Comma Incision for Impacted Mandibular Third Molars

Journal of Oral & Maxillofacial Surgery 60:1506-1509, 2002

Dr. Amit T. SuryawanshiDentist & Oral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.comMobile No - 9405622455

Introduction -

Surgical removal of impacted mandibular third

molars is the most frequently performed

procedure in oral and maxillofacial surgical

practices.

Trismus, pain, swelling, lingual nerve damage and

compromised periodontal status of the preceding

second molar are complications that occur too

frequently to be ignored.

Some authors call is as a sequelae while others call it as

complications of surgery.

Factors that affect Complications are Patients related and

physician related. Incision and flaps are in Surgeons hand

hence incision should be made such to avoid postoperative

complications.

Principles of incision making

It should provide sufficient operating space andoptimum exposure.

Clean incision should be made with one stroke orevenly applied pressure on the scalpel.

It should preserve integrity of as many underlyingstructures as possible.

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Incision and flap design in any surgicalprocedure is based on time-tested principles.Incision lines should not, as far as possible, lieover prospective bony defects or cut acrossmajor muscle or tendon insertions.

They should be minimally extensive. However,the distal leg of the incisions conventionallymade to access impacted mandibular thirdmolars comes close to or even cuts across theinsertion of the temporalis tendon.

It also commonly lies over the bone defectformed after removal of the tooth. This could beresponsible, at least in part, for the occurrence ofthese complications. This, therefore, is thereason enough to consider alternative incisionand flap designs. This study suggests analternative(COMMA INCISION) and demonstratesits advantages.

Design of the Distolingually Based Flapby Buccal Comma-Shaped Incision

The buccal vestibule below the precedingsecond molar is stretched down as far as ispossible with the index finger or thumb of thehand not wielding the scalpel. This stretches thebuccinator beyond its origin on the mandible.Starting from a point at the depth of thisstretched vestibular reflection posterior to thedistal aspect of the preceding second molar, theincision is made in an anterior direction.

The incision is made to a point below the second

molar, from where it smoothly curves up to

meet the gingival crest at the distobuccal line

angle of the second molar. Then incision

continues as a crevicular incision around the

distal aspect of the second molar.

Comma incision design

Materials and Methods

• One hundred subjects scheduled to undergo surgical removal of impacted mandibular third molars in the Department OMFS 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 into 2 groups of 50 subjects:

Group 1- included subjects scheduled to undergo

surgical removal of impacted mandibular third

molars by conventional modified envelope

incision.

Group 2-included subjects scheduled to undergo

Surgery Using the new incision and flap design.

A single surgeon 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 analyzed

statistically:

1. postoperative pain

2. Swelling

3. Trismus.

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 distancebetween the base of tragus and a reproducible softtissue pogonion along the skin surface.

Maximum interincisal distance was used as an index oftrismus.

The percentage difference between the postoperativeAnd preoperative measurements was calculated.

The exercise summarized the differences between thePostoperative effects of the 2 incision methods.

Discussion-

The incisions used to expose impacted Mandibular

third molars 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 flare of the ramus.

These standard incisions have been modified by

several surgeons to minimize postoperative

complications or improve surgical access.

Reference

• 1. Alling CC, Helfrick JE, Alling RD: Impacted Teeth (ed1). Philadelphia, PA, Saunders, 1993, pp 167-170

Groves and Moore (1970) described the vertical

Incision from a point distal to the distobuccal

line angle of the second molar to conserve

the distal periodontal tissues of the second molar.

References –

2. Groves BJ, Moore JR: The periodontal implications of flap design in lower third molar extraction. Dent PracDent Rec 20:297, 1970

• Guralnick (1984) used a horizontal incision only to achieve good exposure and ease of closure,

and Donlan and Trinta(1999) affirmed this technique.

References –

9. Guralnick W: Third molar surgery. Br Dent J 156:389, 1984

3. Donlon W, Trinta M: Minimal incision third molar impaction surgery. Int J Oral Maxillofac Surg 28:57, 1999 (suppl 1)

Berwick (1966) designed a tongue-shaped lingually

based flap 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.

References –

10. Berwick WA: Alternate method of flap reflection.

Br Dent J 21:295, 1966

Several authors have recognized thatperiodontal status is compromised, especiallyat the distal Aspect of the preceding secondmolar, as a result of third molar extraction.

Stephens et al (1983) found no significantdifference in the resultant periodontal status.

When different flaps were compared. However, the extent of periodontal effects was sometimes severe enough to prompt the development of special techniques to manage the resultant defects.

Reference -4. Chin Quee TA, Gosselin D, Millar EP, et al: 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 56:625, 1985

5. Stephens RJ, App GR, Foreman DW: Periodontal evaluation of two mucoperiosteal flaps used in removing impacted mandibular third molars. J Maxillofac Surg 48:719, 1983

Conclusion

• In this study none of the patients developed lingual nerve paresthesia or any other morbidity. Results of the study suggest that the new incision design “COMMA INCISION”

is preferable although it, being new techniquemay require some practice initially.

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 flap design in lower third molar extraction. Dent Prac Dent Rec 20:297, 1973

3. Donlon W, Trinta M: Minimal incision third molar impaction surgery. Int J Oral Maxillofac Surg28:57, 1999 (suppl 1)

4. Chin Quee TA, Gosselin D, Millar EP, et al: Surgical removalOf the fully impacted mandibular third molar: The influence offlap design and alveolar bone height on the periodontal statusof the second molar. J Periodontol 56:625, 1985

5. Stephens RJ, App GR, Foreman DW: Periodontal evaluationOf two mucoperiosteal flaps used in removing impactedMandibular third molars. J Maxillofac Surg 48:719, 1983

6. Van Gool AV, Ten Bosch JJ, Boering G: Clinical consequencesof complaints and complications after removal of theMandibular third molar. Int J Oral Surg 6:29, 1977

7. Schow SR: Evaluation of post-operative localized osteitis inmandibular third molar surgery. Oral Surg Oral Med OralPathol 38:352, 1974

8. Walters H: Reducing lingual nerve damage in third molarsurgery: 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 flap reflection. 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 OralRadiol Endod 90:140, 2000

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