The document describes a study comparing a new "comma incision" technique for surgically removing impacted mandibular third molars to the conventional modified envelope incision. One hundred patients were divided into two groups, with one group receiving the conventional incision and the other receiving the comma incision. The comma incision was designed to provide exposure while avoiding cutting across structures like the temporalis tendon insertion and lying over bone defects. Results found the comma incision reduced postoperative pain, swelling and trismus compared to the conventional incision. The study concludes the comma incision is preferable and can help reduce complications from third molar surgery.

1. Comma Incision for Impacted
Mandibular Third Molars
Journal of Oral & Maxillofacial Surgery 60:1506-1509, 2002
Dr. Amit T. Suryawanshi
Dentist & Oral and Maxillofacial Surgeon
Pune, India
Contact details :
Email ID - amitsuryawanshi999@gmail.com
Mobile No - 9405622455

2. 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.

3. 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.

4. Principles of incision making
It should provide sufficient operating space and
optimum exposure.
Clean incision should be made with one stroke or
evenly applied pressure on the scalpel.
It should preserve integrity of as many underlying
structures as possible.
‡

5. Incision and flap design in any surgical
procedure is based on time-tested principles.
Incision lines should not, as far as possible, lie
over prospective bony defects or cut across
major muscle or tendon insertions.
They should be minimally extensive. However,
the distal leg of the incisions conventionally
made to access impacted mandibular third
molars comes close to or even cuts across the
insertion of the temporalis tendon.

6. It also commonly lies over the bone defect
formed after removal of the tooth. This could be
responsible, at least in part, for the occurrence of
these complications. This, therefore, is the
reason enough to consider alternative incision
and flap designs. This study suggests an
alternative(COMMA INCISION) and demonstrates
its advantages.

7. Design of the Distolingually Based Flap
by Buccal Comma-Shaped Incision
The buccal vestibule below the preceding
second molar is stretched down as far as is
possible with the index finger or thumb of the
hand not wielding the scalpel. This stretches the
buccinator beyond its origin on the mandible.
Starting from a point at the depth of this
stretched vestibular reflection posterior to the
distal aspect of the preceding second molar, the
incision is made in an anterior direction.

8. 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.

9. Comma incision design

10. 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.

11. 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.

12. 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.

13. 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.

14. Swelling was assessed by measuring the distance
between the base of tragus and a reproducible soft
tissue pogonion along the skin surface.
Maximum interincisal distance was used as an index of
trismus.
The percentage difference between the postoperative
And preoperative measurements was calculated.
The exercise summarized the differences between the
Postoperative effects of the 2 incision methods.

19. 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.

20. 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.

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

22. 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 Prac
Dent Rec 20:297, 1970

23. • 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)

24. 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

25. Several authors have recognized that
periodontal status is compromised, especially
at the distal Aspect of the preceding second
molar, as a result of third molar extraction.
Stephens et al (1983) found no significant
difference in the resultant periodontal status.

26. 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

27. 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 technique
may require some practice initially.

28. 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 Surg
28:57, 1999 (suppl 1)

29. 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

30. 6. Van Gool AV, Ten Bosch JJ, Boering G: Clinical consequences
of complaints and complications after removal of the
Mandibular third molar. Int J Oral Surg 6:29, 1977
7. Schow SR: Evaluation of post-operative localized osteitis in
mandibular third molar surgery. Oral Surg Oral Med Oral
Pathol 38:352, 1974
8. Walters H: Reducing lingual nerve damage in third molar
surgery: A clinical audit of 1350 cases. Br Dent J 178:140, 1995

31. 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 Oral
Radiol Endod 90:140, 2000

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