Evaluating Envelope vs. Triangular Flap Techniques in Impacted Mandibular Wisdom Tooth Extraction (A Comparative Study)

Evaluating Envelope vs. Triangular Flap Techniques in Impacted Mandibular Wisdom Tooth Extraction (A Comparative Study) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating Envelope vs. Triangular Flap Techniques in Impacted Mandibular Wisdom Tooth Extraction (A Comparative Study) Aliaa Ahmed Habib, Ahmed Elsayed Abdelghany Shararah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7160894/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Surgical removal of impacted third molars is a commonly applied oral surgery operation. It can be quite discomforting for the patients because of postoperative complications, such as bleeding, pain, swelling, trismus, wound dehiscence, and alveolar osteitis. Many attempts have been made to reduce those complications, and the use of various flap designs have been investigated. Aim of the study: to evaluate the effect of flap designs, Envelope Flap (EF) and Modified Triangular Flap (MTF) on postoperative pain and soft tissue healing after mandibular wisdom tooth extraction. Materials and Methods Twenty patients with unilateral impacted third molars completed the study with an envelope flap and a modified triangular flap design for third molar removal. Clinical parameters, including pain and soft tissue healing, were assessed postoperatively. Results The VAS percentage decrease (%) was statistically significantly better (more decrease) in the Envelope Flap group than in the Modified triangular flap group. The Healing Index was statistically significantly higher in the Modified Triangular Flap Group compared with the Envelope Flap Group postoperatively. Conclusion The study revealed that the modified triangular flap had higher postoperative healing compared with the envelope flap, although the envelope flap had lower postoperative pain scores. Envelope flap flap design impacted teeth modified triangular flap third molar surgery Figures Figure 1 Figure 2 Figure 3 1. INTRODUCTION Impacted teeth refer to a particular anatomical condition in which a tooth fails to erupt within the expected time of physiological development. ( 1 ) In fact, 33% of the population has at least one impacted third molar, which frequently leads to food retention, caries, pain, edema, and second molar root resorption and, consequently, its surgical extraction. Despite the frequent surgical removal of third molars, the occurrence of accompanying postoperative morbidities is relatively common. ( 2 ) The invasive manipulation of soft and hard tissues during tooth extraction involves different factors that can influence the patient’s postoperative course in terms of pain, swelling, trismus, and healing. ( 3 ) Among the available surgical access flaps for third molar surgery, the envelope flap consists of a linear incision along the top of the alveolar ridge distal to the second mandibular molar, followed by an intrasulcular incision that extends from the distal of the second molar up to, sometimes, the first mandibular molar, the triangular flap (TF) differs from EF by incorporating a vertical or oblique relief incision in the middle of the second molar envelope wall, after the intrasulcular incision that reaches 1/3 or 2/3 of its envelope wall. Similarly, the modified triangular flap (MTF) starts with an incision from the top of the alveolar crest that reaches the second mandibular molar but leaves a 2 mm gingival collar around its buccal side and finishes with a final vertical or oblique relief incision. Whereas EF uses a single horizontal incision and flap elevation, causing minimal disruption of the vascular supply and facilitating wound closure, TF and MTF use an additional vertical buccal releasing incision, which allows better visibility and accessibility during osteotomy. ( 4 ) This study aimed to compare the effect of envelope and modified triangular flap designs on postoperative pain and soft tissue healing in impacted mandibular third molar surgery. 2. MATERIALS AND METHODS This study was approved by the ethical committee of Pharos University in Alexandria, Oral and Maxillofacial Surgery Department, Faculty of Dentistry. Twenty patients (12 males and 8 females, aging between 19 and 35) who had unilateral full bony impacted, vertical or slightly mesioangular mandibular third molars were selected. 2.1. Criteria of selection 2.1.1. Inclusion criteria Patients with unilateral impacted inferior third molars that were of comparable clinical presentation and technical difficulty (Pell and Gregory), positioning, and angulations as seen on periapical and panoramic radiographs. Patients who were not on any medication that would influence the surgical procedure or postoperative course of healing. Nonsmokers and patients with healthy dental status. 2.1.2. Exclusion criteria Pregnancy during the extraction. Patients with chronic periodontal disease. 2.2. Materials 2.2.1. Instrument Surgical autoclavable bur with different sizes. Contra-angle high-speed handpiece with micro motor. Surgical instrument (mucoperiosteal elevator, scalpel, bone file, sutures, curved and straight elevator). 2.3 Preoperative phase Radiographic examination: Extraoral radiographs (panoramic X-ray) (Fig. 1). 2.4. Operative phase 2.4.1. Anesthesia All surgical procedures were carried out under local anesthesia. The operation was performed in the Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Pharos University in Alexandria. 2.4.2. Surgical procedures For the envelope flap, a sulcular incision from the first to the second mandibular molar and a distal relieving incision along the external oblique ridge to the ramus were made (Fig. 2). The modified triangular flap was prepared as described by Jakse et al. ( 5 ) An incision was made from the distobuccal edge of the second molar, dropping into the vestibule, and a relieving incision from the ramus to the distobuccal aspect of the second molar (Fig. 3). The periodontium of the second molar was touched only at the distolabial edge. A lingual mucoperiosteal flap similar to the one used with the envelope flap was raised as well. After the surgical site was seen, removal of the impacted tooth was completed in the usual way. Overlying bony tissue was removed with a bur under copious saline irrigation, and the tooth was sectioned if needed. Following the removal of the tooth and dental follicle remnants, the wound was thoroughly irrigated. The envelope flaps were closed with interrupted sutures. For the triangular flap, the same suturing technique was used distally, whereas the perpendicular incision was only adapted with a single coronally placed suture as described by Jakse et al. The loose adaptation of the apical portion is claimed to allow for easy relief of a hematoma. ( 5 ) 2.5. Postoperative phase 2.5.1. Postoperative medication All patients received postoperative antibiotics (amoxicillin, 2 g/d) for one week postoperatively. Analgesics (Brufen 400 mg thrice daily) for one week. Mouthwash (0.12% chlorhexidine, twice a day). 2.5.2. Delayed postoperative care The sutures were removed after 7 days. 2.6. Clinical follow-up 2.6.1. Pain Visual Analogue Scale (VAS) was used to analyze pain. A zero to ten (0–1 = None, 2–4 = Mild, 5–7 = Moderate, 8–10 = Severe) scale. All patients were instructed to come for postoperative follow-up after one day, 3 days, and one week to evaluate pain. ( 6 ) 2.6.2. Wound healing For assessment of wound healing, the intraoral incision was regularly assessed and monitored for any indications of dehiscence, infection, or inflammation during the postoperative period by Landry's healing index. ( 7 ) All patients were instructed to come for postoperative follow-up after one day, 3 days, and one week. 3. RESULTS This study included 20 patients (12 males and 8 females, aged between 19 and 35) who underwent mandibular wisdom tooth extraction. They were equally allocated according to the flap design used: Envelope Flap Group: ten patients with envelope flap and Modified Triangular Flap Group: ten patients with modified envelope flap. Data are presented as median (95% Confidence Interval (CI) of the median) There was no statistically significant difference in age and sex between the two groups ( p = .761; p = 1.000). There was no statistically significant difference in VAS between the two groups one day postoperatively ( p = .761). The VAS was statistically significantly lower in the Envelope Flap Group (2.50 [2.00–3.00] compared with the Modified Triangular Flap Group (4.00[4.00–5.00]) three days postoperatively (p = .014). Also, at one week postoperatively (0.50 [0.00–1.00]) in the Envelope Flap group, compared with (2.00 [2.00–2.00]) in the Modified Triangular Flap Group ( p = .001). The VAS percentage decrease (%) was statistically significantly better (more decrease) at D3 vs. D1, D7 vs. D1, and D7 vs D3 in the Envelope Flap group than in the Modified triangular flap group ( p = .010, p = .001, and p = .006; respectively) (Table 1). The Healing Index was statistically significantly higher in the Modified Triangular Flap Group (2.50 [2.00–3.00] compared with the Envelope Flap Group [1.00] One day postoperative ( p = .003). Also, it is statistically significantly higher in the Modified Triangular Flap Group (3.00 [3.00–4.00]) compared with the Envelope Flap Group [2.00] three days postoperatively ( p = .007). At one week postoperative, it is statistically significantly higher in the Modified Triangular Flap Group (4.50 [5.00–5.00]) compared with the Envelope Flap Group [3.03] ( p < .001). (Table 2) 4. DISCUSSION Many authors agree that TF and MTF have better results than EF regarding postoperative pain after third molar surgery. ( 8 , 9 ) ; however, these differences are not all statistically significant. ( 10 ) According to Sandhu et al. ( 9 ) (2010), patients in the EF group experienced significantly more pain as compared to the MTF group (P < 0.05). Similarly, Koyuncu and Cetingül ( 8 ) (2013) described that MTF-intervened patients also reported less postoperative pain. Kirk, et al. ( 11 ) (2007), in turn, showed no statistically significant differences between the EF and MTF groups regarding pain. Although EF is the most commonly used surgical by approach for lower third molar removal, the extensive exposition of buccal bone from the adjacent second molar during this procedure has been frequently associated with patients perceiving more pain, when compared with the other less invasive approaches. ( 8 ) Healing is often not reported as a clinical parameter after third molar surgery; however, the few articles analyzing healing showed better healing in patients treated with the MTF approach. ( 9 , 12 , 13 ) Mohajerani, et al. ( 12 ) (2018) showed that the application of MTF might lead to a reduction in dry socket incidence and better healing 7 days after lower-impacted third molar surgeries. On the other hand, Desai, et al. ( 13 ) (2014) reported no statistical differences between EF and TF-treated patients in the healing of flap due to the presence of gaps, hematoma, sensitivity of adjacent teeth, and dry socket. When considering the initial phases of healing, alveolar osteitis (AO) can be considered as a relatively frequent complication. Interestingly, Elo, et al. ( 14 ) (2016) proposed a modified approach by incorporating a double-pass single-layered running continuous primary closure to provide a tighter protection of the clot. The modified flap design, which consisted in a sulcular incision starting at the midfacial portion of the second molar and extending distolaterally across the lateral body or ramus of the mandible, resulted in a significantly less risk of developing AO and other complications when compared with both the traditional EF and MTF designs. In this study, the VAS scores were significantly lower in the Envelope Flap Group (2.50 [2.00–3.00]) compared to the Modified Triangular Flap Group (4.00 [4.00–5.00]) three days after surgery (p = .014). Additionally, at one week after the operation, the scores in the Envelope Flap Group were (0.50 [0.00–1.00]), while those in the Modified Triangular Flap Group were (2.00 [2.00–2.00]) (p = .001). The percentage reduction in VAS scores was statistically significantly greater (indicating more reduction) at D3 compared to D1, D7 compared to D1, and D7 compared to D3 in the Envelope Flap group when contrasted with the Modified Triangular Flap Group (p = .010, p = .001, and p = .006; respectively). In this study, the Healing Index was found to be statistically significantly greater in the Modified Triangular Flap Group (2.50 [2.00–3.00]) compared to the Envelope Flap Group (1.00) one day after surgery (p = .003). Furthermore, it showed a statistically significant increase in the Modified Triangular Flap Group (3.00 [3.00–4.00]) when compared to the Envelope Flap Group (2.00) three days after the procedure (p = .007). At one week post-surgery, the Healing Index was statistically significantly higher in the Modified Triangular Flap Group (4.50 [5.00–5.00]) versus the Envelope Flap Group (3.03) (p < .001). 5. CONCLUSION The study revealed that the modified triangular flap had higher postoperative healing compared with the envelope flap, although the envelope flap had lower postoperative pain scores. Abbreviations EF Envelope Flap MTF Modified Triangular Flap TF Triangular Flap VAS Visual Analogue Scale CI Confidence Interval AO Alveolar Osteitis Declarations Ethics approval : We declare and confirm that the work covered in this manuscript that has involved patients has been conducted only after receiving relevant institutional ethical approvals, PUA02202409293262, Unit of Research Ethics Approval Committee [UREAC], Pharos University in Alexandria. Consent to participate : Patient consent has been obtained. Consent for publication: We declare that the submitted manuscript is original, has not been published before, and is not being considered for publication elsewhere. We understand that the Corresponding Author is the contact for the Editorial process and that he is responsible for communicating with the other authors the processes of submission, revision, final proofing, and publication. We confirm that the manuscript has been proofed and approved by all the authors. We also confirm that the order of authors listed has received our approval. Funding : Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB). Self-funding. References Carter K, Worthington SJJ (2015) Morphologic and demographic predictors of third molar agenesis: a systematic review and meta-analysis. 94(7):886–894 Arta SA, Kheyradin RP, Mesgarzadeh AH (2011) Hassanbaglu BJJodr, dental clinics, dental prospects. Comparison of the influence of two flap designs on periodontal healing after surgical extraction of impacted third molars. 5(1):1 Monaco G, Daprile G, Tavernese L, Corinaldesi G (2009) Marchetti CJJoo, surgery m. Mandibular third molar removal in young patients: an evaluation of 2 different flap designs. 67(1):15–21 Chen Y-W, Lee C-T, Hum L, Chuang S (2017) -KJIjoo, surgery m. Effect of flap design on periodontal healing after impacted third molar extraction: a systematic review and meta-analysis. 46(3):363–372 Jakse N, Bankaoglu V, Wimmer G, Eskici A, Pertl CJOS, Oral Medicine O, Pathology O, Radiology (2002) Endodontology. Primary wound healing after lower third molar surgery: evaluation of 2 different flap designs. 93(1):7–12 Seymour RA, Simpson JM, Charlton JE, Phillips MEJP (1985) An evaluation of length and end-phrase of visual analogue scales in dental pain. 21(2):177–185 Pippi RJIjoms (2017) Post-surgical clinical monitoring of soft tissue wound healing in periodontal and implant surgery. 14(8):721 Koyuncu BÖ (2013) Çetingül EJOs, oral medicine, oral pathology, radiology o. Short-term clinical outcomes of two different flap techniques in impacted mandibular third molar surgery. 116(3):e179–e84 Sandhu A, Sandhu S (2010) Kaur TJIjoo, surgery m. Comparison of two different flap designs in the surgical removal of bilateral impacted mandibular third molars. 39(11):1091–1096 Erdogan Ö, Tatlı U, Üstün Y, Damlar IJO (2011) Influence of two different flap designs on the sequelae of mandibular third molar surgery. 15:147–152surgery m Kirk DG, Liston PN, Tong DC, Love RMJOS, Oral Medicine O, Pathology O, Radiology E (2007) Influence of two different flap designs on incidence of pain, swelling, trismus, and alveolar osteitis in the week following third molar surgery. 104(1):e1–e6 Mohajerani H, Esmaeelinejad M, Jafari M, Amini E, Sharabiany SPJT (2018) Comparison of Envelope and Modified Triangular Flaps on Incidence of Dry Socket after Surgical Removal of Impacted Mandibular Third Molars: A Double-blind. Split-mouth Study 19(7):836–841 Desai A, Patel R, Desai K, Vachhani NB, Shah KA, Sureja RJC (2014) Comparison of two incision designs for surgical removal of impacted mandibular third molar: A randomized comparative clinical study. 5(2):170–174 Elo JA, Sun H-HB, Dong F, Tandon R (2016) Singh HMJOs, oral medicine, oral pathology, radiology o. Novel incision design and primary flap closure reduces the incidence of alveolar osteitis and infection in impacted mandibular third molar surgery. 122(2):124–133 Tables Table (1): The VAS in the two studied groups at different time intervals VAS Group Test of significance p-value Envelope flap (n=10) Modified triangular flap (n=10) One Day postoperative Min. – Max. Median 95% CI of the median 5.00 – 7.00 6.00 6.00 – 7.00 5.00 – 7.00 6.00 6.00 – 7.00 Z (MW) =0.000 p =1.000 NS Three Days postoperative Min. – Max. Median 95% CI of the median 2.00 – 4.00 2.50 2.00 – 3.00 2.00 – 5.00 4.00 4.00 – 5.00 Z (MW) =2.463 p =.014* One Week postoperative Min. – Max. Median 95% CI of the median 0.00 – 1.00 0.50 0.00 – 1.00 1.00 – 2.00 2.00 2.00 – 2.00 Z (MW) =3.245 p =.001* Friedman Test p -value c 2 (df=2) =20.000 p <.001* c 2 (df=2) =20.000 p <.001* Percentage change D3 vs D1 Min. – Max. Median 95% CI of the median -71.43 – -40.00 -58.57 -66.67 – -50.00 -60.00 – -20.00 -42.86 -42.86 – -28.57 Z (MW) =2.591 p =.010* Percentage change D7 vs D1 Min. – Max. Median 95% CI of the median -100.00 – -83.33 -92.86 -100.00 – -85.71 -85.71 – -60.00 -71.43 -80.00 – -60.00 Z (MW) =3.233 p =.001* Percentage change D7 vs D3 Min. – Max. Median 95% CI of the median -100.00 – -50.00 -87.50 -100.00 – -66.67 -80.00 – -33.33 -50.00 -50.00 – -33.33 Z (MW) =2.754 p =.006* n: Number of patients Min-Max: Minimum – Maximum CI: Confidence interval MW: Z Test of Mann-Whitney Test *: Statistically significant (p<.05) NS: Statistically not significant (p≥.05) Table (2): The Healing Index in the two studied groups at different time intervals Healing Index Group Test of significance p-value Envelope flap (n=10) Modified triangular flap (n=10) (One Day postoperative) Min. – Max. Median 95% CI of the median 1.00-2.00 1.00 NA 1.00-3.00 2.50 2.00-3.00 Z (MW) =3.022 p =.003* (Three Days postoperative) Min. – Max. Median 95% CI of the median 2.00-3.00 2.00 NA 2.00-4.00 3.00 3.00-4.00 Z (MW) =2.690 p =.007* (One Week postoperative) Min. – Max. Median 95% CI of the median 3.00-4.00 3.03 NA 4.00-5.00 4.50 5.00-5.00 Z (MW) =3.698 p <.001* Friedman Test p -value c 2 (df=2) =18.541 p <.001* c 2 (df=2) =18.86 p <.001* Percentage change D3 vs D1 Min. – Max. Median 95% CI of the median 0.00-200.00 100.00 100.00-200.00 0.00-200.00 33.33 33.33-100.00 Z (MW) =1.739 p =.082 NS Percentage change D7 vs D1 Min. – Max. Median 95% CI of the median 50.00-300.00 200.00 200.00-300.00 33.33-400.00 83.33 66.67-150.00 Z (MW) =1.224 p =.221 NS Percentage change D7 vs D3 Min. – Max. Median 95% CI of the median 0.00-100.00 50.00 50.00-100.00 25.00-100.00 50.00 25.00-66.67 Z (MW) =0.154 p =.877 NS n: Number of patients Min-Max: Minimum – Maximum CI: Confidence interval MW: Z Test of Mann-Whitney Test NA: Non-applicable (The 95% confidence interval of the median could not be calculated because most data points have the same value). *: Statistically significant (p<.05) NS: Statistically not significant (p≥.05) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7160894","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":490920769,"identity":"e9d233a8-4fc6-4215-8167-829f44a3f084","order_by":0,"name":"Aliaa Ahmed Habib","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYDACdsYGIHmAwYCZh/EBRCiBgBZmhBZmAyK1gEmgFgYeNgmitPA3Mzd++MFwR96cnfdYdWGbHQM/e44Bw4dfuLVIHGZsluxheGa4s5kv7fbMtmQGyZ43Bowz+/BYc5ixQYIHSG44zGN2m7eNmcHgRo4BM28Pbh3yQFt+/mE4bA/SUszbVs9gD9LyF48Wg8OMbdJAWxJBWph52w4zGEgAtTD8wK3FEKjFWsbgcDLQL8nSM84d55E486zgYG8Dbi1yx9sf33xTcdh2O//Zg58Lyqrl+NuTNz748QeP9yHOg1CgOOIBMQ4wthHSwoDQAgUEbRkFo2AUjIIRBACxtVBj+LflRQAAAABJRU5ErkJggg==","orcid":"","institution":"Pharos University in Alexandria","correspondingAuthor":true,"prefix":"","firstName":"Aliaa","middleName":"Ahmed","lastName":"Habib","suffix":""},{"id":490920770,"identity":"fe33101c-37a4-43a5-9966-b512af0f7f86","order_by":1,"name":"Ahmed Elsayed Abdelghany Shararah","email":"","orcid":"","institution":"Academy of Scientific Research and Technology","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Elsayed Abdelghany","lastName":"Shararah","suffix":""}],"badges":[],"createdAt":"2025-07-18 23:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7160894/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7160894/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87831817,"identity":"8b9e2444-a97f-46b6-b8f8-bed4bb7a02c8","added_by":"auto","created_at":"2025-07-29 12:38:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":770451,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative extraoral radiographs (panoramic X-ray).\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7160894/v1/bd4907de2fe9ad2d67f10317.png"},{"id":87831782,"identity":"2ac81760-a404-4e8c-9da1-7775c9c20834","added_by":"auto","created_at":"2025-07-29 12:38:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":976980,"visible":true,"origin":"","legend":"\u003cp\u003eEnvelope flap.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7160894/v1/67073a7a5686e2eb54846f6f.png"},{"id":87831809,"identity":"2b9a744b-44c6-41b2-973b-2b962bd7b33d","added_by":"auto","created_at":"2025-07-29 12:38:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1996580,"visible":true,"origin":"","legend":"\u003cp\u003eModified triangular flap.\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7160894/v1/5408a7485e606dad044a5ba1.png"},{"id":88585960,"identity":"5db2cd54-ac75-44ed-92e1-8bcf6f34efb9","added_by":"auto","created_at":"2025-08-08 04:16:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6574170,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7160894/v1/ab523874-396f-4a5e-8a0d-0692b9500ad8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEvaluating Envelope vs. Triangular Flap Techniques in Impacted Mandibular Wisdom Tooth Extraction (A Comparative Study)\u003c/p\u003e","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eImpacted teeth refer to a particular anatomical condition in which a tooth fails to erupt within the expected time of physiological development.\u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn fact, 33% of the population has at least one impacted third molar, which frequently leads to food retention, caries, pain, edema, and second molar root resorption and, consequently, its surgical extraction. Despite the frequent surgical removal of third molars, the occurrence of accompanying postoperative morbidities is relatively common.\u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe invasive manipulation of soft and hard tissues during tooth extraction involves different factors that can influence the patient\u0026rsquo;s postoperative course in terms of pain, swelling, trismus, and healing.\u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAmong the available surgical access flaps for third molar surgery, the envelope flap consists of a linear incision along the top of the alveolar ridge distal to the second mandibular molar, followed by an intrasulcular incision that extends from the distal of the second molar up to, sometimes, the first mandibular molar, the triangular flap (TF) differs from EF by incorporating a vertical or oblique relief incision in the middle of the second molar envelope wall, after the intrasulcular incision that reaches 1/3 or 2/3 of its envelope wall. Similarly, the modified triangular flap (MTF) starts with an incision from the top of the alveolar crest that reaches the second mandibular molar but leaves a 2 mm gingival collar around its buccal side and finishes with a final vertical or oblique relief incision. Whereas EF uses a single horizontal incision and flap elevation, causing minimal disruption of the vascular supply and facilitating wound closure, TF and MTF use an additional vertical buccal releasing incision, which allows better visibility and accessibility during osteotomy.\u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study aimed to compare the effect of envelope and modified triangular flap designs on postoperative pain and soft tissue healing in impacted mandibular third molar surgery.\u003c/p\u003e"},{"header":"2. MATERIALS AND METHODS","content":"\u003cp\u003e This study was approved by the ethical committee of Pharos University in Alexandria, Oral and Maxillofacial Surgery Department, Faculty of Dentistry. Twenty patients (12 males and 8 females, aging between 19 and 35) who had unilateral full bony impacted, vertical or slightly mesioangular mandibular third molars were selected.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Criteria of selection\u003c/h2\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003e2.1.1. Inclusion criteria\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePatients with unilateral impacted inferior third molars that were of comparable clinical presentation and technical difficulty (Pell and Gregory), positioning, and angulations as seen on periapical and panoramic radiographs.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePatients who were not on any medication that would influence the surgical procedure or postoperative course of healing.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNonsmokers and patients with healthy dental status.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\u003ch2\u003e2.1.2. Exclusion criteria\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePregnancy during the extraction.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePatients with chronic periodontal disease.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Materials\u003c/h2\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.2.1. Instrument\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSurgical autoclavable bur with different sizes.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eContra-angle high-speed handpiece with micro motor.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSurgical instrument (mucoperiosteal elevator, scalpel, bone file, sutures, curved and straight elevator).\u003c/p\u003e\u003cp\u003e\u003cb\u003e2.3 Preoperative phase\u003c/b\u003e\u003c/p\u003e\u003cli\u003e\u003cp\u003eRadiographic examination: Extraoral radiographs (panoramic X-ray) (Fig.\u0026nbsp;1).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Operative phase\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.4.1. Anesthesia\u003c/h2\u003e\u003cp\u003eAll surgical procedures were carried out under local anesthesia. The operation was performed in the Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Pharos University in Alexandria.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\u003ch2\u003e2.4.2. Surgical procedures\u003c/h2\u003e\u003cp\u003eFor the envelope flap, a sulcular incision from the first to the second mandibular molar and a distal relieving incision along the external oblique ridge to the ramus were made (Fig.\u0026nbsp;2).\u003c/p\u003e\u003cp\u003eThe modified triangular flap was prepared as described by Jakse et al.\u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e An incision was made from the distobuccal edge of the second molar, dropping into the vestibule, and a relieving incision from the ramus to the distobuccal aspect of the second molar (Fig.\u0026nbsp;3).\u003c/p\u003e\u003cp\u003eThe periodontium of the second molar was touched only at the distolabial edge. A lingual mucoperiosteal flap similar to the one used with the envelope flap was raised as well.\u003c/p\u003e\u003cp\u003eAfter the surgical site was seen, removal of the impacted tooth was completed in the usual way. Overlying bony tissue was removed with a bur under copious saline irrigation, and the tooth was sectioned if needed.\u003c/p\u003e\u003cp\u003eFollowing the removal of the tooth and dental follicle remnants, the wound was thoroughly irrigated. The envelope flaps were closed with interrupted sutures. For the triangular flap, the same suturing technique was used distally, whereas the perpendicular incision was only adapted with a single coronally placed suture as described by Jakse et al. The loose adaptation of the apical portion is claimed to allow for easy relief of a hematoma.\u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.5. Postoperative phase\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e2.5.1. Postoperative medication\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAll patients received postoperative antibiotics (amoxicillin, 2 g/d) for one week postoperatively.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAnalgesics (Brufen 400 mg thrice daily) for one week.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMouthwash (0.12% chlorhexidine, twice a day).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e2.5.2. Delayed postoperative care\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe sutures were removed after 7 days.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e2.6. Clinical follow-up\u003c/h2\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e2.6.1. Pain\u003c/h2\u003e\u003cp\u003eVisual Analogue Scale (VAS) was used to analyze pain. A zero to ten (0\u0026ndash;1\u0026thinsp;=\u0026thinsp;None, 2\u0026ndash;4\u0026thinsp;=\u0026thinsp;Mild, 5\u0026ndash;7\u0026thinsp;=\u0026thinsp;Moderate, 8\u0026ndash;10\u0026thinsp;=\u0026thinsp;Severe) scale. All patients were instructed to come for postoperative follow-up after one day, 3 days, and one week to evaluate pain.\u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e2.6.2. Wound healing\u003c/h2\u003e\u003cp\u003eFor assessment of wound healing, the intraoral incision was regularly assessed and monitored for any indications of dehiscence, infection, or inflammation during the postoperative period by Landry's healing index.\u003csup\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003eAll patients were instructed to come for postoperative follow-up after one day, 3 days, and one week.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003eThis study included 20 patients (12 males and 8 females, aged between 19 and 35) who underwent mandibular wisdom tooth extraction. They were equally allocated according to the flap design used: Envelope Flap Group: ten patients with envelope flap and Modified Triangular Flap Group: ten patients with modified envelope flap.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData are presented as median (95% Confidence Interval (CI) of the median)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThere was no statistically significant difference in age and sex between the two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.761; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000).\u003c/p\u003e\u003cp\u003eThere was no statistically significant difference in VAS between the two groups one day postoperatively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.761). The VAS was statistically significantly lower in the Envelope Flap Group (2.50 [2.00\u0026ndash;3.00] compared with the Modified Triangular Flap Group (4.00[4.00\u0026ndash;5.00]) three days postoperatively (p\u0026thinsp;=\u0026thinsp;.014). Also, at one week postoperatively (0.50 [0.00\u0026ndash;1.00]) in the Envelope Flap group, compared with (2.00 [2.00\u0026ndash;2.00]) in the Modified Triangular Flap Group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001). The VAS percentage decrease (%) was statistically significantly better (more decrease) at D3 vs. D1, D7 vs. D1, and D7 vs D3 in the Envelope Flap group than in the Modified triangular flap group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.010, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001, and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.006; respectively) (Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eThe Healing Index was statistically significantly higher in the Modified Triangular Flap Group (2.50 [2.00\u0026ndash;3.00] compared with the Envelope Flap Group [1.00] One day postoperative (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.003). Also, it is statistically significantly higher in the Modified Triangular Flap Group (3.00 [3.00\u0026ndash;4.00]) compared with the Envelope Flap Group [2.00] three days postoperatively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.007).\u003c/p\u003e\u003cp\u003eAt one week postoperative, it is statistically significantly higher in the Modified Triangular Flap Group (4.50 [5.00\u0026ndash;5.00]) compared with the Envelope Flap Group [3.03] (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). (Table\u0026nbsp;2)\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eMany authors agree that TF and MTF have better results than EF regarding postoperative pain after third molar surgery.\u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e; however, these differences are not all statistically significant.\u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e According to Sandhu et al.\u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e (2010), patients in the EF group experienced significantly more pain as compared to the MTF group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Similarly, Koyuncu and Ceting\u0026uuml;l \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e (2013) described that MTF-intervened patients also reported less postoperative pain. Kirk, et al.\u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e (2007), in turn, showed no statistically significant differences between the EF and MTF groups regarding pain. Although EF is the most commonly used surgical by approach for lower third molar removal, the extensive exposition of buccal bone from the adjacent second molar during this procedure has been frequently associated with patients perceiving more pain, when compared with the other less invasive approaches.\u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e Healing is often not reported as a clinical parameter after third molar surgery; however, the few articles analyzing healing showed better healing in patients treated with the MTF approach.\u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMohajerani, et al.\u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e (2018) showed that the application of MTF might lead to a reduction in dry socket incidence and better healing 7 days after lower-impacted third molar surgeries.\u003c/p\u003e\u003cp\u003eOn the other hand, Desai, et al. \u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e (2014) reported no statistical differences between EF and TF-treated patients in the healing of flap due to the presence of gaps, hematoma, sensitivity of adjacent teeth, and dry socket. When considering the initial phases of healing, alveolar osteitis (AO) can be considered as a relatively frequent complication. Interestingly, Elo, et al.\u003csup\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e(2016) proposed a modified approach by incorporating a double-pass single-layered running continuous primary closure to provide a tighter protection of the clot. The modified flap design, which consisted in a sulcular incision starting at the midfacial portion of the second molar and extending distolaterally across the lateral body or ramus of the mandible, resulted in a significantly less risk of developing AO and other complications when compared with both the traditional EF and MTF designs.\u003c/p\u003e\u003cp\u003eIn this study, the VAS scores were significantly lower in the Envelope Flap Group (2.50 [2.00\u0026ndash;3.00]) compared to the Modified Triangular Flap Group (4.00 [4.00\u0026ndash;5.00]) three days after surgery (p\u0026thinsp;=\u0026thinsp;.014). Additionally, at one week after the operation, the scores in the Envelope Flap Group were (0.50 [0.00\u0026ndash;1.00]), while those in the Modified Triangular Flap Group were (2.00 [2.00\u0026ndash;2.00]) (p\u0026thinsp;=\u0026thinsp;.001). The percentage reduction in VAS scores was statistically significantly greater (indicating more reduction) at D3 compared to D1, D7 compared to D1, and D7 compared to D3 in the Envelope Flap group when contrasted with the Modified Triangular Flap Group (p\u0026thinsp;=\u0026thinsp;.010, p\u0026thinsp;=\u0026thinsp;.001, and p\u0026thinsp;=\u0026thinsp;.006; respectively).\u003c/p\u003e\u003cp\u003eIn this study, the Healing Index was found to be statistically significantly greater in the Modified Triangular Flap Group (2.50 [2.00\u0026ndash;3.00]) compared to the Envelope Flap Group (1.00) one day after surgery (p\u0026thinsp;=\u0026thinsp;.003). Furthermore, it showed a statistically significant increase in the Modified Triangular Flap Group (3.00 [3.00\u0026ndash;4.00]) when compared to the Envelope Flap Group (2.00) three days after the procedure (p\u0026thinsp;=\u0026thinsp;.007). At one week post-surgery, the Healing Index was statistically significantly higher in the Modified Triangular Flap Group (4.50 [5.00\u0026ndash;5.00]) versus the Envelope Flap Group (3.03) (p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eThe study revealed that the modified triangular flap had higher postoperative healing compared with the envelope flap, although the envelope flap had lower postoperative pain scores.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eEF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnvelope Flap\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMTF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eModified Triangular Flap\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eTF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTriangular Flap\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eVAS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVisual Analogue Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAO\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAlveolar Osteitis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e: We declare and confirm that the work covered in this manuscript that has involved patients has been conducted only after receiving relevant institutional ethical approvals, PUA02202409293262, Unit of Research Ethics Approval Committee [UREAC], Pharos University in Alexandria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e: Patient consent has been obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e We declare that the submitted manuscript is original, has not been published before, and is not being considered for publication elsewhere. We understand that the Corresponding Author is the contact for the Editorial process and that he is responsible for communicating with the other authors the processes of submission, revision, final proofing, and publication. We confirm that the manuscript has been proofed and approved by all the authors. We also confirm that the order of authors listed has received our approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Open access funding provided by The Science, Technology \u0026amp; Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB). Self-funding.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCarter K, Worthington SJJ (2015) Morphologic and demographic predictors of third molar agenesis: a systematic review and meta-analysis. 94(7):886\u0026ndash;894\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArta SA, Kheyradin RP, Mesgarzadeh AH (2011) Hassanbaglu BJJodr, dental clinics, dental prospects. Comparison of the influence of two flap designs on periodontal healing after surgical extraction of impacted third molars. 5(1):1\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMonaco G, Daprile G, Tavernese L, Corinaldesi G (2009) Marchetti CJJoo, surgery m. Mandibular third molar removal in young patients: an evaluation of 2 different flap designs. 67(1):15\u0026ndash;21\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen Y-W, Lee C-T, Hum L, Chuang S (2017) -KJIjoo, surgery m. Effect of flap design on periodontal healing after impacted third molar extraction: a systematic review and meta-analysis. 46(3):363\u0026ndash;372\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJakse N, Bankaoglu V, Wimmer G, Eskici A, Pertl CJOS, Oral Medicine O, Pathology O, Radiology (2002) Endodontology. Primary wound healing after lower third molar surgery: evaluation of 2 different flap designs. 93(1):7\u0026ndash;12\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSeymour RA, Simpson JM, Charlton JE, Phillips MEJP (1985) An evaluation of length and end-phrase of visual analogue scales in dental pain. 21(2):177\u0026ndash;185\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePippi RJIjoms (2017) Post-surgical clinical monitoring of soft tissue wound healing in periodontal and implant surgery. 14(8):721\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoyuncu B\u0026Ouml; (2013) \u0026Ccedil;eting\u0026uuml;l EJOs, oral medicine, oral pathology, radiology o. Short-term clinical outcomes of two different flap techniques in impacted mandibular third molar surgery. 116(3):e179\u0026ndash;e84\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSandhu A, Sandhu S (2010) Kaur TJIjoo, surgery m. Comparison of two different flap designs in the surgical removal of bilateral impacted mandibular third molars. 39(11):1091\u0026ndash;1096\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eErdogan \u0026Ouml;, Tatlı U, \u0026Uuml;st\u0026uuml;n Y, Damlar IJO (2011) Influence of two different flap designs on the sequelae of mandibular third molar surgery. 15:147\u0026ndash;152surgery m\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKirk DG, Liston PN, Tong DC, Love RMJOS, Oral Medicine O, Pathology O, Radiology E (2007) Influence of two different flap designs on incidence of pain, swelling, trismus, and alveolar osteitis in the week following third molar surgery. 104(1):e1\u0026ndash;e6\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMohajerani H, Esmaeelinejad M, Jafari M, Amini E, Sharabiany SPJT (2018) Comparison of Envelope and Modified Triangular Flaps on Incidence of Dry Socket after Surgical Removal of Impacted Mandibular Third Molars: A Double-blind. Split-mouth Study 19(7):836\u0026ndash;841\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDesai A, Patel R, Desai K, Vachhani NB, Shah KA, Sureja RJC (2014) Comparison of two incision designs for surgical removal of impacted mandibular third molar: A randomized comparative clinical study. 5(2):170\u0026ndash;174\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElo JA, Sun H-HB, Dong F, Tandon R (2016) Singh HMJOs, oral medicine, oral pathology, radiology o. Novel incision design and primary flap closure reduces the incidence of alveolar osteitis and infection in impacted mandibular third molar surgery. 122(2):124\u0026ndash;133\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable (1):\u0026nbsp;\u003c/strong\u003eThe VAS in the two studied groups at different time intervals\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest of significance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnvelope flap\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModified triangular flap\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOne Day postoperative\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.00 \u0026ndash;\u0026nbsp;7.00\u003c/p\u003e\n \u003cp\u003e6.00\u003c/p\u003e\n \u003cp\u003e6.00 \u0026ndash;\u0026nbsp;7.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.00 \u0026ndash;\u0026nbsp;7.00\u003c/p\u003e\n \u003cp\u003e6.00\u003c/p\u003e\n \u003cp\u003e6.00 \u0026ndash;\u0026nbsp;7.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=0.000\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=1.000 NS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThree Days postoperative\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2.00 \u0026ndash; 4.00\u003c/p\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003cp\u003e2.00 \u0026ndash;\u0026nbsp;3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2.00 \u0026ndash; 5.00\u003c/p\u003e\n \u003cp\u003e4.00\u003c/p\u003e\n \u003cp\u003e4.00 \u0026ndash;\u0026nbsp;5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=2.463\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=.014*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOne Week postoperative\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.00 \u0026ndash;\u0026nbsp;1.00\u003c/p\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003cp\u003e0.00 \u0026ndash;\u0026nbsp;1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00 \u0026ndash;\u0026nbsp;2.00\u003c/p\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003cp\u003e2.00 \u0026ndash;\u0026nbsp;2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=3.245\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFriedman Test\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e\u003csub\u003e(df=2)\u0026nbsp;\u003c/sub\u003e=20.000\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026lt;.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e\u003csub\u003e(df=2)\u0026nbsp;\u003c/sub\u003e=20.000\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026lt;.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage change D3 vs D1\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e-71.43 \u0026ndash; -40.00\u003c/p\u003e\n \u003cp\u003e-58.57\u003c/p\u003e\n \u003cp\u003e-66.67 \u0026ndash;\u0026nbsp;-50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e-60.00 \u0026ndash; -20.00\u003c/p\u003e\n \u003cp\u003e-42.86\u003c/p\u003e\n \u003cp\u003e-42.86 \u0026ndash;\u0026nbsp;-28.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=2.591\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=.010*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage change D7 vs D1\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e-100.00 \u0026ndash; -83.33\u003c/p\u003e\n \u003cp\u003e-92.86\u003c/p\u003e\n \u003cp\u003e-100.00 \u0026ndash;\u0026nbsp;-85.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e-85.71 \u0026ndash; -60.00\u003c/p\u003e\n \u003cp\u003e-71.43\u003c/p\u003e\n \u003cp\u003e-80.00 \u0026ndash;\u0026nbsp;-60.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=3.233\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage change D7 vs D3\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e-100.00 \u0026ndash; -50.00\u003c/p\u003e\n \u003cp\u003e-87.50\u003c/p\u003e\n \u003cp\u003e-100.00 \u0026ndash;\u0026nbsp;-66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e-80.00 \u0026ndash; -33.33\u003c/p\u003e\n \u003cp\u003e-50.00\u003c/p\u003e\n \u003cp\u003e-50.00 \u0026ndash;\u0026nbsp;-33.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=2.754\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=.006*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003en: Number of patients \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Min-Max: Minimum \u0026ndash; Maximum\u003c/p\u003e\n\u003cp\u003eCI: Confidence interval \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;MW: Z Test of Mann-Whitney Test\u003c/p\u003e\n\u003cp\u003e*: Statistically significant (p\u0026lt;.05) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;NS: Statistically not significant (p\u0026ge;.05)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (2):\u0026nbsp;\u003c/strong\u003eThe Healing Index in the two studied groups at different time intervals\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealing Index\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 43px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest of significance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnvelope flap\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModified triangular flap\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(One Day postoperative)\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00-2.00\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00-3.00\u003c/p\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003cp\u003e2.00-3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=3.022\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(Three Days postoperative)\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.00-3.00\u003c/p\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.00-4.00\u003c/p\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003cp\u003e3.00-4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=2.690\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=.007*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(One Week postoperative)\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.00-4.00\u003c/p\u003e\n \u003cp\u003e3.03\u003c/p\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.00-5.00\u003c/p\u003e\n \u003cp\u003e4.50\u003c/p\u003e\n \u003cp\u003e5.00-5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=3.698\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026lt;.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFriedman Test\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e\u003csub\u003e(df=2)\u0026nbsp;\u003c/sub\u003e=18.541\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026lt;.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e\u003csub\u003e(df=2)\u0026nbsp;\u003c/sub\u003e=18.86\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026lt;.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage change D3 vs D1\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.00-200.00\u003c/p\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003cp\u003e100.00-200.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.00-200.00\u003c/p\u003e\n \u003cp\u003e33.33\u003c/p\u003e\n \u003cp\u003e33.33-100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=1.739\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=.082 NS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage change D7 vs D1\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e50.00-300.00\u003c/p\u003e\n \u003cp\u003e200.00\u003c/p\u003e\n \u003cp\u003e200.00-300.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e33.33-400.00\u003c/p\u003e\n \u003cp\u003e83.33\u003c/p\u003e\n \u003cp\u003e66.67-150.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=1.224\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=.221 NS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage change D7 vs D3\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eMin. \u0026ndash; Max.\u003c/li\u003e\n \u003cli\u003eMedian\u003c/li\u003e\n \u003cli\u003e95% CI of the median\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.00-100.00\u003c/p\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003cp\u003e50.00-100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e25.00-100.00\u003c/p\u003e\n \u003cp\u003e50.00\u003c/p\u003e\n \u003cp\u003e25.00-66.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eZ\u003csub\u003e(MW)\u003c/sub\u003e=0.154\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e=.877 NS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003en: Number of patients \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Min-Max: Minimum \u0026ndash; Maximum\u003c/p\u003e\n\u003cp\u003eCI: Confidence interval \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; MW: Z Test of Mann-Whitney Test\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNA: Non-applicable (The 95% confidence interval of the median could not be calculated because most data points have the same value).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e*: Statistically significant (p\u0026lt;.05) NS: Statistically not significant (p\u0026ge;.05)\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Envelope flap, flap design, impacted teeth, modified triangular flap, third molar surgery","lastPublishedDoi":"10.21203/rs.3.rs-7160894/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7160894/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003eSurgical removal of impacted third molars is a commonly applied oral surgery operation. It can be quite discomforting for the patients because of postoperative complications, such as bleeding, pain, swelling, trismus, wound dehiscence, and alveolar osteitis. Many attempts have been made to reduce those complications, and the use of various flap designs have been investigated.\u003c/p\u003e\u003ch2\u003eAim of the study:\u003c/h2\u003e\u003cp\u003eto evaluate the effect of flap designs, Envelope Flap (EF) and Modified Triangular Flap (MTF) on postoperative pain and soft tissue healing after mandibular wisdom tooth extraction.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e\u003cp\u003eTwenty patients with unilateral impacted third molars completed the study with an envelope flap and a modified triangular flap design for third molar removal. Clinical parameters, including pain and soft tissue healing, were assessed postoperatively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe VAS percentage decrease (%) was statistically significantly better (more decrease) in the Envelope Flap group than in the Modified triangular flap group. The Healing Index was statistically significantly higher in the Modified Triangular Flap Group compared with the Envelope Flap Group postoperatively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe study revealed that the modified triangular flap had higher postoperative healing compared with the envelope flap, although the envelope flap had lower postoperative pain scores.\u003c/p\u003e","manuscriptTitle":"Evaluating Envelope vs. Triangular Flap Techniques in Impacted Mandibular Wisdom Tooth Extraction (A Comparative Study)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-29 12:38:10","doi":"10.21203/rs.3.rs-7160894/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cda32cc2-9611-4551-b69e-e52bae4eeab8","owner":[],"postedDate":"July 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-08T04:08:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-29 12:38:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7160894","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7160894","identity":"rs-7160894","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}