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Comparison of three flap designs on postoperative complication after third

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Article  in  Intisari Sains Medis · June 2018

DOI: 10.15562/ism.v9i2.267

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 ORIGINAL ARTICLE
Intisari Sains Medis 2018, Volume 9, Number 2: 89-94
P-ISSN: 2503-3638, E-ISSN: 2089-9084

Comparison of three flap designs on postoperative

complication after third molar surgery
CrossMark
Pingky Krisna Arindra,* Adyaputra Indrapradana
Published by DiscoverSys

ABSTRACT

Introduction: Third molar surgery can cause post-operative Results: The results of one way ANOVA (p > 0.05) shows there was
complications to the patient due to the presence of wound from the no difference between treatment groups both for swelling and mouth
incision. The study aimed to compare modified triangular (triangular opening, but there was a difference between treatment groups for
reverse) flap with triangular and envelope flap on postoperative dehiscence on days 7 and 14. The results of the Post Hoc test show that
complications by the measurements on post-surgical swelling, trismus, flap envelope differs from the other flap design, whereas triangular
pain scale, wound dehiscence and the occurrence of alveolar osteitis. and triangular reverse flap showed no difference. Friedman test results
Methods: Study design using a single-blind randomized clinical (p > 0.05) showed no difference in VAS score. There was no alveolar
trial. Each treatment group consisted of 10 patients. An assessment osteitis occurred in each treatment group during postoperative control.
was performed on day 1, 7 and 14 after surgery. The swelling was Kruskal Wallis test (p > 0.05) showed that there was no difference of
measured using different anatomical points, and trismus was VAS score between treatment group during post-operative control.
measured using the distance of inter-incisal opening. The occurrence Conclusion: The triangular reverse flap design may decrease the
of dehiscence was measured from the width of the incision line. occurrence of postoperative complication after mandibular third
Alveolar osteitis and pain scale was observed. molar surgery.

Keywords: third molar surgery, post-operative complications, reverse triangular flap

Cite This Article: Arindra, P.K., Indrapradana, A. 2018. Comparison of three flap designs on postoperative complication after third molar surgery.
Intisari Sains Medis 9(2): 89‑94. DOI: 10.1556/ism.v9i2.267

Department of Oral and INTRODUCTION incision design by creating a vertical releasing flap
Maxillofacial Surgery, Faculty on the distal side of the lingual side leading to the
of Dentistry, Universitas Gadjah Post third molar surgery discomfort is often felt by lower third molar side of the line past the external
Mada, Yogyakarta, Indonesia. patients arising from complications at the time of oblique linea.
surgery or after surgery. Patients often experience Several studies have reported the effect of flap
pain, swelling, trismus, dehiscence, alveolar oste- design on postoperative complications after third
itis, infection, nerve injury and periodontal tissue molar surgery, but the reverse triangular flap design
damage.1 Complications can be prevented through has not been previously reported.
atraumatic, aseptic, drug administration, and phys-
iotherapy, suturing technique and also flap design.
Flap design is intended to achieve good access to
METHOD
the third molar impacted teeth, and facilitate easy
suturing, so it is expected to have good post-surgi- Patient and surgery
cal healing.1,2 The study design used a single-blind randomized
During this time, flap design research was done clinical trial, patients who fit the inclusion criteria
on the condition of fully covered impacted teeth by were included as research subjects. The inclusion
oral mucosa or alveolar bone.1,2,4,5 Daily conditions criteria were patients with partially erupted partial
show that partially impacted dental impaction mandibular third molar, aged between 18 to 60 years,
cases are the most prevalent. Surgical extraction on had no pain before surgery, healthy periodontal
*
Correspondence to: partially erupted third molar mandible requires a tissue, did not suffer from systemic disease and
Pingky Krisna Arindra, Department
of Oral and Maxillofacial Surgery,
distinct challenge in the flap design to prevent acute were not taking any medication and underwent a
Faculty of Dentistry, Universitas postoperative complications.6 For that purpose, third molar tooth surgery in Prof. Seodomo Dental
Gadjah Mada, Yogyakarta, Indonesia research on triangular modification (triangular Hospital, Faculty of Dentistry Universitas Gadjah
[email protected] reverse) flap design was compared with conven- Mada.
tional and triangular conventional flap envelope The subjects were 30 patients divided into
Diterima: 2018-05-15
design for the occurrence of postoperative compli- three study groups and consisted of 10 samples of
Disetujui: 2018-06-1 cation after third molar surgery. Triangular reverse the conventional flap envelope design group, ten
Diterbitkan: 2018-08-1 flap design is a modification of the triangular samples of triangular flap design group, ten samples

Open access: http://isainsmedis.id/ 89

ORIGINAL ARTICLE

of reverse triangular flap design group (Figure 1). Statistic Analysis

Third molar surgery performed by Oral and Data were analyzed using SPSS version 20.0
Maxillofacial Surgeon. After anamnesis, patient (Statistical Package for Social Science). Test of
samples signed informed consent and approval as normality was analyzed with Shapiro-Wilk test.
a sample of research before surgery. Third molar Repeated measure ANOVA test was used to deter-
surgery was performed with an inferior alveolar mine the difference of swelling and trismus between
nerve block anesthesia and lingual nerve and infil- control days in each flap group. The paired test was
trating the long buccal nerve using a 2% lidocaine performed to determine the difference of dehisence
1: 80.000. Mucoperiosteal flap with envelope flap on the 7th day and the 14th postoperative day in
design, triangular flap design or reverse triangular each group, while the one-way ANOVA test to know
flap design on mandibular third molars. Ostectomy the difference between the three groups. If the data
on the buccal and distal bone of the third molar is not normally distributed, then nonparametric
use Moore and Gilby’s guttering technique.7 After Friedman test is performed, this test is to know the
surgery, the tooth follicle is cleaned. In the tooth difference between the control days of each group,
socket on the alveolar bone laid gelatin sponge and Kruskal Wallis test to evaluate the difference
and then performed the primary wound suturing. of VAS score in each day of control between each
If there is no history of allergy, the patient is given treatment group.
500 mg of amoxicillin caplet taken daily 3 times
every 8 hours for 5 days, and ibuprofen 400 mg
is taken for every 8 hours for 3 days. The suture
RESULT
release was done 7 days post operation. The study Swelling evaluation results measured before
received approval from the local ethics committee surgery and after surgery are shown in table 1.
and in accordance with the Helsinki. Repeated measure ANOVA (p1) shows a value
of p < 0.05 which means there is a difference of
Pre and postoperative assessment swelling from day to day in each flap group. This
All patients controlled on day 1, 7, and 14 after indicates a postoperative inflammatory healing
surgery. Measurements of edema and trismus process. The average value of the highest swelling
were performed before surgery and after surgery, was in the triangular group, and swelling in all
consisting of H+0 (immediately after suturing), groups increased on day 1 postoperatively. The
H + 1 (first day after surgery), H + 7 (the seventh 7th and 14th-day swellings show almost the same
day after surgery) and H + 14 (the fourteenth day value as the preoperative swelling measurements.
after surgery). Measurement of edema by using three The one-way ANOVA (p1) result shows p > 0.05
facial lines ie the tragus distance (point a) to the in preoperative swelling measurement, one-day
corner of the mouth (point b) as line 1, the tragus and a week postoperative swelling measurement,
distance (point a) to pogonion (point c) as line 2 and while p < 0.05 on day 14 postoperative swelling
line 3 is the angular distance (point d) to the lateral measurement. This means that the measurement
angle of the eye (point e). The distance between the of preoperative swelling, one-day and a week post-
three lines is measured in length and the average operatively shows no significant difference. While
value is measured (Figure 2). The tool used is soft on day 14 preoperative swelling measurements
wire to be sterilized.8 Trismus was measured by the there are differences in swelling measurements
subjects opened the mouth wide to the vertical and between groups. Post hoc test results showed only
measured the distance between the incisal edge of triangular flap groups whose values differed from
the maxillary central incisor to the lower incisor by those of the envelope and triangular reverse flap
using the sliding caliper.9 (Figure 3) groups. Higher mean value results in the triangular
The dehiscence assessment was done visually flap group compared with the other group could
and carefully explored with periodontal probes. be assumed that the triangular flap group caused
The distance along the incision line is defined as swelling compared to the other group, but when
dehiscence.1 The occurrence of alveolar osteitis compared with the preoperative measurements
was observed by looking at whether there was showed similar results between the preoperative
an open alveolar bone area and was not filled by measurements with the day 14 postoperative swell-
granulation tissue and the patient complained of ing measurements.
postoperative pain. The postoperative third molar Table 2, shows the results of a trismus evalua-
pain was measured by the Visual Analog Scale tion of the width of the interincisal opening of the
(VAS) pain scale.3,5 maxilla and the lower jaw. The result of repeated

90 Published by DiscoverSys | Intisari Sains Medis 2018; 9(2): 89-94 | doi: 10.15562/ism.v9i2.267
 ORIGINAL ARTICLE

Table 1  Statistical analysis of postoperative swelling after third molar surgery with different flap designs
Swelling Pre Swelling Post Swelling Post Swelling Post Swelling Post
Surgery Surgery H+0 Surgery H+1 Surgery H+7 Surgery H+14 p1
Research groups
Mean SD Mean SD Mean SD Mean SD Mean SD
Envelope 120.29 6.56 120.88 7.07 130.05 6.44 120.79 6.37 115.36 0.83 0.000
Triangular 124.07 8.82 124.76 7.80 131.50 8.06 125.89 8.76 124.10* 8.88 0.000
Reverse Triangular 119.28 3.58 119.69 3.62 128.29 4.13 120.35 4.08 119.17 3.66 0.000
p2 0.257 0.202 0.541 0.140 0.006
p1) Repeated measure; p2) One-way ANOVA;*) p<0.05 post hoc ANOVA Flap Triangular vs. Flap Envelope

Table 2. Statistical analysis of postoperative trismus after third molar surgery with different flap designs
Trismus Pre Trismus Post Trismus Post Trismus Post Trismus Post
Surgery Surgery H+0 Surgery H+1 Surgery H+7 Surgery H+14 p1
Research groups
Mean SD Mean SD Mean SD Mean SD Mean SD
Envelope 39.17 2.34 36.73 2.22 31.43 3.31 38.04 2.32 38.85 1.95 0.008
Triangular 41.60 2.77 36.13 3.76 28.90 1.75 40.89 2.54 41.60 *
2.55 0.000
Reverse Triangular 40.62 2.34 34.31 4.08 29.30 4.99 39.48 3.09 40.26 2.50 0.002
p2 0.109 0.280 0.258 0.076 0.047
p1) Repeated measure; p2) One-way ANOVA;*) p<0.05 post hoc ANOVA Flap Triangular vs. Flap Envelope

Table 3  Statistical analysis of postoperative dehiscence after third molar surgery with different flap designs
Dehiscence H+7 Dehiscence H+14
Research groups Mean SD Mean SD p1
Envelope 5.83 1.54 2.87 0.67 0.000
Triangular 3.65* 1.14 1.45* 0.71 0.000
Reverse Triangular 3.03* 0.97 0.90* 0.50 0.000
p2 0,000 0,000
p1) Paired T test; p2) One-way ANOVA;*) p<0.05 post hoc ANOVA Flap Triangular vs. Flap Envelope, Flap Reverse Triangular vs. Flap Envelope

Table 4  Statistical analysis of postoperative pain after third molar surgery with different flap designs
VAS Post Surgery VAS Post Surgery VAS Post Surgery VAS Post Surgery
VAS Pre Surgery H+0 a H+1 H+7 H+14 p1
Research groups
Mean SD Mean SD Mean SD Mean SD Mean SD
Envelope 0.2 0.4 0.0 0.0 1.5 1.2 0.2 0.4 0.0 0.0 0.000
Triangular 0.4 0.5 0.7 1.1 1.6 0.7 0.4 0.5 0.0 0.0 0.000
Reverse Triangular 0.4 0.5 0.5 0.7 1.5 0.7 0.2 0.4 0.0 0.0 0.000
p2 0.560 0.075 0.951 0.517 1.000
p1) Friedman test; p2) Kruskal Wallis test

measure ANOVA (p1) shows p-value <0.05 meaning 7 and 14 occurs inflammatory healing involving
that there is a difference in trismus measurement mastication muscles. At the moment the surgery
between measurement before surgery and measure- is completed and at one day after surgery shows a
ment after surgery at each treatment group. The decrease in interincisal opening width.
results of the average postoperative score indicate It shows the presence of inflammation involv-
values ​​that approximate the measurements before ing mastication muscles. The result of one way
the surgical operation on the 7th and 14th-day ANOVA (p2) shows the value of p > 0.05 before
measurements. This means that the control of days the operation, shortly after surgery, one day after

Published by DiscoverSys | Intisari Sains Medis 2018; 9(2): 89-94 | doi: 10.15562/ism.v9i2.267 91
ORIGINAL ARTICLE

Table 3, shows the dehiscence measurements

between day 7 and day 14, based on the results
of paired t-test (p1), there is a difference between
dehiscence on day 7 and day 14 in each flap design
group. This shows that there is healing on day 14.
The result of one way ANOVA (p2) test shows the
significance of p < 0.05 on day 7 and day 14, mean-
Figure 1 Design of envelope flap (A), triangular (B), reverse triangular (C) ing that there is a difference between treatment
on partial eruption lower third molar group on day 7 and day 14. Result of the Post Hoc
test shows that the flap envelope differs from the
triangular and reverse triangular flap, whereas the
reverse triangular and triangular flap do not show
any difference.
The occurrence of alveolar osteitis is supported
by the presence of postoperative pain. Visual Analog
Scale pain scale measurements were measured at
day 1, 7 and 14 postoperative controls. The control
results did not show the occurrence of postoperative
alveolar osteitis in each treatment group. Shapiro
Wilk test results obtained p < 0.05 which means
the data is not normally distributed. Furthermore,
nonparametric analysis with Friedman test was
used to know the difference between the control
days of each group, and Kruskal Wallis test to
know the difference of VAS score in each day of
control between each treatment group. The results
Figure 2 The points of edema measurement on of the analysis are presented in table 4. There is no
the face difference in VAS score from time to time in each
treatment group. These results showed no Alveolar
Osteitis in each treatment group at the time of
postoperative control. While the result of Kruskal
Wallis test shows p value > 0.05 meaning there is no
difference of VAS score between treatment group at
the time of post-operation control.

DISCUSSION
This study aimed to evaluate whether reverse trian-
gular flap design was able to prevent postoperative
Measurement of interincisal opening
Figure 3  complications of swelling, trismus, dehiscence,
with sliding caliper alveolar osteitis and pain after surgery of the partial
eruption mandibular third molars compared with
surgery, and one week after surgery. These results triangular and envelope flap design. The results
mean that there is no difference in interincisal show that the triangular flap design tends to cause
width measurements between flap design groups swelling when compared with other flap designs.
on pre-operative measurements up to one week Factors that affect the occurrence of swelling due
postoperatively. While 14 days after surgery to the addition of releasing incision so that it is
shows p-value < 0,05, it means there is a differ- assumed to produce edema due to an inflamma-
ence of interincisal width measurement between tory process.10,11 Similar results were also found
flap design group on day 14. Post hoc test show by Mobilio et al. (2017) comparing envelope inci-
only different triangular flap design compared to sions and conventional triangular incisions.13 The
design group of flap envelope and reverse trian- mucosa will respond to tissue trauma by releasing
gular with most interincisal opening value wide. antibodies and leukocytes present in the blood-
This shows that the triangular flap design is a flap stream, plasma exudation, protein, and neutrophils
design capable of reducing the occurrence of tris- in the injury area resulting in inflammatory clinical
mus postoperative third molar surgery. symptoms of swelling.12

92 Published by DiscoverSys | Intisari Sains Medis 2018; 9(2): 89-94 | doi: 10.15562/ism.v9i2.267
 ORIGINAL ARTICLE

The occurrence of facial swelling in the first supports tension free tension making it possible to
postoperative day in all treatment groups showed close primarily, while the envelope flap is not possi-
an increase in extracellular fluid and extravascular ble to close primarily.12 Triangular flap produces a
fluid accompanied by abnormal fluid accumula- better viewing field and is wider than the flap enve-
tion in between tissue and facial serous cavity after lope, due to a vertical releasing incision but will
third molar surgery.10,11 Edema that occurs is an result in swelling and other signs of postoperative
inflammatory process for healing and reaches its complications.10-12
peak at 24-48 hours and will be reduced and lost The reverse triangular flap is a triangular flap by
on the third and fourth days after lower third molar creating a vertical releasing flap on the distal side
surgery.13 This is in accordance with the results that leads from the lingual side to the buccal side
of studies showing a decrease in facial swelling of through the external oblique linea in the retromo-
seven and fourteen days postoperatively. lar area of the
​​ mandibular third molar and adds a
Trismus measurements showed that triangular sulcular horizontal incision on the distobuccal side
flap groups resulted in better interincisal opening of the mandibular second molar.
compared to the flap envelope and reverse triangu- This flap is a modification of the conventional
lar design groups. Trismus is a spasm of the muscles triangular flap and this flap can be transposed as
of mastication caused by trauma to the musculus a short triangular flap design, supporting primary
and blood vessels in the infratemporal space that sewing, and allowing to add a visible field on the
leads to open mouth disorders, trigeminal nerve distal side of a buried third molar tooth. There is
motor disorders due to nervous structures that are the flexibility to increase the length of the sulcular
suppressed due to the edema that occurs. The cause incision in the buccal second molar. The deficiency
of trauma to the muscle is the recurrent needle of this flap is to increase the risk of bleeding and
insertion in the inferior alveolar nerve anesthetic lingual nerve injury especially if the trigonum
block, particularly in the medial pterygoid cavity, retromolar is thin and the incision line is not
infection, haemorrhage or hematoma irritating directly above the bone in the area of ​​the trigonum
tissue and impairing the function of muscle, retromolar.
mouth rinse containing alcohol or substances that The results of this study indicate that flap design
irritate, third molar surgery and direct trauma to choices determine the occurrence of postoperative
the temporomandibular joint.3,5 In this study the complications. The risk of alveolar osteitis is caused
occurrence of trismus after third molar surgery by a lack of postoperative oral hygiene and immu-
caused by inflammation of the muscles of mastica- nocompromised patients.14 Need to educate the
tion leading to spasm secondary to the raising of a patient to be careful when performing oral cleans-
mucoperiosteal flap. ing cavity either rinsing or brushing teeth because
Postoperative dehiscence appears on the enve- if too often or gargle too hard will release the blood
lope flap design, and it is reported that dehiscence formed so as to cause a dry socket or alveolar oste-
is more common in envelope flap than in bayonet itis after the third mandibular molar surgery.
flap or triangular flap.6,7 The advantage of the flap
envelope is being able to provide sufficient viewing CONCLUSION
space on the surgical side and allow the elongation
of the incision to the anterior if necessary, good for The reverse triangular flap design can reduce the
blood supply and facilitate easy suturing. The disad- occurrence of postoperative third molar compli-
vantage is the breakdown of the periodontal liga- cations. Reverse triangular flap design can be an
ment when making a sulcular incision around the alternative to flap design options because it gives
tooth, this damage will increase osteoclast activity the same results as triangular flap design.
when opening the mucoperiosteal flap and increase
the risk of wound dehiscence. Dehiscence may REFERENCES
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Published by DiscoverSys | Intisari Sains Medis 2018; 9(2): 89-94 | doi: 10.15562/ism.v9i2.267 93
ORIGINAL ARTICLE

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