The influence of flap design on patients’ experiencing pain, swelling, and trismus after mandibular third molar surgery: a scoping systematic review

Abstract

Third molar removal surgery usually comes accompanied by postoperative discomfort, which could be influenced by the surgical approach chosen. This scoping systematic review aimed at compiling the available evidence focused on the influence of flap design, including envelope flap (EF), triangular flap (TF), and modified triangular flap (MTF), on postoperative pain, swelling, and trismus, as primary outcome measures, and any result mentioning healing promotion or delay, as secondary outcome measure, after mandibular third molar extraction surgery. An electronic search, complemented by a manual search, of articles published from 1999 to 2020 was conducted in the Medline (PubMed), EMBASE and Web of Science databases including human randomized controlled trials, prospective, and retrospective studies with at least 15 patients. The risk of bias of the included studies was assessed either with the Cochrane’s Risk of Bias tool or with the Newcastle-Ottawa scale. Every step of the review was performed independently and in duplicate. The initial electronic search recovered 2102 articles. After applying the inclusion criteria, 12 articles were included. For patient’s perceived postoperative pain, TF and MTF frequently reported better results than EF. For swelling, the literature is divided, despite a trend favoring EF. For trismus, data showed that its occurrence is mostly associated with the duration of the surgery rather than with the chosen flap. For healing, the limited data is inconclusive. Finally, randomized studies showed a high risk of bias, whereas nonrandomized studies were mostly of good quality and low risk of bias. Although there was no clear consensus regarding the influence of different flap designs for third mandibular molar extraction on postoperative clinical morbidities; the surgeon’s experience, estimated surgical difficulty, molar position and orientation, and surg ery duration should be considered when choosing among the different flap designs.

Manejo Do Atendimento Clínico Diante De Acidentes E Complicações Em Cirurgia De Terceiros Molares: Revisão Sistemática Da Literatura

“…Estudos demonstram que os procedimentos a serem adotados para a correção de necroses teciduais permeiam desde os procedimentos emergenciais, imediatamente após a verificação dos primeiros sinais sintomas locais 14,15 , até procedimentos mais significativos, quando o quadro se encontra mais avançado 17…”

“…Outra complicação cirúrgica de terceiros molares que tem aumentado com o uso de peças de mão em alta rotação é o enfisema subcutâneo e como prevenção, o cirurgiãodentista deve realizar um tamanho adequado do retalho, controlar a quantidade de força, evitando injúrias no tecido mole, a gengiva do terceiro molar superior precisa ser suturada, anteriormente a osteotomia no antagonista, orientar devidamente a cabeça da turbina de alta rotação e escolher a utilização dos cinzéis para remover o osso, principalmente na maxila, por apresentar um tecido ósseo mais fino e trabecular (COSTA et al, 2017) A cirurgia de exodontia de terceiros molares inferiores geralmente apresenta características clínicas de dente impactado, sendo necessário a utilização de um retalho, entretanto, muitos profissionais apresentam dificuldades na escolha do retalho, o qual influi diretamente no pós-cirúrgico do paciente, podendo causar desconforto, devido à manipulação tecidual realizada durante o ato cirúrgico. O retalho apresenta grande importância, pois proporciona uma melhor visualização do campo operatório, assim reduz o tempo cirúrgico, porém, ainda existe divergência entre os autores sobre um padrão específico de desenho ideal do retalho (MARCO et al, 2021).…”

“…As linhas secundárias de intervenção podem envolver Ozonioterapia, oxigenoterapia hiperbárica e agentes vasodilatadores auxiliares, como da prostaglandina E1. 14,15,16,17,18 O caso clínico descrito propõe uma forma de tratamento emergencial de paciente com quadro de necrose tecidual diagnosticado e ocorrido em função de obliteração vascular por injeção de AH para correção de Sulco Nasogeniano.…”

Influence of Surgical Technique on Post-Operative Complications in the Extraction of the Lower Third Molar: A Retrospective Study

“…Some of the most frequent postoperative complications in impacted third molar extraction are pain, swelling, trismus, prolonged bleeding, dry socket, alveolar osteitis, surgical site infections, abscess and sensory alterations of the inferior alveolar nerve (IAN) or lingual nerve (LN) [4,5,7,10,12,13]. The frequency of these postoperative complications for lower impacted third molars varies in the literature between 0% and 30% [4,[14][15][16] .…”

“…During tooth extraction surgery, the manipulation of hard and soft tissues for mucoperiosteal flap reflection and subsequent bone removal involves various factors that can affect the patient's postoperative course in terms of pain, swelling, trismus, and healing. In this context, the choice of surgical access flap can affect the postoperative outcomes of third molar surgery, including the development of numerous complications [13,22].…”