The envelope flap with a distal relieving incision to the

mandibular ramus is the most common approach for

lower third molar surgery. This flap technique has often
been described extensively in the relevant literature and
is certainly favored by a majority of the oral surgery
centers.
1-7
Usually, a primary wound closure is
performed, both to diminish the patients discomfort
and to simplify postsurgical treatment.
There are no specific data available from the litera-
ture, but when using the envelope flap, it must be
remembered that wound dehiscences at the distofacial
edge of the adjacent second molar are very frequent in
the first phase of wound healing.
8
Such dehiscences
may heal secondarily without any additional discom-
fort or consequences. Nevertheless, they potentially
extend the time of postsurgical treatment. From the
patients point of view, they could cause a longer
period of discomfort and continuous pain. Furthermore,
they may favor the development of alveolar osteitis,
and, in consequence, they could be the reason for a loss
of attachment distal to the adjacent second molar (Fig
1, A and B).
With the aim of avoiding potential periodontal
complications to the adjacent second molar, several
different flap techniques were developed, compared,
and discussed.
3-5,9-15
Nevertheless, all published
studies are restricted to long-term results of the peri-
odontal tissue around the second and the first molar.
None of the studies evaluates primary wound healing
after third molar surgery.
It was the aim of this prospective study to evaluate
the influence of flap design on the course of primary
wound healing. We examined whether a modification
of a vestibular triangular flap, as first described by
Szmyd,
2
would reduce the incidence of dehiscences. In
addition, the importance of flap design for wound
healing was compared with factors such as nicotine
habits, the patients age, the duration of surgery, and
the level of impaction.
Primary wound healing after lower third molar surgery: Evaluation
of 2 different flap designs
Norbert Jakse, MD, DDS,
a
Vedat Bankaoglu, DDS,
a
Gernot Wimmer, MD,
b
Antranik Eskici, MD,
DDS,
a
and Christof Pertl, MD, DDS,
a
Graz, Austria
KARL-FRANZENS UNIVERSITY GRAZ
Objectives. Wound dehiscences after lower third molar surgery potentially extend the time of postsurgical treatment and may
cause long-lasting pain. It was the aim of this prospective study to evaluate the primary wound healing of 2 different flap
designs.
Methods. Sixty completely covered lower third molars were removed. In 30 cases, the classic envelope flap with a sulcular
incision from the first to the second molar and a distal relieving incision to the mandibular ramus was used, whereas the other
30 third molars were extracted after preparation of a modified triangular flap first similarly described by Szmyd. Wound
healing was controlled on the first postoperative day, as well as 1 and 2 weeks after surgery.
Results. The overall result was a total of 33% wound dehiscence. In the envelope-flap group, wound dehiscences developed
in 57% of the cases. This represents a relative risk ratio of 5.67, with a 95% CI from 1.852 to 12.336. With the modified trian-
gular-flap technique, only 10% of the wounds gaped during wound healing.
Conclusion. This study confirms evidence that the flap design in lower third molar surgery considerably influences primary
wound healing. The modified triangular flap is significantly less conducive to the development of wound dehiscence.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:7-12)
a
The Department for Oral Surgery and Radiology, Dental School,
Karl-Franzens University Graz.
b
Department for Prosthetics and Periodontology, Dental School,
Karl-Franzens University Graz.
Received for publication Apr 12, 2001; returned for revision Jun 8,
2001; accepted for publication Aug 13, 2001.
Copyright 2002 by Mosby, Inc.
1079-2104/2002/$35.00 + 0 7/12/119519
doi:10.1067/moe.2002.119519
7
ORAL AND MAXILLOFACIAL SURGERY Editor: Larry J. Peterson
ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY
Vol. 93 No. 1 January 2002
MATERIAL AND METHODS
A total of 60 completely covered lower third molars
from 60 patients were removed by 3 experienced oral
surgeons. Patients were between 15 and 60 years old,
with the average age being 25 years. There were 32
female and 28 male patients.
The medical history revealed no sickness or medica-
tion that would influence the course of wound healing
after oral surgery. The number of smokers among those
60 patients was 9, with 5 of them smoking occasionally
(ie, up to 10 cigarettes a day), 3 patients smoking up to
20 cigarettes a day, and 1 patient more than 20 a day.
Among the relevant criteria for the study were a healthy
dental and periodontal state (CPITN 0-1). All patients
were referred for wisdom teeth removal. The referring
doctor gave the indication in each case, with all of the
cases being prophylactic or concerning orthodontics.
There was no case of local inflammation or pathology.
Before the procedure, all patients were informed
about the operation, the recommended postsurgical
behavior, and possible complications. All patients
agreed to the operation, indicated by their signature (in
case of minors, the parents gave the signed consent).
Out of 60 completely covered lower third molars, 38
were totally osseously impacted. There were 33 left
lower wisdom teeth and 27 right lower wisdom teeth.
The surgery was carried out with the patients under
local anesthesia. The anesthetic was Articaine in a 4%
solution with additional epinephrine in a concentration
of 1:100 000 (Ultracaine-Dental forte; Hchst Marion
Roussel, Frankfurt/Main, Germany).
In 30 cases, which were chosen at random, the enve-
lope flap with a sulcular incision from the first to the
second molar and a distal relieving incision to the
mandibular ramus were used (technique I), whereas the
other 30 wisdom teeth were extracted after a modified
triangular flap design first described by Szmyd
2
(tech-
nique II).
Flap designs
Technique I: envelope flap with a sulcular incision
from the first to the second molar and a distal
relieving incision to the mandibular ramus. The inci-
sion was done from the mandibular ramus to the disto-
buccal crown edge of the second molar, cutting in one
move through all layers of the soft tissue to the bone.
From there, a sulcular buccal incision was made to the
middle of the first molar (Fig 2). The mucoperiosteal
flap was elevated entirely down to the buccal surface of
the mandible. Distal to the second molar a periosteal
elevator was used to prepare subperiosteally to the
lingual area, to protect the lingual nerve.
Technique IImodified triangular flap. The first
part of the incision was similar to technique I. The inci-
sion was done from the mandibular ramus to the disto-
buccal crown edge of the second molar, continued by a
perpendicular incision line, obliquely into the
mandibular vestibulum, with a length of about 10 mm.
In contrast to the incision line originally described by
Szmyd,
2
the modified incision extends over the
mucogingival borderline. The periodontium of the
second molar was only touched at the distofacial edge
(Fig 3). By preparing the buccal mucoperiosteum, a
triangular flap was formed (vestibular triangular flap).
The lingual preparation was the same as for technique I.
After mobilizing the mucoperiosteal flap and uncov-
ering the surgical site, the proceedings were always the
8 Jakse et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
January 2002
Fig 1. A, B, Illustration and clinical view of a dehiscence after
third molar surgery using the envelope flap technique.
A
B
same, regardless of the flap design. The crown, which
was partially or even completely osseously covered,
was uncovered from occlusal down to the equator with
rotating instruments of diminishing size. In case of
tilted teeth, a fissure bur was used to separate the tooth.
After extraction, potential rests of the dental follicle
were removed. The alveolus was filled with a gelatin
sponge (Spongostan; Johnson & Johnson Medical
Limited, Gargrave, Skipton, United Kingdom). In all
cases a primary wound closure was carried out with
atraumatic sutures (Supramid 3-0; B. Braun Surgical
GmbH, Melsungen, Germany).
The envelope flap was closed with 2 or 3 single-button
sutures distal to the second molar, paying special atten-
tion to an exact repositioning in the area of the gingival
margin. In addition, the flap was adapted with inter-
dental sutures between the first and the second molar.
For the triangular flap, the same suturing technique was
used distally, whereas the perpendicular incision was only
adapted with a single coronally placed suture. Again,
exact reposition of the gingival margin in the area of the
second molar was the aim. The loose adaption in the
apical portion allows easy relief of a hematoma (Fig 4).
After the operation, all patients were treated antibiot-
ically and antiphlogistically as follows: for 4 days with
cephalosporin (Ospexin, 1000 mg 3 1; Biochemie,
Vienna, Austria), and for 2 days with diclofenac
(Voltaren, 50 mg 3 1; Novartis Pharma, Vienna,
Austria).
All patients were seen on days 1, 7, and 14 after
surgery. On the first postoperative day, all wounds were
relieved distally by slight spreading and compression
in case of envelope flaps, whereas triangular flaps were
relieved in the area of the vestibular incision. Visual
control and cautious exploration with a periodontal
probe were used to evaluate a possible dehiscence. In
this study, every gaping along the entire incision line
was defined as a dehiscence. In this respect, particular
attention was paid to the gingival margin at the distal
rim of the second molar. This evaluation, as well as the
preoperative periodontal diagnosis, was performed by
one periodontist who was not involved in the surgical
procedure. Sutures were removed after 1 week.
Only patients with good oral hygiene and no signs of
plaque-induced inflammation before and after surgery
were included in the study.
The subsequent statistical evaluation was performed
with the relative risk ratio of cohort or prospective
studies.
16
It was composed of the factors that may
influence wound healing (ie, flap design, the patients
age, duration of the surgery, level of retention, and
nicotine habits). These aspects were defined in terms of
their relationship with the occurrence of dehiscences.
The relative risk of a disturbance in the healing process
(ie, wound dehiscences) was determined for each of the
aforementioned factors.
RESULTS
Out of the 60 surgical sites, 20 dehiscences (33%)
were found. Although on the first day after surgery, all
wounds were well closed without any sign of a begin-
ning rupture, after 1 week, 20 cases showed gaping
wound margins distobuccal to the second molar. No
additional dehiscence developed between day 7 and
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Jakse et al 9
Volume 93, Number 1
Fig 2. Illustration of the incision line used for the envelope
flap in lower third molar surgerydistal relieving incision to
the mandibular ramus and sulcular incision from the second
molar to the first molar.
Fig 3. Illustration of the incision line used for the triangular
flap in lower third molar surgerywith a distal relieving inci-
sion to the mandibular ramus and a perpendicular anterior
incision into the mandibular vestibulum.
day 14 postsurgery. Neither the size nor the shape of
the present dehiscences changed during this time.
The age of the patient did not influence the incidence
of dehiscences. In the group of patients up to the age of
25 years (n = 41), a dehiscence occurred in 34% of the
cases, whereas for those older than 25 years (n = 19),
the percentage was 32%. The relative risk ratio for a
dehiscence was 0.93 (95% CI from 0.421 to 2.031) in
the group of older patients.
The duration of the surgery was between 10 and 50
minutes. When the surgery lasted less than 25 minutes
(n = 42), dehiscences occurred in 29% of the cases
during wound healing. When the duration of the
surgery exceeded 25 minutes (n = 18), there was a
dehiscence percentage of 44%. This represents a rela-
tive risk ratio of 1.56 (95% confidence interval from
0.769 to 3.145) for a dehiscence in the group with the
longer surgery duration compared with the ratio of the
group with a surgery shorter than 25 minutes.
Among the 38 osseous impacted teeth, 10 cases
(26%) of postoperative dehiscences were found. The
22 molars that were only partially covered by bone in
10 cases (46%) showed dehiscences. The relative risk
ratio of a rupture of the primary wound closure for this
group was 1.73 (95% CI from 0.856 to 3.485).
Without considering the extent of the individual
nicotine habit, there was a 40% dehiscence rate found
in the group of smokers. The relative risk ratio for the
smoking patients to develop a dehiscence was 1.25
(95% CI from 0.529 to 2.954).
Duration of surgery, level of impaction, and smoking
habit did influence the primary wound healing, but
these factors did not attain statistical significance.
In 17 (57%) of the 30 surgeries performed with the
envelope-flap technique, a dehiscence was found. The
30 cases done with the triangular-flap technique, a
dehiscence developed in only 3 cases (10%). This
result represents a relative risk ratio of 5.67 (95%
confidence interval from 1.852 to 12.336) for the enve-
lope-flap design, which is of high statistical signifi-
cance (Fig 5).
DISCUSSION
An envelope flap with a sulcular incision from the
first to the second molar and a distal relieving incision
to the mandibular ramus is a widely used technique for
lower third molar surgery.
3-7
There are definite advan-
tages of this flap design. The surgical site is generously
uncovered, ensuring a good overview during surgery.
The sulcular incision can be prolonged mesially any
time, in case cystic lesions should extend mesially or if
additional endosurgery of the adjacent molars is
requested. As a consequence of the extensively
prepared mucoperiosteal flap, the osseous defect can
always be safely covered after the removal of the
molar. Moreover, a large flap with a broad base guar-
antees good vascularity up to the wound margins.
In the literature, possible disadvantages of this
method are discussed. Every preparation of a mucoper-
iosteal flap leads to a growing activity of osteoclasts in
the area of the alveolar process, inducing loss of alve-
olar bone.
17
Every sulcular incision is an intervention
to the periodontal ligament and may lead to periodontal
damage. Alternatively, paragingival
13
and vestibular
tongue-shaped
11
flap designs, which aim at sparing the
periodontal ligament of the adjacent molar, have been
described. Especially in cases of thin keratinized
gingiva in the area of the second molar, the conven-
tional flap design may lead to a total loss of the
attached gingiva in this area after the operation. This,
again, can cause pocket formation and loss of attach-
ment in the area of the second molar.
18
In addition, the frequent occurrence of dehiscences
distofacial to the second molar seems to be another
disadvantage of the envelope-flap design.
8
To our
knowledge, such primary wound healing disorders
have not been studiedparticularly in lower third
molar surgery.
These gapings are usually located at the distobuccal
gingival rim of the adjacent second molar, where the
distal relieving incision leads into the sulcular incision.
In this area, soft tissue tensions resulting from postop-
erative hematoma and masticatory movements may
induce a rupture of the wound margins during the first
few postoperative days. This is particularly true for the
envelope flap because it is fixed anteriorly with inter-
sulcular sutures. Such dehiscences can take place
inconspicuously and unnoticed by the patient and may
heal secondarily. Thus, secondary wound healing can
cause wedge-shaped defects of the gingiva distal to the
second molar, or it can favor a loss of attachment distal
10 Jakse et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
January 2002
Fig 4. The triangular flap allows easy relief of the hematoma
during the first postoperative day.
to the second molar. This periodontal complication
after lower third molar surgery has been studied by
several authors.
1,3-5
A dehiscence does make hygiene more difficult and
requires intense follow-up treatment (ie, frequent irri-
gation and possible local medication). There is also a
chance for longer-lasting discomfort caused by hyper-
sensitivity in the area of the distally exposed root
surface of the second molar. Alveolar osteitis and soft
tissue abscess are more severe complications that are
possible.
The present study has clearly shown that the flap
design considerably influences primary wound healing
in lower third molar surgery. When the conventional
sulcular flap design is used, 56% of the patients
develop a disorder in primary wound healing, although
a primary wound closure was the aim. With the modi-
fication of a flap design, primary wound healing can be
significantly improved. With this flap design, dehis-
cences occurred in only 10% of our cases. We suggest
that this was because of a tension decrease in the area
of the distal wound closure compared with the situation
of the envelope flap technique. The vestibular trian-
gular flap can be easily moved to lingual, ensuring a
wound closure that is almost tension-free. The mesial
vestibular relieving incision, which is only adapted
coronally by a single suture, allows depletion of the
postoperative hematoma during masticatory move-
ments. On the first postoperative day, a present
hematoma is easy to relieve by spreading and compres-
sion. In this respect, we can see the advantage that the
release area has bone support.
This study has shown that the conventional sulcular flap
design has a nearly 6-times-higher risk of rupture of the
primary wound closure than the modified triangular flap.
The patients age has been described as one of the
factors influencing primary wound healing. Wound
healing up to age 25 years was supposed to be more
uncomplicated.
5
In our group of patients, primary
wound healing was not influenced by age.
Molars with complete bone coverage do not cause
bone loss distal to the adjacent molar, nor do they exert
a traumatic stimulus on the oral mucosain contrast
with impacted teeth, which lie directly underneath the
mucosa. In these cases, the covering mucosa often
displays chronic inflammation, with the impacted
molar having already caused loss of attachment of the
adjacent molar at the time of its removal. This seems to
explain the higher rate of dehiscences in the group of
not completely osseous impacted teeth.
It is obvious that longer-lasting and, thus, more
complicated surgery causes wound healing disorders,
but in our study the influence of the duration of the
surgery seemed to be less important than the flap design.
The group of smokers in this study is too small to
have statistical relevance. Nevertheless, it can be said
that the percentage of wound healing disorders was
higher in the smoking group, which corresponds to
results in the literature.
19
In conclusion, it can be said that the flap design
considerably influences primary wound healing after
lower third molar surgery. The modified triangular flap
design, when compared with the conventional sulcular
incision, definitely makes primary wound healing
easier. Factors such as the degree of impaction, the
duration of the surgery, and nicotine habits clearly have
less influence on primary wound healing.
REFERENCES
1. Ash MM, Costich ER, Hayward JR. A study of periodontal
hazards of third molars. Periodontol 1962;33:209-19.
2. Szmyd L. Impacted teeth. Dent Clin North Am 1971;15:299-
318.
3. Stephens RJ, App GR, Foreman DW. Periodontal evaluation of
two mucoperiosteal flaps used in removing impacted mandibular
third molars. J Oral Maxillofac Surg 1983;41:719-24.
4. Quee TA, Gosselin D, Millar EP, Stamm JW. Surgical removal
of the fully impacted mandibular third molar. The influence of
flap design and alveolar bone height on the periodontal status of
the second molar. J Periodontol 1985;56:625-30.
5. Kugelberg CF, Ahlstrm U, Ericson S, Hugoson A, Kvint S.
Periodontal healing after impacted lower third molar surgery in
adolescents and adults. A prospective study. Int J Oral
Maxillofac Surg 1991;20:18-24.
6. Sands T, Pynn BR, Nenniger S. Third molar surgery: current
concepts and controversies. Part 2. Oral Health 1993;83:19, 21-
2, 27-30.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Jakse et al 11
Volume 93, Number 1
Fig 5. The relative risk ratio and 95% CI of dehiscences for
factors that might influence wound healing (ie, flap design,
level of retention, duration of the surgery, nicotine habits, and
patient age). Compared with the triangular flap, the envelope
flap has a relative risk of a dehiscence during primary wound
healing of 5.67, with a 95% CI from 1.852 to 12.336. This
result is highly statistically significant, whereas the factor
levels of retention, duration, and smoking habits seemed to
influence primary wound healingbut without statistical
significance.
7. Pajarola GF, Jaquiery C, Lambrecht JT, Sailer HF. Die
Entfernung unterer retinierter Weisheitszhne (II) Schweiz
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8. Klatil L. Komplikationen bei der Entfernung von
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9. Thoma KH. The management of malposed inferior third molars.
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10. Szmyd L, Hester WR. Crevicular depth of the second molar in
impacted third molar surgery. J Oral Surg Anesth Hosp Dent
Serv 1963;21:185-8.
11. Berwick WA. Alternative method of flap reflection. Br Dent J
1966;121:295-6.
12. Groves BJ, Moore JR. The periodontal implications of flap
design in lower third molar extractions. Dent Pract Dent Rec
1970;20:297-304.
13. Magnus WW, Castner DV, Hiatt WR. An alternative method of
flap reflection of mandibular third molars. Mil Med
1972;137:232-3.
14. Woolf RH, Malmquist JP, Wright WH. Third molar extractions:
periodontal implications of two flap designs. Gen Dent
1978;26:52-6.
15. Papassotiriou A. Parodontalbefunde nach Zahnfleischrandschnitt
zur Weisheitszahnentfernung. Zahnrztliche Praxis 1991;6:206-
11.
16. Norusis MJ. SPSS for Windows: Base system users guide,
Release 5.0. Chicago: SPSS Inc; 1992. p. 211.
17. Tavtigian R. The height of facial radicular alveolar crest
following apically positioned flap operations. J Periodontol
1970;41:412-8.
18. Motamedi MH. A technique to manage gingival complications
of third molar surgery. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2000;90:140-3.
19. Silverstein P. Smoking and wound healing. Am J Med
1992;93(1A):S22-S24.
Reprint requests:
Norbert Jakse, MD, DDS
Department for Oral Surgery and Radiology
Dental School, Karl-Franzens University Graz
Auenbruggerplatz 12, 8036 Graz, Austria
norbert.jakse@uni-graz.at
12 Jakse et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
January 2002
CALL FOR REVIEW ARTICLES
The January 1993 issue of Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,
and Endodontics contained an Editorial by the Journals Editor in Chief, Larry J. Peterson, that
called for a Review Article to appear in each issue.
These Review Articles should be designed to review the current status of matters that are
important to the practitioner. These articles should contain current developments, changing
trends, as well as reaffirmation of current techniques and policies.
Please consider submitting your article to appear as a Review Article. Information for
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We look forward to hearing from you.