Lingual Based Four Cornered Flap for Third Molar Surgery

A narrative review of papilla preservation techniques in clinical dentistry

The interdental papilla is closely associated with oral health and dental aesthetics. Interproximal papilla is an essential component of pink aesthetics as well as an indispensable prerequisite for the health of oral tissues. The loss of papillary height not only considerably affects final esthetic results, but also brings a series of periodontal complications. The deficiency of papilla can be induced by iatrogenic factors, particularly the flap technique, which is usually employed in oral surgeries. Therefore, preservation of the interdental papilla must be a consideration of flap designs. To avoid papilla defects secondary to conventional flaps, papilla-preserving flap designs have been widely studied in clinical practice. With numerous papilla preservation techniques (PPTs) increasingly being employed, not only is the postoperative pink aesthetic better maintained, but the predictability of surgical outcomes has been significantly enhanced. However, there is a lack of adequate literature that provides a comprehensive overview of PPTs in the field of dentistry. This review summarizes the latest developments in papilla preservation flap designs in the field of oral surgery, with a particular emphasis on their indications, limitations, incision characteristics, and clinical benefits. This review may provide optimal protocols for the personalized treatment.

Comparison of buccal based triangular flap and lingual based triangular flap on postoperative course after impacted mandibular third molar surgery: a prospective randomized controlled study

Introduction: The present study is to compare the buccal based triangular flap with lingual based triangular flap on postoperative pain, swelling and trismus after mandibular third molar surgery. Materials and methods: This study comprised of 100 patients, of which, 50 patients underwent buccal based triangular flap technique and 50 patients underwent lingual based triangular flap. The patients in both the groups were evaluated for pain, swelling and trismus on 1st, 3rd and 7th postoperative days. The wound healing was assessed on the 7th postoperative day. The obtained data's were statistically analyzed using SPSS software. Results: Patients in lingual based triangular flap group had less pain on all three postoperative days (P < 0.001). While, the amount of swelling was less on the 3rd postoperative day (P < 0.05) and the degree of trismus was less on 1st and 3rd postoperative days (P < 0.05). The patients in buccal based triangular flap group showed statistical significance for swelling on 1st and 7th postoperative days (P < 0.05) and for trismus on 7th postoperative day (P < 0.05). 2 Patients reported with tissue dehiscence in lingual based triangular flap group. In buccal based triangular flap group, 7 patients presented with wound gaping and 2 patients developed dry socket. Conclusion: Lingual based triangular flap was found to be superior and effective flap design in controlling pain, swelling and trismus with reduced postoperative complications when compared to buccal based triangular flap.

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

PURPOSE

The lingual-based mucoperiosteal flap, a novel flap, was unclear about the effects on the prognosis of surgery for impacted mandibular third molars. This study aimed to compare the lingual- and buccal-based mucoperiosteal flaps with respect to postoperative responses and complications.

MATERIALS AND METHODS

A systematic review with a meta-analysis was designed and the PubMed, Cochrane Library, EMBASE, and Web of Science databases and Google Scholar from January 1, 2000 to April 30, 2020 were searched for randomized clinical trials. The predictor variable was buccal- or lingual-based flap in the surgery, and the outcome variables were pain, swelling, trismus, operative time, and wound dehiscence. Other study variables were sex and retention depth of impacted teeth. RevMan 5.3 software was used for data analysis. Mean differences or standardized mean differences and risk ratios were computed to assess associations between 2 variables, where statistical significance was set at P < .05.

RESULTS

Seven publications met the inclusion criteria, contributing 370 subjects who had 590 teeth removed to sample. The lingual-based flap failed to significantly reduce postoperative discomfort. However, subgroup analysis revealed that subjects who underwent comma flap (a type of lingual-based flap) surgeries complained of milder pain than those who underwent buccal-based flap surgeries on day 1 (mean difference = -1.18, 95% confidence interval [CI] [-1.53, -0.83], P < .001) and day 7 (mean difference = -1.80, 95% CI [-2.13, -1.48], P < .001) after surgery. Significant differences were also observed on days 1, 3, and 7 regarding postoperative swelling and trismus (P < .01). In addition, the lingual-based flap was reported to cause a significantly lower rate of wound dehiscence (relative risk = 0.46, 95% CI [0.30, 0.69], P = .0002).

CONCLUSIONS

The lingual-based flap was associated with better primary wound closure in third molar removal. The comma flap, as a subtype, was preferable for relieving postoperative pain, swelling, and trismus over the buccal-based flap.

Effect of lingual-based flap design on postoperative pain of impacted mandibular third molar surgery: Split-mouth randomized clinical trial

Background

The extraction of third molars is one of the most common procedures in oral and maxillofacial surgery clinic. Surgical extraction involves the manipulation of both soft and hard tissues, so the patient usually experiences pain, swelling, and trismus in the immediate post-operative period. Several studies have been conducted using different types of surgical flaps to provide access with the least possible damage of soft tissues. Designing and implementing an optimum flap, which provides easier technique, better visibility, minimal post-operative complications, and best healing, is an aspired goal of every oral surgeon. This study aimed to compare lingual-based four-cornered flap with conventional triangular flap, and to evaluate its effect on post-operative pain after surgical extraction of impacted lower third molars.

Material and Methods

Seventeen patients (age ranged from 19 to 26 years) with bilateral, symmetrical impacted lower third molars (n=34) were included in the study. This was a randomized clinical trial with a split-mouth design. The impacted molars were assigned randomly, by coin flipping, to two groups: Case side with lingual-based four-cornered flap (Group A), and control side with conventional triangular flap (Group B). Away from the incision, the prognosis, surgical intervention, and postoperative procedures were exactly the same for the two groups. Postsurgical pain was assessed for 5 days using visual analogue scale (VAS) and by recording patients need for analgesics on a daily basis. Patients were also evaluated via a self-reporting questionnaire, i.e. Postoperative Symptoms Severity (PoSSe) scale, administered on the seventh postoperative day.

Results

Pain scores recorded in Group A were found to be significantly lower as compared to pain scores in Group B in the 5 postoperative days (P<0.05). Total analgesic intake in Group B was significantly higher (P<0.05). PoSSe scores were lower in Group A, however, this difference was insignificant (P>0.05).

Conclusions

According to the data of the current study and within its limits, it appeared that lingual-based four-cornered flap design was superior to the conventional triangular flap regarding the postsurgical discomfort and pain.

Key words:Impaction, third molar surgery, flap design, pain, PoSSe scale, split-mouth, RCT.