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Novel Incision Design and Flap Closure to Reduce Incidence of Alveolar Osteitis in Mandibular Third Molar Extractions
Board / Fri 9:30, 26 Jun 2015

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To demonstrate that utilizing an alternative incision and flap design along with meticulous primary closure may help reduce the incidence of alveolar osteitis (AO) in the removal of impacted mandibular third molars



Alveolar osteitis (AO), also known as “dry socket,” is reported to be a relatively common complication following impacted mandibular third molar removal surgery, where the incidence has been as high as 45%.1 Though the etiology of AO remains debatable, its cause has often been attributed to the partial or total disintegration of the blood clot in the alveolar socket, which leads to a loss of the reparative agents normally present in coagulated blood. To help mitigate this condition, studies have investigated the effects of a wide variety of proposed etiologic factors in AO such as antibiotics, chlorhexidine rinses, tobacco products, menstrual status, and the age of the patient.2-5 These studies give strong indications that the duration of AO is self-limited,6 but few investigators have taken into account the potential differences in the efficacy of alternative surgical techniques in preventing the initiation of AO. 



392 bilateral, impacted mandibular third molars were removed from 196 patients. In this randomized split-mouth study, one side was treated using a second molar mesial papilla-sparing marginal incision with distobuccal release (MPMI) accompanied by a double-layered closure, while the contralateral mandibular third molar was accessed via 1 of 3 method and closed with a single-layered closure: modified triangular flap (MTF) (Group 1), envelope flap (EF) (Group 2), or another MPMI (Group 3). All patients were evaluated at 5-7 days PO by an independent OMS.



Group 1: 65 patients, 130 impacted teeth (58 PBI, 72 FBI)


MPMI side: 0/65 AO; MTF side: 7/65 AO


Group 2: 63 patients, 126 impacted teeth (56 PBI, 70 FBI)


MPMI side: 0/63 AO; EF side: 8/63 AO


Group 3: 68 patients, 136 impacted teeth (64 PBI, 72 FBI)


MPMI double closure: 0/68 AO; MPMI single closure: 2/68 AO




Pairing MPMI with double-layered primary closure is a relatively simple surgical technique that could be utilized in impacted mandibular third molar surgery in a private clinic setting. The evidence from the present study suggests that a minimally invasive flap design, such as the MPMI, accompanied by a double-layered primary closure could be considered a viable option to reduce alveolar osteitis when removing full bony and partial bony impacted mandibular third molars.



Our flap design proved to be smaller than the traditional modified triangular and envelope flap designs, and possibly less traumatic to the gingival tissues which could expedite tissue healing. As a result, the MPMI flap could be closed with greater ease. Still, despite our evidence, it is hard to say with certainty whether the double layer of suture is necessary when obtaining primary closure. Data from Group 3 suggests that better outcomes can be achieved with the double layered primary closure, perhaps as a measure against the increased pressure placed on the site by tissue edema. Additional studies addressing whether the potential benefit lies in the incision design (plus primary closure) versus primary closure alone may yield further relevant results. 

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