Effect of 2 flap designs on postoperative pain and swelling after impacted third molar surgery Dogan Dolanmaz, DDS, PhD, a Alparslan Esen, DDS, PhD, b Kubilay Isik, DDS, PhD, c and Celal Candirli, DDS, PhD, d Konya, Antalya, and Ankara, Turkey SELCUK UNIVERSITY, ANTALYA ORAL AND DENTAL HEALTH CENTER, BASKENT UNIVERSITY, AND FATIH UNIVERSITY HOSPITAL Objective. The aim of this study was to evaluate 2 flap designs (envelope and modified triangular flap) for postoperative pain and swelling after mandibular impacted third molar surgery. Study Design. Thirty patients who had symmetric bilateral fully impacted mandibular third molars were selected. Left teeth were approached with an envelope flap, and right teeth were removed using a modified triangular flap. Postoperative pain and swelling were evaluated until the seventh day by using 2 verbal rating scales. Results. Statistical analyses showed that there were no significant differences between the 2 incision techniques regarding postoperative pain and swelling (P  .05). Conclusions. There is no significant difference between the envelope and modified triangular flap regarding postoperative pain and swelling after impacted third molar surgery. (Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:e244-e246) Surgical removal of impacted third molars is a com- monly applied oral surgery operation. It can be quite discomforting for the patients because of postoperative complications, such as bleeding, pain, swelling, tris- mus, and alveolar osteitis. 1 Many attempts have been made to reduce those complications and use of various flap designs have been investigated. 2-7 The envelope flap with a distal relieving incision to the ramus 4 and the triangular flap, which was first described by Szmyd, 6 are the most common approaches in impacted third molar surgery. Several studies have been conducted to compare the effect of those flaps on pain, swelling, trismus, and primary wound healing in the postoperative period. 2-5 Although it has been re- ported that the influence of flap design is of importance on wound healing after third molar surgery, 4 there is not an agreement. Whereas some authors reported that flap design had no clinical significance in point of postoperative pain and trismus, 2 others 4 stated that tri- angular flap is more advantageous for primary wound healing and wound dehiscence was less when a trian- gular flap was used. 4 The aim of this study was to compare the effect of envelope and triangular flap designs on postoperative pain and swelling in impacted mandibular third molar surgery. MATERIAL AND METHODS This study was approved by the ethical committee of Selcuk University, Faculty of Dentistry. Thirty patients (14 males and 16 females, aging between 17 and 31) who had symmetric bilateral full bony impacted, verti- cal or slightly mesioangular mandibular third molars were selected. The patients had no preexisting medical conditions that could influence the surgery or wound healing and there were no significant pathologies asso- ciated with the teeth. All surgeries were done by the same surgeon under local anesthesia. The left or right impacted mandibular third molar was removed in a randomized order. Second surgeries were performed 2 weeks after the first operations. Left teeth were ap- proached with an envelope flap, and right teeth were removed using a modified triangular flap. For the envelope flap, a sulcular incision from the first to the second mandibular molar and a distal reliev- ing incision along the external oblique ridge to the ramus were made (Figure 1). A lingual flap distal to the second molar was also gently elevated to avoid lingual nerve damage. The modified triangular flap was pre- pared as described by Jakse et al. 4 An incision was made from the distobuccal edge of the second molar dropping into the vestibule and a relieving incision from the ramus to the distobuccal aspect of the second molar (Figure 2). The periodontium of the second mo- lar was touched only at the distolabial edge. A lingual a Professor, Faculty of Dentistry, Department of Oral and Maxillofa- cial Surgery, Selcuk University, Konya, Turkey. b Oral Surgeon, Antalya Oral and Dental Health Center, Antalya, Turkey. c Oral Surgeon, Faculty of Dentistry, Department of Oral and Maxil- lofacial Surgery, Baskent University, Ankara, Turkey. d Oral Surgeon, Fatih University Hospital, Dental Clinic, Ankara, Turkey. Received for publication Jun 14, 2011; returned for revision Nov 9, 2011; accepted for publication Nov 28, 2011. © 2013 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter doi:10.1016/j.oooo.2011.11.030 Vol. 116 No. 4 October 2013 e244