal of
tion of impacted third molar with different flap designs impacted mandibular third molars - a prospective controlled clinical
study. J Oral Maxillofac Surg Med Path. 2015;27:183-8.
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condition of the adjacent second molar (28). However flap design on periodontal healing of second molars after extraction
longer observation day until day 90 shows that there is of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol
correlation between probing depth and flap design using Oral Radiol Endod. 2002;93:404-7.
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triangular and envelope flap (6,29). At present there is flap designs in the periodontal healing of second molars after fully
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triangular and reversed triangular flap designs. 2007;65:2206-10.
The results of the study on day 14 and day 30 did not 11. Ghoreishian M, Gheisari R, Fayazi M. Tissue adhesive and sutu-
ring for closure of the surgical wound after removal of impacted man-
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Acknowledgements
The author(s) acknowledge and thankful for the assistance in the pro-
ject to Dr. Lina Marlina and the original idea of the novel flap design
to the late Dr. Masykur Rahmat.

Conflict of Interest
The author(s) declare(s) that there is no conflict of interest regarding
the publication of this paper. The funding of the research and publica-
tion of the research is supported privately.

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