Int. J. Oral Maxillofac. Surg.

2010; 39: 1091–1096

doi:10.1016/j.ijom.2010.07.003, available online at http://www.sciencedirect.com

Clinical Paper
Oral Surgery

Comparison of two different flap A. Sandhu, S. Sandhu, T. Kaur

Department of Oral and Maxillofacial Surgery,
SGRD Institute of Dental Sciences and
Research, Mall Mandi, G.T. Road, Amritsar,

designs in the surgical removal Punjab – 143006, India

of bilateral impacted mandibular

third molars
A. Sandhu, S. Sandhu, T. Kaur: Comparison of two different flap designs in the
surgical removal of bilateral impacted mandibular third molars. Int. J. Oral
Maxillofac. Surg. 2010; 39: 1091–1096. # 2010 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The purpose of this study was to compare the effects of flap design on the
postoperative sequelae of pain, swelling, trismus and wound dehiscence after
surgical removal of bilateral impacted mandibular third molars (M3). 20 patients
aged 20–30 years who required removal of bilateral impacted M3 were included in
the study. Maximum interincisal opening and facial measurements were recorded
preoperatively. Bayonet flap was used on one side and envelope flap on the other
side for the removal of impacted M3. The effect of flap design on pain, swelling,
trismus and wound dehiscence was evaluated postoperatively. Pain and wound
dehiscence were significantly greater in the envelope flap group compared with the
Keywords: impacted mandibular third molar;
bayonet flap group (P < 0.05). No significant difference in postoperative swelling flap design; postoperative sequelae.
and trismus was found in either group (P > 0.05). The bayonet flap was superior to
the envelope flap for postoperative pain and wound dehiscence. There was no Accepted for publication 7 July 2010
difference in postoperative swelling and trismus between the two groups. Available online 19 August 2010

The surgical removal of an impacted
mandibular third molar (M3) is a common
procedure associated with various tech-
niques and anecdotal opinion. The tech-
niques used for incision in the mucosa
and reflection of the mucoperiosteal flap
affect the intensity and frequency of post-
operative complications in M3 surgery10.
This study compares two flap designs, the
bayonet flap and the envelope flap, and
their effect on the postoperative sequelae
of pain, swelling, trismus and wound
dehiscence after surgical removal of
bilateral M3.
Materials and methods able technical difficulty, positioning and
angulation as seen on panoramic radio-
20 patients (3 male and 17 female), aged
graphs.
20–30 years (mean 25 years), were
Preoperatively, intraoral periapical,
selected for this study. Inclusion criteria
panoramic radiographs and informed
consisted of: patients with no history of
consent were obtained and the following
medical illness or medication that could
parameters were evaluated. The maxi-
influence the course of postoperative
mum interincisal mouth opening was
wound healing; and healthy dental and
recorded using Vernier calipers as the
periodontal status with no local inflamma-
distance between the upper and lower
tion or pathology at the time of tooth
central incisors. The facial measurements
removal.
were recorded by a thread, which was
An attempt was made to include only
transferred to a standardized calibrated
those bilateral M3s that were of compar-
scale. The horizontal facial measurement

0901-5027/1101091 + 06 $36.00/0 # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
[(Fig._1)TD$IG]
1092 Sandhu et al.
Fig. 1. Incision used for the envelope flap.
[(Fig._2)TD$IG]
Fig. 2. Incision used for the bayonet flap.
[(Fig._3)TD$IG]
Fig. 3. To facilitate the use of VAS by the patients legends were placed over different parts of
the scale.
was taken as the distance from the corner
of the mouth to the attachment of the
earlobe. The vertical measurement was
taken as the distance from the outer
canthus of the eye to the angle of the
mandible by palpating and marking the
inferior border1. The facial measurement
was calculated as1:
Horizontal measurement
þ vertical measurement
2 the second molar and then extended as a
A standard surgical protocol was fol-
lowed. One surgeon, experienced in the
use of both the flap designs, performed the
surgery while another carried out the eva-
luation. Prophylactic intravenous antibio-
tic, amoxycillin 1 g and clavulanic acid
200 mg (Augmentin 1.2 g; GlaxoSmithK-
line Pharmaceuticals Limited, Mumbai,
India) and tablet ibuprofen (Brufen
600 mg; Abbott Group of Companies,
India) was given 1 h before surgery.
0.2% chlorhexidine rinses were given to
all patients for 30 s before the procedure.
The local anaesthetic used was 2% lido-
caine with 1:200,000 adrenaline (Xylo-
caine1; Astra Zeneca Pharma India
Limited, Bangalore, India). A bayonet flap
was made on one side and an envelope flap
on the other. Side selection was rando-
mized by systematic allocation and both
the patients and evaluator were blinded to
the flap groups. The minimum time inter-
val between the two sides was 1 month.
The envelope flap incision started on the
ascending ramus, following the centre of
the M3 shelf to the distobuccal surface of
sulcular incision to the mesiobuccal corner
of the first molar (Fig. 1)2,14.
The bayonet flap incision started on the
ascending ramus, following the centre of
the M3 shelf to the distobuccal surface of
second molar and then extended as a
sulcular incision up to the midpoint of
the buccal sulcus of the second molar,
Table 1. Mean duration of surgery in both envelope flap and bayonet flap groups.
Total no. of patients Env
Mean duration of surgery (min)
20 37.50
Env = envelope flap.
Bnt = bayonet flap.
followed by an oblique vestibular exten-
sion (Fig. 2)2,14. After exposing the surgi-
cal site, ostectomy was carried out using a
bur technique and the tooth was sectioned
as necessary. The flap was approximated
with 3-0 mersilk (Ethicon). The duration
of surgery was noted from the time of
incision until the insertion of the last
suture (Table 1). In case of the bayonet
flap, a suture was also placed on the
vertical limb. All patients were prescribed
ibuprofen 600 mg tds for 5 days and 0.2%
chlorhexidine mouth rinses for 7 days
postoperatively. Pain, swelling, trismus
and wound dehiscence were noted on post-
operative days 1, 3, 7, 14 and 30. Pain was
evaluated by the patient on a daily basis
for 7 postoperative days or until the patient
was pain free using a visual analogue scale
(VAS) calibrated from 0 to 10,with 0 as no
pain, 1–3 as mild pain, 4–6 as moderate
pain, 7–9 as severe pain and 10 as worst
pain. To facilitate the use of VAS by the
patients, the end points were marked as
‘no pain’ and ‘worst pain’. Legends were
placed over different parts of the scale as
shown in Fig. 3.
Facial swelling (%) was calculated as1:
Postoperative measurement
 preoperative measurement
Preoperative measurement
 100
Trismus (%) was calculated as1:
Preoperative measurement
 postoperative measurement
Preoperative measurement
 100
The relationship of tooth angulation,
eruption status and duration of surgery
with postoperative sequelae (pain, swel-
ling and trismus) was evaluated on post-
operative days 1 and 7. Wound dehiscence
was noted on the seventh postoperative
day. The wound was considered to be
dehisced if there was gaping along the
entire incision line11. If found to be posi-
tive, the wound was not re-sutured and the
time taken for complete wound healing
was noted. Postoperative complications in
any of the groups were noted and treated.
Bnt
Mean duration of surgery (min)
28.85
 Comparison of two different flap designs in the surgical removal of bilateral impacted mandibular third molars 1093

Table 2. Comparison of pain scores in the envelope and bayonet flap group. (r) = +0.4655, P = 0.038 for envelope flap
No. of patients in pain category (n) group and r = 0.4695, P = 0.036 for bay-
Post op. days Type of flap x2 P onet flap group}.
None Mild Moderate Severe Application of the KP test revealed a
1 Env 1 1 4 14 11.050* <0.05 significant association between the type of
Bnt 1 6 9 4 flap and extent of pain. The association
2 Env 1 4 7 8 3.202ns >0.05 was to the level of 0.4652 (KP) on the first,
Bnt 1 6 10 3 and 0.4569 (KP) on the seventh postopera-
tive day.
3 Env 2 4 10 4 1.537ns >0.05
Bnt 2 7 9 2
Comparison of the degree of pain in the
partially erupted and full bony impaction
4 Env 3 6 8 3 4.429ns >0.05 showed no statistical difference (P > 0.05)
Bnt 4 10 6 0 on both days 1 and 7. Similar results were
5 Env 3 10 6 1 3.600ns >0.05 obtained on comparing the degree of pain
Bnt 7 10 3 0 and the angulation of M3 on days 1 and 7.
6 Env 4 14 2 0 2.620ns >0.05
Bnt 8 9 3 0 Swelling
7 Env 5 13 2 0 10.556* <0.05 Student’s unpaired t-test was applied for
Bnt 15 5 0 0
comparing the mean swelling (Table 3) in
Env = envelope flap group. both the groups. No significant difference
Bnt = bayonet flap group. was observed on any postoperative day, but
x2 computed at three degrees of freedom. using Student’s paired t-test, a highly sig-
NS – non significant.
P – probability value.
nificant (P < 0.01) decrease in swelling
*
Statistically significant. was observed from the 1st to the 3rd post-
operative day (T-statistic value = 5.770 for
envelope and 3.865 for bayonet flap), from
Statistical analysis remaining 15 patients (75%) in 7–14 days. the 3rd to the 7th postoperative day (T-
In the bayonet flap group, pain subsided in statistic value = 6.608 for envelope flap
Data were subjected to different types of
15 patients (75%) by day 7 and in the and 5.045 for bayonet flap) and the 7th to
statistical analyses such as x2, Karl Pear-
remaining five patients (25%) in 7–14 the 14th postoperative day (T-statistic
son test (KP), analysis of variance
days. This difference was statistically sig- value = 3.645 for envelope flap and 4.461
approach (ANOVA) and Student’s t-test.
nificant (P < 0.05) (Table 2 and Fig. 4). for bayonet flap) in both the groups. No
Statistical analysis was carried out by
On postoperative days 14 and 30, 100% of significant relation (P > 0.05) was found
computer-developed software on MS
patients reported no pain in both the flap between duration of surgery and post-
DOS and windows based R language.
design groups. operative swelling on postoperative days
ANOVA applied to x2 showed that, 1 and 7 for both the groups. The relation-
Results although the two attributes (type of flap ship between degree of swelling and
and degree of pain) were highly signifi- eruption status was not significant on post-
Pain cantly associated (x2 = 17.663; df = 3) operative days 1 and 7. On average, the
Statistical analysis using the x2 test with respect to the pooled data, there degree of swelling between vertically
revealed significant difference (P < 0.05) was no heterogeneity (x2 = 19.331; impacted teeth was significantly lower
in the number of patients reporting severe df = 18) among the x2 values computed (P = 0.0161) on day 1. The relation
pain in the envelope flap (n = 14; 70%) for the 7 days. between degree of swelling and angulation
and the bayonet flap (n = 4; 20%) group on A significant amount of correlation was not significant for all other categories
the first postoperative day. In the envelope between the degree of pain and duration on days 1 and 7.
flap group, pain subsided completely in of surgery was found only at the seventh
[(Fig._4)TD$IG]five patients (25%) by day 7 and in the postoperative day {correlation coefficient
Trismus
Student’s unpaired t-test was applied for
comparing the mean trismus (Table 4) in
both the groups. No significant difference
was observed on all postoperative days.
Using Student’s paired t-test, a highly sig-
nificant (P < 0.01) decrease in trismus was
observed from the 1st to 3rd postoperative
day (T-statistic value = 4.510 for envelope
and 4.043 for bayonet flap), from the 3rd to
7th postoperative day (T-statistic value =
6.973 for envelope flap and 5.335 for bay-
onet flap) and from the 7th to 14th post-
operative day (T-statistic value = 6.401 for
envelope flap and 5.878 for bayonet flap)
Fig. 4. Comparison of mean pain scores in envelope and bayonet flap groups. and from the 14th to 30th postoperative day
1094 Sandhu et al.

Table 3. Comparison of mean swelling (%) in envelope flap and bayonet flap designs at of the tooth follicle at the time of initial
different postoperative days. surgery. In the bayonet flap group, one
Post op. days Flap design N Mean (SD) (%) P value patient had swelling and bleeding from the
1 Env 20 3.767 (1.737) >0.05 extraction site on the second postoperative
Bnt 20 5.237 (3.058) day.
3 Env 20 2.514 (1.648) >0.05
Bnt 20 3.948 (2.744) Discussion
7 Env 20 0.670 (0.801) >0.05 The effect of different flap designs on
Bnt 20 1.376 (1.322) postoperative sequelae has been reported
5,10,11,13,21
14 Env 20 0.000 (0.00) >0.05 . GOOL et al.10 and SUAREZ-CUN-
21
Bnt 20 0.074 (0.320) QUEIRO et al. attributed pain following
30 Env 20 0.071 (0.309) >0.05 M3 surgery to the incision and reflection
Bnt 20 0.000 of mucoperiosteum rather than the flap
design. In this study, pain was signifi-
Env = envelope flap.
Bnt = bayonet flap. cantly greater in the envelope flap group
N = total number of patients in respective flaps. than the bayonet flap group. Contrary to
SD = standard deviation. this, KIRK et al.13 did not find any influence
P = probability value. of flap design on postoperative pain. Both
groups showed a reduction in the severity
of pain from postoperative days 1 to 7.
GARCIA et al.9 reported that the severity of
Table 4. Comparison of mean trismus (%) in the envelope flap and the bayonet flap designs at pain following M3 surgery declined
different postoperative days. between days 1 and 5.
Post op. days Flap design N Mean (SD) (%) P value In the present study, the relationship
1 Env 20 50.884 (13.995) >0.05 between eruption status of M3 and post-
Bnt 20 48.220 (13.282) operative pain was not significant, which
is supported by YUASA and SUGIURA22.
3 Env 20 41.470 (15.998) >0.05
Bnt 20 35.313 (14.591) BENEDIKTSDOTTIR et al.4 found higher pain
scores for partially erupted M3 than for
7 Env 20 30.025 (16.027) >0.05 fully impacted M3. MACGREGOR and
Bnt 20 24.303 (14.716) HART16 reported more pain after the
14 Env 20 9.256 (8.992) >0.05 removal of unerupted teeth.
Bnt 20 8.939 (13.935) The effect of angulation of M3 on post-
30 Env 20 0.345 (1.504) >0.05 operative pain has been studied. The pre-
Bnt 20 0.000 sent authors have found no significant
relationship between these two attributes,
Env = envelope flap
Bnt = bayonet flap. but GOOL et al.10 reported least pain after
N = total number of patients in respective flaps. the removal of vertically impacted M3,
SD = standard deviation. which increased sequentially in mesioan-
P = probability value. gular, distoangular, horizontal and aber-
rant M3.
(T-statistic value = 4.483 for envelope and compared with the bayonet flap group. Duration of surgery was evaluated as a
2.796 for bayonet flap) in both groups. The The average time taken for healing was variable for the degree of postoperative
decrease continued to be highly significant comparable in both the groups (Table 5). pain and a significant correlation between
(P < 0.01) from postoperative days 14 the two was found for both groups on day
to 30 in the envelope flap group and sig- 7. These results are similar to those
Postoperative complications
nificant (P < 0.05) in the bayonet flap reported by KIM et al.12 and PEDERSEN19
group. Trismus and duration of surgery In the envelope flap group, two patients who stated that increased duration of sur-
were significantly related (P = 0.038, developed infection, which manifested as gery was associated with significantly
r = 0.4649) on the first postoperative day suppuration and was treated with antibio- higher pain scores on days 1 and 7. MEN-
and highly significantly related (P = 0.004, 17
tic therapy. In one patient, a small cyst DEZ et al. reported a significant associa-
r = 0.6032) on the seventh postoperative developed postoperatively, which prob- tion between the two variables, but only
day in the envelope flap group, but the ably developed from incomplete removal on postoperative day 1. MACGREGOR and
relationship was not significant (P >
0.05) in the bayonet flap group on these
days. The relationship of trismus with state Table 5. Comparison of the incidence of wound dehiscence and time taken for wound healing in
both the flap design groups.
of eruption and with angulation was not
significant on days 1 and 7. Wound dehiscence Env (n = 20) Bnt (n = 20)
Present 07 01
Average time taken for wound healing (days) 23.86 23.00
Wound dehiscence Absent 13 19
There was significantly more wound x2 at 1 df = 05.625.
dehiscence in the envelope flap group Central x2 = 03.84 at P = 0.05 and 06.63 at P = 0.01.
 Comparison of two different flap designs in the surgical removal of bilateral impacted mandibular third molars
HART16 stated that the duration of the
surgical procedure was not related to the
severity of pain.
Postoperative swelling after removal of
M3 has been attributed to the reflection of
mucoperiosteum10,21. In this study, com-
parison of swelling between the two
groups revealed no significant difference
on all postoperative days. KIRK et al.13
found a greater degree of swelling with
the use of a modified triangular flap com-
pared with an envelope flap.
Irrespective of the flap design, swelling
decreased from its maximum reading on
the first postoperative day and in most
patients it was zero by day 14. GOOL
et al.10 reported that swelling following
M3 surgery was a function of time and
maximum swelling occurred between 24
and 48 h postoperatively.
Influence of eruption status of M3 on
the degree of postoperative swelling has
been studied15,22. The present authors
found no significant relationship between
them. This is supported by YUASA and
SUGIURA22. Contrary to this, MACGREGOR
and ADDY15 reported that partially erupted
M3 produced greater swelling than full
bony impactions. Angulation of M3 also
influences the degree of postoperative
swelling. The authors observed a signifi-
cantly lower swelling in vertical M3 com-
pared with mesioangular M3 only on day
1. GOOL et al.10 reported an increase in
postoperative swelling sequentially from
vertical, mesioangular, distoangular to
horizontal impacted M3. The degree of
postoperative swelling was not influenced
by duration of surgery in the present study,
which is supported by PEDERSEN19 and
MACGREGOR and HART16. KIM et al.12 found
a significant relationship between the two
variables only on postoperative day 1.
Irrespective of flap design, there was a
decrease in trismus over days, with the
highest value being on the first postopera-
tive day. On average, it extended beyond 1
week. BOSCH and GOOL5 found that trismus
increased, then decreased and extended
beyond 1 week.
CONARD et al.7 found severe trismus
following M3 surgery on the first post-
operative day. AZAZ et al.3 found 13% of
cases of mild–moderate trismus 10 days
postoperatively with slow regression of
trismus. CERQUEIRA et al.6 found that tris-
mus was greatest at 24 h and was still
present 15 days postoperatively following
M3 surgery. In the present study, the
severity of trismus in the envelope flap
group was not significantly different from
that in the bayonet flap group during fol-
low up. GOOL et al.10, KIRK et al13 and
SUAREZ-CUNQUEIRO et al.21 concluded that
trismus was not affected by the type of
incision.
In the present study, the correlation of
angulation and eruption status of M3 with
trismus revealed no significant relation-
ship. GOOL et al.10 found that trismus was
maximum following surgical removal of
horizontal M3 followed by distoangular,
mesioangular and vertical impacted M3.
CERQUEIRA et al.6 observed that trismus
occurred maximally following removal
of distoangular M3.
The association of duration of surgery
and postoperative trismus was significant
on both the first and seventh postoperative
days in the envelope flap group but it was
not significant in the bayonet flap group.
KIM et al.12 reported a significant associa-
tion between the two variables but only on
the first postoperative day. PEDERSEN19
reported a significant association on the
seventh postoperative day.
The association of age, gender and use
of oral contraceptives with postoperative
pain, swelling and trismus has been stu-
died4,8,18,20,22 but no such correlation was
established in the present study as the
patients were aged 20–30 years, the num-
ber of male and female patients was dis-
proportionate and none of the patients was
using oral contraceptives.
Wound dehiscence was found in 35% of
patients in the envelope flap group and 5%
of patients in the bayonet flap group. JAKSE
et al.11 also found a higher incidence of
wound dehiscence with the envelope flap.
They stated that because the envelope flap
is fixed anteriorly with intersulcular
sutures, soft tissue tension resulting in
postoperative hematoma and masticatory
movements causes a higher incidence of
wound dehiscence. SUAREZ-CUNQUEIRO
et al.21 also found that the type of incision
affected primary wound healing. In con-
clusion, it was observed that the bayonet
flap had the advantage of resulting in less
postoperative pain and wound dehiscence,
while no difference regarding swelling
and trismus was found between the two
flap design groups.
The shortcomings of the present study,
which affected the ability to generalize the
findings, were small sample size, and
unequal distribution of different angula-
tions and positions of M3. The use of
Vernier calipers has limitations because
they may forcibly open the mouth, to some
extent, leading to inaccurate readings.
Minor differences may occur in the extent
to which the patient opens their mouth.
Circumferential facial measurements are
not representative of the total swelling
because postoperative facial oedema has
three planes of measurements. Transfer-
1095
ring the contour is subject to errors in
accuracy and reproducibility. Additional
multicentric studies are required to deter-
mine the best flap design for third molar
surgery.
Funding
None.
Competing interests
None.
Ethical approval
Not required.
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Corresponding author
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E-mail: sumeet_sandhu@hotmail.com