TECHNICAL NOTES

J Oral Maxillofac Surg 60:1506-1509, 2002

Comma Incision for Impacted Mandibular Third Molars

Nageshwar, BDS, MDS*
Surgical removal of impacted mandibular third molars is the most frequently performed procedure in many oral and maxillofacial surgical practices. Therefore, reducing the incidence of complications becomes imperative. Trismus, pain, swelling, lingual nerve damage, and compromised periodontal status of the preceding second molar are complications that occur too frequently to be ignored. Incision and ap design in any surgical procedure is based on time-tested principles. Incision lines should not, as far as possible, lie over prospective bony defects or cut across major muscle or tendon insertions. They should be minimally extensive. However, the distal leg of the incisions conventionally made to access impacted mandibular third molars comes close to or even cuts across the insertion of the temporalis tendon. It also commonly lies over the bone defect formed after removal of the tooth. This could be responsible, at least in part, for the occurrence of these complications. This, therefore, is reason enough to consider alternative incision and ap designs. This study suggests an alternative and demonstrates its apparent advantages. second molar, from where it is smoothly curved up to meet the gingival crest at the distobuccal line angle of the second molar. The incision is continued as a crevicular incision around the distal aspect of the second molar (Figs 1, 2). This comma-shaped incision allows reection of a distolingually based ap adequately exposing the entire third molar area. The resulting surgical eld allows a surgeon to use the conventional buccal bone removal method or the lingual split technique with relative ease. After the process of removing the impacted tooth is complete, the ap can easily be placed back in position and secured with 1 or occasionally 2 sutures. No part of the wound lies on the resultant bone defect; nor does it approach the retromolar pad or the insertion of the temporalis muscle tendon. The incision and ap design seems best suited to cases in which the third molar is completely covered with soft tissues. In cases in which part of the impacted tooth is visible in the mouth, a small modication is made. After the aforementioned incision is completed, a second incision is made from the distobuccal point on the exposed portion of the third molar to join the rst incision approximately midway down (Fig 3). This allows excision of a triangular gingival ap. After the surgical procedure is completed, the distolingually based ap is stretched and sutured. Adequate release can be obtained by incising the periosteum distolingually if necessary.

Design of the Distolingually Based Flap by Buccal Comma-Shaped Incision

The reection of the buccal vestibule below the preceding second molar is stretched down as far as is possible with the index nger or thumb of the hand not wielding the scalpel. This stretches the buccinator beyond its origin on the mandible. Starting from a point at the depth of this stretched vestibular reection posterior to the distal aspect of the preceding second molar, the incision is made in an anterior direction. The incision is made to a point below the

Materials and Methods

One hundred subjects scheduled to undergo surgical removal of impacted mandibular third molars in the Maxillofacial Surgery Department of DAV Centenary Dental College, in Yamunanagar, India, were selected serially for the study. Age, gender, race, and socioeconomic status were not considered, but patients needed to be in fair health otherwise. Patients were divided at random into 2 groups of 50 subjects: group 1 included subjects scheduled to undergo surgical removal of impacted mandibular third molars by conventional modied envelope incision, and group 2 included subjects scheduled to undergo surgery using the new incision and ap design. A single surgeon,

*Assistant Professor, Department of Oral & Maxillofacial Surgery, DAV Centenary Dental College, Yamunanagar, Haryana, India. Address correspondence and reprint requests to Dr Nageshwar: 420-L, Model Town, Yamunanagar, Haryana, PIN: 135001 India; e-mail: oromaxface@vsnl.net
2002 American Association of Oral and Maxillofacial Surgeons

0278-2391/02/6012-0024$35.00/0 doi:10.1053/joms.2002.36152

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FIGURE 3. Modied incision design. Illustration shows buccal and occlusal aspects. FIGURE 1. Comma incision design.

using local anesthesia and conventional methods of bone removal and tooth sectioning as needed, performed the surgery for all subjects. Analgesics and antibiotics were prescribed as indicated. Chlorhexidine mouth rinses were prescribed for all patients until suture removal. The following clinical parameters were noted and analyzed statistically: postoperative pain, swelling, and trismus. The position of the coronal limit of epithelial attachment on all aspects of the preceding second molar in relation to the cementoenamel junction was measured using a blunt, curved explorer and a mouth mirror. This measure was used because measurements of pocket depth (as performed in previous studies) was deemed irrelevant. Even gingival recession can cause problems similar to those caused by formation of a pocket. Pain was estimated subjectively by asking the patient to rate the nociceptive experience on a visual analog scale of 0 to 10. Swelling was assessed by measuring the distance between the base of tragus and a reproducible soft tissue pogonion along the skin surface. The percentage difference between the postoperative and preoperative measurements was calculated. Maximum interincisal distance was used as the index of trismus. The exercise summarized the differences between the postoperative effects of the 2 incision methods.

Results
Tables 1 to 6 display the results of the study. Statistical analysis was done using a Microsoft Excel XP package (Redmond, WA). Two-way analysis of variance (ANOVA) was performed to yield F-values for pain, swelling, and trismus data. A 2 test was performed to analyze data on periodontal sequelae. The new incision and ap design were seen as superior overall.

Discussion
The incisions used to expose impacted mandibular third molars that have been described in textbooks and various studies1-5 can be broadly grouped under triangular (vertical) and envelope types. Regardless of variations in the anterior end of the incisions, all extend posteriorly from the distal aspect of the preceding second molar toward the ascending ramus. The length and angulation of this extension depend on the position of the third molar and the proximity and lateral are of the ramus.1 These standard incisions have been modied by several surgeons to minimize postoperative complications6-8 or improve surgical access.1 Groves and Moore2 began the vertical incision from a point distal to the distobuccal gingival line angle of the second molar to conserve the distal periodontal tissues of the second molar. Guralnick9 used a horizontal incision only to achieve good exposure and ease of closure, and Donlan and Trinta3 reafrmed this technique. Berwick10 designed a tongue-shaped lingually based ap using an incision line that did not lie over the bony defect created by the removal of the impacted tooth. This incision, however, crossed the posterior end of the retromolar pad on its distal stroke. Several authors have recognized that periodontal status is compromised, especially at the distal aspect of the preceding second molar, as a result of third molar extraction.4,5 Stephens et al5 found no signicant difference in the resultant periodontal status

FIGURE 2. Comma incision design. Illustration shows buccal and occlusal aspects.

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COMMA INCISION FOR IMPACTED THIRD MOLARS

Table 1. AGE AND GENDER DISTRIBUTION OF PATIENTS

Group Group 1 Group 2

Patients (n) 50 50

Male (n) 26 29

Female (n) 24 21

Mean Age (yr) 26.12 25.20

SD (yr) 4.8766 3.9795

Range (yr) 19 to 35 19 to 33

Abbreviation: SD, standard deviation.

Table 2. MEAN PAIN SCORES

Group Group 1 Group 2

Preoperative 0 0

Day 1 4.04 2.86

Day 3 1.68 0.76

Day 7 0.74 0.22

Day 14 0.22 0.06

NOTE. Visual analog scale of 0 to 10 was used.

Table 3. SWELLING

Group Group 1 Group 2

Preoperative 0 0

Day 1 21.44 8.82

Day 3 10.95 2.98

Day 7 3.26 0.88

Day 14 0.96 0.35

NOTE. Swelling is dened as the percentage ratio of increase in linear measurement between tragal base and soft tissue pogonion. It was calculated by the formula: (Postoperative measurement Preoperative measurement) 100 Preoperative measurement

Table 4. TRISMUS INDEX

Group Group 1 Group 2

Preoperative (mm) 39.94 39.92

Day 1 (mm) 27.2 35.02

Day 3 (mm) 34.46 38.22

Day 7 (mm) 38.18 39.38

Day 14 (mm) 38.54 39.74

NOTE. Numbers show maximal interincisal opening.

Table 5. PERIODONTAL SEQUELAE AS THE POSITION OF EPITHELIAL ATTACHMENT ON DISTAL ASPECT OF SECOND MOLAR

Group Group 1 Group 2

Total Patients (n) 50 50

Below Cementoenamel Junction at 28 Days Postop* (n/%) 9/18 2/4

Below Cementoenamel Junction at 56 Days Postop* (n/%) 13/26 3/6

*The number of patients with epithelial attachment below cementoenamel junction at the given time point is shown.

Table 6. STATISTICAL ANALYSIS

Parameter Pain (up to 7 days) Swelling Trismus Periodontal sequelae (28 days) Periodontal sequelae (56 days)

Test ANOVA ANOVA ANOVA Chi2 Chi2

Calculated Value of Statistic F 20.701 F 4.643 F 5.001 2 5.01 2 7.44

Table Value of Statistic F 18.513 F 10.128 F 10.128 2 3.84 2 6.63

Degrees of Freedom 1,2 1,3 1,3 1 1

Inference P .05 P .05 P .05 P .05 P .01

Abbreviation: ANOVA, analysis of variance.

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1509 tients who had bilateral impacted third molars extracted using the new incision on one side and the conventional incision on the other side for comparison. Continuous use of the new incision in over 2,000 patients (not included in the study) has led to it becoming a habit. Standard incisions now seem too extensive for the surgical procedure. In fact, a similarly oriented incision may be considered for the surgical extraction of maxillary third molars. None of the patients in the study developed lingual nerve paresthesia or any other morbidity. The results of this study suggest that the new incision design is preferable, although it may require some practice initially.

when different access aps were compared. However, the extent of periodontal effects was sometimes severe enough to prompt the development of special techniques to manage the resultant defects. For example, Motamedi11 described a lingual gingival nger ap for closing these defects. However, despite sincere attempts, the previous incisions did not fulll the necessary conditions for the ap design, namely that incisions should not lie over bony defects or cut across muscle or tendon insertions. A ap that achieved these conditions could be made by using a distolingually based ap created by an incision made buccal to the distal aspect of the second molar. The ap does not have a distal extension toward the anterior border of the ramus. This technique resulted in an unbroken ap that, on closure, completely covered the bone defect created by the extraction and whose borders lay on sound bone. All the structures in the retromolar pad, the lower end of temporalis tendon, and pterygomandibular raphe bres remained undamaged because no part of the incision extends there. In patients in whom part of the third molar was exposed, the incision was modied as previously described. No sequelae were observed. However, in some cases a short horizontal distal extension of the closed incision line did appear. This required a single suture to ensure closure. In cases in which the soft tissue cover of an impacted tooth was injured, ulcerated, or thin due to impingement of an occluding tooth, a short horizontal incision or excision of a portion of this tissue was warranted. The resultant modication was similar to that performed when the tooth was partially exposed. Although the surgical wound appeared unconventional, it was aesthetic, without a distal extension. A general preference for the new incision design was shown both by surgeons who operated and pa-

References
1. Alling CC, Helfrick JE, Alling RD: Impacted Teeth (ed 1). Philadelphia, PA, Saunders, 1993, pp 167-170 2. Groves BJ, Moore JR: The periodontal implications of ap design in lower third molar extraction. Dent Prac Dent Rec 20:297, 1970 3. Donlon W, Trinta M: Minimal incision third molar impaction surgery. Int J Oral Maxillofac Surg 28:57, 1999 (suppl 1) 4. Chin Quee TA, Gosselin D, Millar EP, et al: Surgical removal of the fully impacted mandibular third molar: The inuence of ap design and alveolar bone height on the periodontal status of the second molar. J Periodontol 56:625, 1985 5. Stephens RJ, App GR, Foreman DW: Periodontal evaluation of two mucoperiosteal aps used in removing impacted mandibular third molars. J Maxillofac Surg 48:719, 1983 6. Van Gool AV, Ten Bosch JJ, Boering G: Clinical consequences of complaints and complications after removal of the mandibular third molar. Int J Oral Surg 6:29, 1977 7. Schow SR: Evaluation of post-operative localized osteitis in mandibular third molar surgery. Oral Surg Oral Med Oral Pathol 38:352, 1974 8. Walters H: Reducing lingual nerve damage in third molar surgery: A clinical audit of 1350 cases. Br Dent J 178:140, 1995 9. Guralnick W: Third molar surgery. Br Dent J 156:389, 1984 10. Berwick WA: Alternate method of ap reection. Br Dent J 21:295, 1966 11. Motamedi MHK: A technique to manage gingival complications of third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90:140, 2000