Journal of Pharmaceutical Research International

34(14A): 58-66, 2022; Article no.JPRI.83011

ISSN: 2456-9119
(Past name: British Journal of Pharmaceutical Research, Past ISSN: 2231-2919,
NLM ID: 101631759)

Comparison between Modified Triangular Flap and

Envelop Flap Techniques for Surgical Removal of
Impacted Mandibular Third Molar
Bharti Kumari a, Suneel Kumar Punjabi b, Lavina c, Naeem Mustafa a,
Reham Iqbal b and Salman Shams d*
a
Oral and Maxillofacial Surgery Department, Bibi Aseefa Dental College, Shaheed Mohtarma Benazir
Bhutto Medical University, Larkana, Pakistan.
b
Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Liaquat University of Medical and
Health Sciences, Pakistan.
c
Oral and Maxillofacial Surgery Department, Muhammad Dental College, Mirpurkhas, Pakistan.
d
Oral Medicine Department, Faculty of Dentistry, Liaquat University of Medical and Health Sciences,
Pakistan.

Authors’ contributions

This work was carried out in collaboration among all authors. All authors read and approved the final
manuscript.

Article Information
DOI: 10.9734/JPRI/2022/v34i14A35649

Open Peer Review History:

This journal follows the Advanced Open Peer Review policy. Identity of the Reviewers, Editor(s) and additional Reviewers,
peer review comments, different versions of the manuscript, comments of the editors, etc are available here:
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Received 10 December 2021

Original Research Article Accepted 19 February 2022
Published 22 February 2022

ABSTRACT

Objective: To compare postoperative outcomes in surgical extraction of mandibular third molar

with envelop flap versus modified triangular flap.
Setting & Duration: Oral & Maxillofacial Surgery Unit at Faculty of Dentistry, Liaquat University of
Medical and Health Sciences Jamshoro. Study period was from January 2021 to December 2021.
Subject and Methods: A set of 60 individuals were sequentially assigned 30 to the Group A
envelop flap and 30 to the Group B modified triangular flap for surgical removal of the mandibular
third molar tooth. The demographic and clinical parameters was identified and recorded in
proforma. The discomfort, swelling, and restricted mouth opening linked with an impacted
mandibular third tooth are all assessed prior to surgery. The flap pattern employed for the
extraction of the impacted lower third molar tooth, pain, and mouth opening was all reported on the
proforma at the end of the procedure. On the seventh postoperative day, each patient was
_____________________________________________________________________________________________________

*Corresponding author: E-mail: [email protected];

 Kumari et al.; JPRI, 34(14A): 58-66, 2022; Article no.JPRI.83011

evaluated again.
Results: - The average age of patients in group A was 29.77±7.17 years and 28.20±6.28 years in
group B. Mean pain score was significantly low in group A as compare to group B [0.87±0.86 vs.
2.93±0.87 p=0.0005]. Mean mouth opening was significantly high in group A than group B
[12.86±3.59 vs. 6.12±1.67; p=0.0005].
Conclusion: In comparison to the envelope flap, the modified triangular flap was more effective
when considering the postoperative periodontal state of the surrounding third molar and the
dehiscence after wound recovery.

Keywords: Mandibular third molar impaction; envelop flap; modified triangular flap; surgical
extraction; mandibular premolar.

1. INTRODUCTION supply is excellent because to the wide base,

and the design allows for simple sealing and re-
"A tooth that is stopped from emerging into place approximation [6].
due of malposition, lack of space, or other
obstructions is termed as an impaction [1]. "An Since it prevents elevating soft tissues from the
impacted tooth" is defined as "teeth that fail to buccal face of the second molar, the modified
erupt into the dental arch within the predicted triangular flap is considered more cautious due to
period [2]. An impacted tooth is a tooth that is a lower degree of tissue reflectance. It's easy to
inhibited from erupting owing to a physical seal and provides a reasonably tension-free seal.
obstacle inside the eruption route," Farman wrote Unlike the envelop flap, though, it cannot be
previously [1,2]. The more prevalent impaction is easily stretched [7,8].
mandibular third molar impaction, which is
preceded by maxillary third molar, maxillary When contrasted to the modified triangular flap,
canine, and mandibular premolar impaction [3]. probable troubles with the envelop flap include
enhanced osteoclastic action when elevating the
The orientation and depth of impaction, the mucoperiosteal flap with possible local bone
proportion of accessible space for tooth eruption, setback, greater danger of wound dehiscence,
and the amount of soft tissue and bone (or both) which might result to a dry socket and an
that covers them (Pell and Gregory excruciating and uncomfortable postoperative
classification), as well as the angulation of the era for the patient, and injury at the level of
impacted third molar with regard to the long axis periodontal fibres to cervical insertion when the
of the neighbouring second molar, are used to incision is conducted. Soft tissue strain, arising in
classify impacted wisdom teeth in the mandible. postoperative hematoma and masticatory
Practitioners can use the categorization motions, promotes a greater frequency
framework to predict the likelihood of impaction, of wound dehiscence when the envelop flap is
infection, and other problems related with anchored anteriorly with intersulcular sutures
wisdom tooth extraction. The presence or [6,9,10].
absence of symptoms and illness can also be
used to classify wisdom teeth [4,5]. Comparing envelop flap with modified triangular
flap, the triangular flap has disadvantage of
The extraction of the lower wisdom tooth limited mouth opening due to raising
surgically is a frequent surgery that might result mucoperiosteal flap which induces inflammation
in discomfort, trismus, edoema, alveolar osteitis, to masticatory muscles causing trimus [11].
and periodontal pocket development close to the Sandhu et al looked at the impact of modified
second molar. Clinicians have examined the use triangular and envelope flap patterns on
of several flaps such as the envelop flap, ward postoperative trismus and found no significant
incision flap, kruger envelop flap, killy and kay differences between the two designs [12,13]. In
incision, berwick tongue shape flap, nageshwar the study conducted by koyuncu BO et al found
comma shaped flap, henry incision, triangle flap, out the mean pain among modified triangular flap
th
and modified triangular flap to decrease these as 0.85±1.15 at 7 day and mean mouth opening
th
complications [6]. The envelop flap provides for at 7 day as 4.03±1.02 [9]. And the mean pain
good visibility of the surgical site, and the incision score for envelop flap as 2.16±1.12, and mouth
can be expanded anteriorly if necessary. Blood opening as 12.25±9.08 [8].

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2. MATERIAL AND METHODS 2.4 Procedure

This is a non-probability consecutive sampling By using a lottery system, all individuals were
research with a Randomized Control Trial. sorted into two identical portions, group A and
Sample size was calculated using open epi. group B. Group A was given to the modified
Sample size calculate by taking statistics for pain triangular flap design, while Group B was given
in modified triangular flap technique as to the envelop flap type. Following patient
0.85±1.15
9 th
at 7 day and for envelope flap stratification, routine preparation and draping
technique the mean as 2.16±1.12, power of test were completed, and all procedures were
90% and 95% CI. The calculated sample size executed under local anaesthetic with two 1.8mL
came out as 30 in each group.5 patients of % xylocaine with 1:10000 epinephrine
additional were enrolled for loss of follow up in (Medicaine; Made in Korea) and all operations
each group. Total sample size was 60. were undertaken under the observation of the
supervisor. Using sterile carbon steel surgical
2.1 Inclusion Criteria blade #15 and a standard full thickness
mucoperiosteal flap (Modified Triangular Flap), a
standard full thickness mucoperiosteal flap
Patients having either gender with age range of
(Modified Triangular Flap) was produced in group
18 to 40 years and having mesioangular
A. (Feather safety razor co. Ltd Japan).
impaction and distoangular impaction
with Class II and Class B were included in the
A typical full thickness mucoperiosteal flap
study.
(Envelop Flap) was developed in group B,
accompanied with a sulcular cut from the first to
2.2 Exclusion Criteria second mandibular molar and a distal relieving
incision along the external oblique ridge to the
Immuno-compromised, pregnant patients, patient ramus. To prevent lingual nerve injury, a lingual
having systemic diseases like diabetes mellitus, flap was softly lifted distal to the mandibular
cancer, hypertension or renal failure was second molar.
assessed on medical record and history,
smokers and patients with bad habits (pan, The crown, which was partially covered, was
guttka, betel nut chewers) uncovered from the occlusal down to the equator
using a rose head round bur in a slow speed
2.3 Data Collection Procedure turbine with continual irrigation of 0.9 % normal
saline after deploying the mucoperiosteal flap
Individuals who met the eligibility conditions and and revealing the surgery location (Searle Ltd.
were prepared to engage in the trial were Pakistan). After exposing the impacted tooth,
enrolled. Before enrolling in the experiment, an tooth was sectioned with slow speed turbine with
informed and signed permission was obtained. a straight fissure bur with copious irrigation
Age, gender, pain, medical history, and tooth Normal Saline0.9%. The tooth was partitioned
extraction process were among the and elevated with the couplain straight elevator,
demographics and clinical factors evaluated and following which any jagged bone was smoothed
documented in a proforma. The lead researcher with a curving bone filer and the incision was
or supervisor took the history, performed the secured with 3-0 Vicryl suture (Johnson &
clinical assessment, and took radiographs (OPG Johnson; made in USA). For 30 minutes, a sterile
and periapical) and recorded them on a wrapped gauze (2 x 2) was placed over the
proforma. Complete preoperative assessment of surgical site to provide pressure and hemostasis.
patient and diagnosis of impaction pattern was For 5 days, I took standard antibiotics (amoxicillin
done. 500mg every 8 hours) and pain relievers
(diclofenac potassium 50mg every 12 hours).
Preoperative evaluation of pain [on a scale of The flap design employed for the extraction of
zero to ten (worst pain imaginable)], degree of the impacted lower third molar tooth, discomfort,
swelling (by comparing the two sides of the and mouth opening was all reported on the
patient's face), and restricted mouth opening [on proforma at the end of the procedure. On the
a millimeter ruler] affiliated with impeded seventh postoperative day, each individual was
mandibular third molar. evaluated again.

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 Kumari et al.; JPRI, 34(14A): 58-66, 2022; Article no.JPRI.83011

2.5 Data Analysis Procedure The average age of patients in group A was
29.77±7.17 years and 28.20±6.28 years in group
The data was examined using SPSS version B as shown in Table 1. There were 50% male
20.0, a statistical software application. For and 50% female. Gender distribution according
quantitative factors including age, pain score, to groups is also presented in Fig. 1.
and mouth opening, mean and standard
deviation were determined. For qualitative factors Out of 60 cases, swelling was observed in 53.3%
such as gender, edoema, trimus, wound in group A and 56.7% in group B, similarly rate of
dehiscence, and impaction kinds, frequencies trismus was 50% in group A and 36.7% in group
and percentages were computed (mesioangular, B, wound dehiscence was 43.3% in group A and
distoangular, class II, class B). For quantitative 33.3% in group B as reported in Table 2.
factors like pain and mouth opening, the T test Regarding impaction types, mesioangular was
was used to compare the two groups. Significant the commonest impaction as presented in
was defined as a P value less than or equal to Fig. 2.
0.05.
Mean pain score was significantly low in group A
3. RESULTS as compare to group B [0.87±0.86 vs. 2.93±0.87
p=0.0005] as presented in Fig. 3. Mean mouth
A total of 60 patients for surgical extraction of opening was significantly high in group A than
mandibular third molar randomly allocated 30 by group B [12.86±3.59 vs. 6.12±1.67; p=0.0005] as
envelop flap and 30 by modified triangular flap. shown in Fig. 4.

Table 1. Descriptive statistics of age according to groups

Descriptive Statistics Group A Group B

n=30 n=30
Mean 29.77 28.20
Std. Deviation 7.17 6.28
95% Confidence Interval for Mean Lower Bound 27.09 25.85
Upper Bound 32.44 30.55

Fig. 1. Gender distribution of the patients according to groups (n=60)

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 Kumari et al.; JPRI, 34(14A): 58-66, 2022; Article no.JPRI.83011

Table 2. Rate of swelling, trims and wound dehiscence between groups

Variables Group A Group B Total

Swelling 16(53.3%) 17(56.7%) 33(55%)
Trimus 15(50%) 11(36.7%) 26(43.3%)
Wound Dehiscence 13(43.3%) 10(33.3%) 23(38.3%)

Fig. 2. Impaction type of the patients, according to groups (n=60)

Fig. 3. Comparison of mean pain score between groups (n=60)

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Fig. 4. Comparison of mean mouth opening between groups (n=60)

4. DISCUSSION dehiscence was 43.3% in group A and 33.3% in

group B as reported. Furthermore, according to a
Based on the surgeon's view, two types of flaps, research done by Dolanmaz, there was no
envelope or modified triangular, can be substantial variation in postoperative edema
employed in lower-impacted wisdom teeth following impacted third molar surgery among the
procedures. The concern is whether the use of envelope and modified triangular flaps [18].
each of those flaps has a distinct effect on the
occurrence of dry sockets [14,15]. Dry socket Minimal incisions with little mucoperiosteum
was detected in 2 out of 32 patients after reflectivity are related with decreased
employing triangle flap and 7 out of 32 instances postoperative discomfort and edema, according
after utilising envelop flap (EF), according to a to research [19]. The observations of the current
research conducted by Kirk et al. [16]. In a investigation demonstrated that the differences in
separate paper by Nusair and Younis [17], they mean pain intensity between the envelope and
reported a 4.8 percent prevalence of dry socket the modified triangular flap were significant
occurrence, with 3.2 % in non-surgical tooth statistically. In comparison to group B, group A's
extraction and 20 % in impacted third molar mean pain score was considerably lower
removal procedures. [p=0.0005]. In a research done by Sandhu et al.
[20] and Aliasghari Abandansari S and Foroughi
The mean age of the individuals in this research R [21], greater pain ratings were seen with the
was 29.77±7.17 years in group A and envelope flap layout, which is comparable to the
28.20±6.28 years in group B. Males made up half results of our investigation.
of the group, while females made up the other
half. Patients in the Koyuncu et al. [9] research Kirk et al. found no statistically meaningful
ranged in age from 18 to 40 years old, with an differences in pain between the envelope and
average age of 23.30 years. There were 29 triangle flap styles, which is consistent with our
women and 7 men among the patients. observations [16]. Sandhu et al investigated the
effects of modified triangular and envelope flap
In present study out of 60 cases, swelling was layouts on postoperative trismus and reported no
observed in 53.3% in group A and 56.7% in differences in either type [13,20]. The average
group B similarly rate of trismus was 50% in discomfort among modified triangular flap
group A and 36.7% in group B. wound patients was 0.85±1.15 on the seventh day, and

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the mean mouth opening was 4.03±1.02.9 on the envelop flap, such as the damage of periodontal
seventh day, according to a research done by ligament during sulcular incisions across the
Koyuncu BO et al. The mean pain score for the teeth, a boost in osteoclastic action during the
envelop flap was 2.16±1.12, while the lifting of the mucoperiosteal flap, which leads to
mean rating for mouth opening was 12.25±9.08 more bone loss, and a higher risk of wound
[9]. rupture during the postsurgical era [8,30].

Since the envelope flap does not necessitate the The modified triangular flap is a more
relieving cut and is highly prudent, it was conservative flap than the others, resulting in
believed that the envelope flap would show a minimal tissue response. The soft tissue on the
reduced constraint in mouth opening throughout buccal of the second molar is elevated as a
the postoperative phase. According to Kim et al. result of this. This state allows for quick wound
[22] and Oliveira et al. [23], the degree of mouth sealing and tension-free sutures, but unlike the
opening reduction is related to the complexity of EF, it is not extensible [14].
the technique, the extent of tooth involvement,
and the surgical time, with the more complex the 5. CONCLUSION
method and the higher the requirement for an
osteotomy and tooth segmentation, the higher Within the report's constraints, it can be inferred
the risk of postoperative side effect. In this trial, that the triangle flap layout was superior to the
group A had a considerably higher mean mouth envelope flap in terms of discomfort and mouth
opening than group B [p=0.0005]. Conard et al. opening. In contrast to the envelope flap, the
[24] discovered acute trismus on the first triangular flap was more effective in terms of
postoperative day after third molar operation in a postoperative periodontal condition of the
clinical investigation. Azaz [25] found sluggish neighboring third molar and wound healing
trismus recovery in 13% of instances of mild– dehiscence.
moderate trismus 10 days after surgery in
another clinical investigation. Trismus was ETHICAL APPROVAL
highest at 24 hours and was remained evident 15
days after third molar surgery, according to As per international standard or university
Cerqueira [26]. The kind of incision had no effect standard written ethical approval has been
on trismus, according to Van Gool [27] and collected and preserved by the author(s).
Suarez-Cunqueiro [28]. Sandhu [20] investigated
the impact of modified triangle and envelope flap CONSENT
layouts on postoperative trismus and observed
no substantial differences in either category.
As per international standard or university
Likewise, Kirk et al. [16] looked at the effects of
standard, patients’ written consent
envelope and modified triangular flap patterns on
has been collected and preserved by the
postoperative trismus and found that the flap
author(s).
patterns they utilised had no negative effects on
participant’s postoperative trismus.
DISCLAIMER
According to Garcia [29], the degree of
discomfort after third molar surgery decreased The products used for this research are
between days 1 and 5. Erdogan [11] investigated commonly and predominantly use products in our
the impact of triangular and envelope flaps on area of research and country. There is absolutely
discomfort following mandibular third molar no conflict of interest between the authors and
removal and discovered that envelope flaps producers of the products because we do not
result in lower VAS ratings than triangle intend to use these products as an avenue for
flaps. any litigation but for the advancement of
knowledge. Also, the research was not funded by
The envelop flap allows the surgeon easier the producing company rather it was funded by
access to the operation site. In this flap, the personal efforts of the authors.
clinician can also deepen the sulcular incision
from the anterior region while maintaining a wide COMPETING INTERESTS
base. In this instance, circulation would be
greater and sewing would be faster. Different Authors have declared that no competing
publications look into the potential drawbacks of interests exist.

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