The influence of flap design on patients' experiencing pain, swelling, and trismus after mandibular third molar surgery: a scoping systematic review

Abstract Third molar removal surgery usually comes accompanied by postoperative discomfort, which could be influenced by the surgical approach chosen. This scoping systematic review aimed at compiling the available evidence focused on the influence of flap design, including envelope flap (EF), triangular flap (TF), and modified triangular flap (MTF), on postoperative pain, swelling, and trismus, as primary outcome measures, and any result mentioning healing promotion or delay, as secondary outcome measure, after mandibular third molar extraction surgery. An electronic search, complemented by a manual search, of articles published from 1999 to 2020 was conducted in the Medline (PubMed), EMBASE and Web of Science databases including human randomized controlled trials, prospective, and retrospective studies with at least 15 patients. The risk of bias of the included studies was assessed either with the Cochrane's Risk of Bias tool or with the Newcastle-Ottawa scale. Every step of the review was performed independently and in duplicate. The initial electronic search recovered 2102 articles. After applying the inclusion criteria, 12 articles were included. For patient's perceived postoperative pain, TF and MTF frequently reported better results than EF. For swelling, the literature is divided, despite a trend favoring EF. For trismus, data showed that its occurrence is mostly associated with the duration of the surgery rather than with the chosen flap. For healing, the limited data is inconclusive. Finally, randomized studies showed a high risk of bias, whereas nonrandomized studies were mostly of good quality and low risk of bias. Although there was no clear consensus regarding the influence of different flap designs for third mandibular molar extraction on postoperative clinical morbidities; the surgeon's experience, estimated surgical difficulty, molar position and orientation, and surg ery duration should be considered when choosing among the different flap designs.

Implant Placement in Fresh Extraction Socket with Simultaneous Bone Regeneration.

The aim of this manuscript is to describe a case of immediate implant placement with simultaneous bone regeneration. A brief review of the literature and the biological rationale is also described in the manuscript. Presentation of Case: A 42 years old woman Affected by a crown-root fracture referred to our Department. After careful extraction, an implant was inserted immediately as well as a simultaneous bone grafting to reduce post-extractional socket-shrinking. After osseointegration (4 months) the implant was loaded and the clinical and radiographic follow-up is presented. A Cone beam computed tomography was also made to show the integrity and the preservation of buccal bone plate one year after loading. Discussion: A traumatic extraction, three-dimensionally positioning of the fixture, the simultaneous bone graft insertion and a tension free wound closure has allowed us to achieve healing without complications and a good clinical result. Conclusion: The use of bone regeneration around immediate implant can help us to obtain good functional and esthetic outcomes.