Oral Flap Outline and Local Blood Supply After Surgical Removal of Lower Third Molar Teeth

Fifty-six systemically healthy adults presenting for surgical removal of a single fully bone-impacted mandibular wisdom tooth were assigned to one of two mucoperiosteal flap outlines by an alternating (non-random) sequence, giving twenty-eight participants per arm. Assignment was stratified by angulation according to Winter's scheme, so that each of the four angulation categories contributed seven cases to each arm.

Microvascular perfusion was quantified in perfusion units using a laser Doppler flowmeter (Perimed, Järfälla, Sweden). One recording site lay on the mid-buccal aspect of the tooth immediately anterior to the extraction site, at the crossing of its mesiodistal and occlusocervical axes, and served as an index of pulp circulation; three further sites were distributed over the adjacent buccal mucosa. Probe position was reproduced across visits by a 2 mm transparent acrylic stent carrying prepared probe housings, constructed individually on a stone model. Each site was sampled for 30 seconds.

Swelling was derived from three facial reference distances (gonion to labial commissure, tragus to labial commissure, and gonion to lateral canthus), averaged to a single value. Mouth opening was taken as the greatest interincisal distance. Every assessment was carried out immediately before surgery and repeated on the third and seventh postoperative days, sutures being removed at the final visit.

All operations were performed by one operator with a standard armamentarium under inferior alveolar, lingual and buccal block anaesthesia, using no more than two cartridges of articaine 40 mg/mL with epinephrine 1:100,000. Bone was removed and the tooth divided with a physiodispenser and steel burs under saline cooling, and the socket was closed with 3/0 silk. All participants received amoxicillin-clavulanate, paracetamol and a benzydamine-chlorhexidine mouthrinse after the procedure. Group means were compared by repeated-measures analysis of variance with Tukey HSD pairwise testing.

Inclusion criteria

• Free of systemic illness and taking no regular medication
• Aged 18 to 40 years
• One fully bone-impacted mandibular wisdom tooth for which surgical removal is indicated
• Ramus relationship of class II or III and depth position A, B or C on the Pell and Gregory scheme
• Angulation falling into one of four categories on Winter's scheme: vertical, mesioangular, horizontal or distoangular
• Neighbouring second molar intact, i.e. without extensive caries, endodontic treatment, a large filling or a crown
• Willing and able to give written consent and to attend both follow-up visits

Exclusion criteria

• Any systemic disorder, or use of medication on a continuing basis
• Tobacco use
• Previous irradiation or chemotherapy involving the head and neck
• Infection within the mouth at the time of surgery, including acute pericoronitis
• Pregnancy or suspected pregnancy
• Menstruation at the time of a scheduled measurement
• Need for more than two anaesthetic cartridges to achieve profound anaesthesia