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Vol. 00 No. 00 && 2021

Third molar surgery: Past, present, and the future

Jose S. Sifuentes-Cervantes, DDS,a Francisco Carrillo-Morales, DDS,b
Jaime Castro-N
u~
nez, DMD, MSD,c,d Larry L. Cunningham, DDS, MD, FACS,e and
Joseph E. Van Sickels, DDS, FACD, FICD, FACSf

Third molar surgery is the most common ambulatory procedure done by oral and maxillofacial surgeons. Surgical approaches for
the removal of third molars have been published since the 20th century. This article reviews the history and development of
extraction techniques through a literature review. The literature was selected through a search of an electronic database. Key
words for the Medline search were “mandibular/maxillary third molar,” “impacted mandibular/maxillary third molar,”
“mandibular/maxillary third molar flap design,” and “mandibular/maxillary third molar incision.” The search was restricted to
English-language articles. Additionally, a manual search in the major oral surgery journals and books was performed. The aim of
this article is to examine the evolution of third molar surgery, recognize pioneering techniques, and compare these techniques to
current approaches. Common approaches employed today are discussed and treatment philosophies with thoughts for future ther-
apies are provided. (Oral Surg Oral Med Oral Pathol Oral Radiol 2021;000:1 9)

Prehistoric evidence has shown that treatment of
decayed teeth was done as early as the Neolithic Age
(10,000-4500 BC). It is likely that teeth were treated
with early drills made of bone, shells, and turquoise.1
The first documented extraction was probably per-
formed by Hippocrates using an instrument called
plumbeum odontogagon.2 Subsequently, Aristotle con-
tinued the practice of extractions employing forceps. In
his book Mechanics, he described the forceps in the
following manner: “[It] is formed by two levers, acting
in contrary sense and having a single fulcrum repre-
sented by the commissure of the instrument. By means
of this double lever it is much easier to move the tooth,
but after having moved it, it is easier to extract it with
the hand than with the instrument.”3 The Romans con-
tinued the development of armamentarium to extract
teeth with an instrument called the dentiducem
(Figure 1). It is unlikely that elevation of the adjacent
tissue was done with any of these procedures. The first
a
PGY 1, Oral and Maxillofacial Surgery Residency Program, School
of Dental Medicine, University of Puerto Rico, Medical Sciences
Campus, San Juan, Puerto Rico.
b
Formerly Chief Resident, Oral and Maxillofacial Surgery Residency
Program, School of Dental Medicine, University of Puerto Rico,
Medical Sciences Campus, San Juan, Puerto Rico.
c
PGY 3, Oral and Maxillofacial Surgery Residency Program, School
of Dental Medicine, University of Puerto Rico, Medical Sciences
Campus, San Juan, Puerto Rico.
d
Research Department, Instituci
on Universitaria Colegios de Colom-
bia, Bogot
a, Colombia.
e
Professor and Chair, Oral and Maxillofacial Surgery Department,
School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA,
USA.
f
Professor and Program Director, Division of Oral and Maxillofacial
Surgery, College of Dentistry, University of Kentucky, Lexington,
KY, USA.
Received for publication Nov 13, 2020; returned for revision Mar 5,
2021; accepted for publication Mar 8, 2021.
Ó 2021 Elsevier Inc. All rights reserved.
2212-4403/$-see front matter
https://doi.org/10.1016/j.oooo.2021.03.004
physician to propose detaching the gingiva from bone
was Aulus Cornelius Celsus. Furthermore, he described
a narcotic potion to alleviate postoperative pain. He
stated that failure to extract the complete tooth with its
roots could raise a possibility for the swelling of the
jaws.4
The belief that tooth extraction should be the last
resource became popular during the middle ages. This
led to a diminution of the development of approaches
for extractions until the late 1700s. Walter Harris, an
Englishman, recommended incisions for difficult
extractions in a pamphlet on acute infantile oral infec-
tions.5 However, during the same century, Kornelis
van Soolingen, a celebrated Dutch physician and sur-
geon, disdainfully described dental extractions as an
activity that should only be performed by barbers and
charlatans. This opinion was largely held across the
entire medical field in Europe.6 However, it must be
noted that barbers and some surgeons from France,
Germany, Spain, and Italy had developed a myriad of
instruments for tooth extraction and many versions of
dental elevators.
THE BEGINNINGS OF THIRD MOLAR
SURGERY
Lower third molars
Techniques to extract third molars gained attention at
the end of the 18th century. At that time, there was not
Statement of Clinical Relevance
The authors provide a historical overview of the dif-
ferent approaches for third molar surgery. Further-
more, current state of the art approaches with
directions for the future are provided. In this article,
surgeons will find current trends and a myriad of
adjuvant procedures employed for the benefit of
patients undergoing third molar surgery.

1
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ORAL AND MAXILLOFACIAL SURGERY OOOO
2 Sifuentes-Cervantes et al. && 2021

Fig. 1. Early Greek and Roman forceps.

an established method or approach for removal of third

molars. Dental extraction techniques were transmitted
through the sharing of ideas between dental surgeons,
each developing their own approaches. Because of this
tradition, it remains unclear who initiated the removal Fig. 2. Mandibular third molar flap design by Winter, 1926.
of third molars using mallets and chisels. Although
unclear, it probably developed in Germany and became
the standard of care during the 1800s in both Europe
and North America. The operation was very traumatic
for the surrounding tissues and the patient. As years
passed, better methods were developed and published
in periodicals of the time.
In 1903, the National Dental Association published a
manual for extraction of third molars. It was probably
the first official manuscript on third molar extraction.
Although the National Dental Association published a
manual for third molar surgery, it is believed that
Charles Edmund Kells (1856-1928) was the first to fos-
ter a comprehensive approach to third molar Fig. 3. Mandibular third molar flap design by Winter, 1926.
removal.7,8 In 1918, Kells, an American dentist best
known for his contributions to oral radiology and for
the invention of the surgical aspirator, published a
paper in Dental Cosmos in which he described a more
“humane” approach to removal of third molars. In this
paper, he stated that practitioners should consider
themselves engineers when designing their techniques
for extraction of wisdom teeth.7-9
In 1926, 8 years after Kells’ paper, George B. Winter
(1878-1940), a professor at Washington University
School of Dentistry, published Principles of Exodontia
as Applied to the Impacted Mandibular Third Molar.10
This became the most comprehensive manual for third
molar surgery at the time. He thoroughly described the
clinical and radiologic findings and surgical techniques
for third molars. He explained that an osteotomy was Fig. 4. Mandibular third molar flap design by Winter, 1926.
to be performed when bone was impeding the path of
extraction and performed in a way that would provide
a fulcrum for the elevator. This was achieved by
employing an ossisector, a sharp instrument that approaches throughout the 20th century, especially
could remove bone. The use of burs was not com- during the first half. During this period, a plethora
mon in his time owing to the amount of heat gener- of articles and books were published advocating
ated and difficulties associated with sterilization. He several approaches, most of which are not used
described 3 flap designs for the extraction of lower today (Figures 5-18).7-25
third molars depending on the axial orientation of Kurt H. Thoma (1883-1972), an oral surgeon from
the teeth (Figures 2-4).10 Kells’ and Winter's publi- Switzerland, developed his oral surgery and oral
cations stimulated interest in third molar surgical pathology career while at the Harvard School of Dental
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Volume 00, Number 00
Fig. 5. Mandibular third molar flap design by Thoma, 1932.
Fig. 6. Flap design by Fry (split bone technique/buccal plate
removal), 1933.
Fig. 7. Flap design by Fry (split bone technique/tooth eleva-
tion), 1933.
Fig. 8. Mandibular third molar flap design by Ward, 1956.
Medicine. He described his own technique in 1932 and
acknowledged the contributions of Kells.12 He stated
that the incision should be made along the post molar
triangle, starting on the ramus and keeping nearer the
lingual side than the buccal. According to him, the inci-
sion should terminate 2 mm behind the second molar;
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Sifuentes-Cervantes et al. 3
Fig. 9. Maxillary third molar flap design by Ward, 1956.
Fig. 10. Modified Ward approach for maxillary third molar,
1956.
Fig. 11. Mandibular third molar flap design by Kruger, 1959.
Fig. 12. Modified Kruger approach for Mandibular third
molar, 1959.
Fig. 13. Maxillary third molar flap design by Kruger, 1959.
from this point, it is extended over the alveolar ridge
and down on the buccal side (Figure 5).12 It was Thoma
who proposed the term odontectomy to describe the
surgical removal of teeth.
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ORAL AND MAXILLOFACIAL SURGERY
4 Sifuentes-Cervantes et al.
Fig. 14. Maxillary third molarflap design by Partsch, 1897.
Fig. 15. Mandibular third molar flap design by Berwick,
1966.
Fig. 16. Mandibular third molar flap design by Smyd, 1971.
Fig. 17. Mandibular third molar flap design by Magnus,
1972.
Fig. 18. Comma flap design by Nageshwar, 2002.
In 1933, William Kelsey Fry (1889-1963) first
described the “split bone technique.”13 However, it
was 23 years later when the technique was officially
published by Terrence George Ward (1906-1991).15
He stated that a 5-mm chisel should be placed distal to
the third molar, with the beveled side upwards and the
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&& 2021
cutting edge parallel to the external oblique ridge. The
rationale was that if the cutting edge was placed paral-
lel to the internal aspect of the mandible, it could cause
the split to extend to the coronoid process. The buccal
plate was to be removed, and elevation of the tooth
was performed (Figures 6,7).13
The following year, Wilfred Fish (1894-1974)
refined the osteotomy technique.14 His contribution
was the concept of sectioning the tooth with a chisel
and mallet. This was accomplished with a
“considerable blow” to the tooth. He used a burr to cre-
ate troughs that facilitated extractions via the creation
of a fulcrum.14 In his 1934 paper, Fish wrote that the
literature on impacted wisdom teeth was already
“voluminous.” Warwick James (1874-1965) stated in
1937 that wide flaps were to be sutured only once and
with little tension to facilitate healing and to reduce
swelling. He also recommended one day of bed rest
after surgery.15 In 1956, Ward described 3 incisions
that are widely used today for both upper and lower
third molars. The incision for the lower third molar
starts on the retromolar pad distobuccally to the third
molar, continues through the sulcus, and finishes with a
vertical incision buccal to the third molar (Figure 8).16
The incision for the upper third molar is similar, start-
ing on the retromolar pad distobuccally to the third
molar, and continues through the sulcus. He described
2 variations in which a vertical incision can be added
depending on visibility (Figures 9,10).18
Harold C. Kilpatrick was one of the first to compare
the use of chisel and mallet, low-speed burr (40,000
rpm), and high-speed burr (200,000 rpm). He noted
that cutting bone with a high-speed burr resulted in bet-
ter postoperative healing. He compared 2 groups of
patients where half of them had third molars removed
using a chisel and mallet and the other half using a
high-speed drill. His study showed that most patients
in the high-speed group had less postoperative pain,
less swelling, and faster healing.17
In 1959, Gustav Otto Kruger (1916-2010), then chair
of the Oral Surgery Department of Georgetown Uni-
versity Dental School, described an envelope flap, in
which a distal-buccal incision is made and continued
into a crevicular incision. A modified version with a
mesial vertical incision was also described for better
visibility (Figures 11,12).18 He also described an
approach for distally angled maxillary third molars. It
consisted of a distal mid-crest incision allowing reflec-
tion of both a palatal and buccal flap (Figure 13).18 The
following year, in 1960, Guillermo Ries-Centeno, pro-
fessor and chair of the Oral Surgery Department at Uni-
versidad de Buenos Aires in Argentina, published El
Tercer Molar Inferior Retenido.19 He provided an in-
depth description of all of the surgical approaches to
the impacted lower third molar. Just as with Kruger's
 ARTICLE IN PRESS
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Volume 00, Number 00
Textbook of Oral Surgery, Ries-Centeno's El Tercer
Molar Inferior Retenido and Cirug
ıa Bucal—Con
Patolog
ıa, Cl
ınica y Terap
eutica rapidly became man-
datory textbooks in most Latin American dental
schools. In 1897, Carl Partsch described a flap for api-
cal surgery; it was later used for upper third molar
extractions (Figure 14).20
In 1966, Alistair Berwick described a flap that he
stated provided a good blood supply, good vision for
instrumentation, and minimum trauma when reflecting
it. The first incision started on the distal point but lat-
erally and downwards, and then a second incision was
made following the external oblique ridge to meet the
first incision with the intention of forming a curved
angle.21 (Figure 15). In 1971, Lucian Szmyd described
numerous techniques to section impacted lower molars
to facilitate extractions. He described an incision start-
ing at the distal surface of the second molar, with a
buccal continuation 5 mm below the gingival margin
of the second molar that ended in a vertical fashion
(Figure 16).22
In 1972, Walt W. Magnus published an approach
that was a novelty at the time. His incision mimicked
the envelope flap; however, it was made 5 mm below
the gingival margin. He explained that the approach
required no sutures and that the postoperative healing
was faster.23 This flap is sometimes chosen when the
patient is under orthodontic treatment at the time of
surgery (Figure 17). In 1999, Donlon and Triuta pub-
lished a minimally invasive approach where an incision
is made on the distal mid-crest aspect of the second
molar and extended buccally and distally toward the
external oblique ridge. They stated that less postopera-
tive swelling and pain and faster healing were advan-
tages of this technique.24
The beginning of the 21st century witnessed the
advent of new surgical proposals to gain access to
impacted third molars. In 2002, Iyer Nageshwar pro-
posed the comma flap, which is an incision on a disto-
buccal point below the second molar that smoothly
curves up to meet the gingival crest at the distobuccal
angle line of the second molar (Figure 18).25 He stud-
ied 2 groups of 50 patients each were his technique
was compared to a traditional flap design. With his
technique there was less postoperative pain, swelling,
and periodontal defects after healing.
CURRENT TRENDS AND CONTROVERSIES IN
THIRD MOLAR SURGERY
Removal of impacted third molars is one of the most
common procedures performed today. As with all sur-
gical procedures, it is associated with postoperative
complications. The most common complications are
pain, swelling, ecchymosis, trismus, infection, and
hematoma. Damage to the inferior alveolar or lingual
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Sifuentes-Cervantes et al. 5
nerves and fracture of the mandible can also occur.26
Contemporary surgery aims to reduce complications
through a variety of modalities. These include analge-
sics and corticosteroids, antibiotics, flap designs,
sutures, drains, and additional therapies such as ozone,
cryotherapy, platelet-rich plasma (PRP), platelet-rich
fibrin (PRF), piezoelectric surgery, and lasers.26-70
Analgesics and corticosteriods
Analgesics and corticosteroids are frequently used to
prevent postoperative pain, swelling, and trismus.
Ngeow and Lim reviewed outcomes of corticosteroid
use after third molar surgery and concluded that there
are benefits from short-term corticosteroids, which
include reduction in pain, swelling, and trismus.27 Sim-
ilarly, Herrera-Briones et al. found that corticosteroids
significantly improve postoperative quality of life by
reducing trismus and swelling when parenteral cortico-
steroids are administered before surgery.28
Antibiotics
Controversy exists regarding prophylactic and postop-
erative antibiotic therapy. Pasupathy and Alexander
evaluated the effectiveness of prophylactic antibiotic
in a randomized clinical trial with 89 patients.29 They
found no significant advantage in their routine use.
Similar results were obtained by Siddiqi et al. in a ran-
domized, double-blind, placebo-controlled clinical trial
with 100 third molar patients.30 They found that pro-
phylactic antibiotics did not have a significant effect on
pain, swelling, infection, trismus, or postoperative
infections. Multiple studies have suggested that postop-
erative antibiotic therapy is unnecessary in the absence
of infection.31,32
Wound closure and flap design
Intraoperative flap designs, wound closure, and place-
ment of drains have been studied to see whether their
use reduces postoperative pain, trismus, and swelling.
Erdogan et al. compared envelope and triangular flaps
and noted a decrease in facial swelling and pain when
using the envelope flap.33 However, there were no sig-
nificant differences between the 2 flap designs in opera-
tive time, trismus, and number of analgesics taken after
surgery. In another study where the same flaps were
compared, there was increased facial swelling and tris-
mus when a triangular flap when was used.34 Kirk et al.
also found increased facial swelling with a modified tri-
angular flap compared to a buccal envelope flap.35
They saw no significant differences in postoperative
pain and trismus. Collectively these studies suggest
that an envelope flap may reduce postoperative pain
and swelling compared to the triangular flap. It is likely
that the anterior releasing incision of the triangular flap
induces a greater inflammatory response and
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ORAL AND MAXILLOFACIAL SURGERY
6 Sifuentes-Cervantes et al.
postoperative pain secondary to the incised periosteum
and subsequent masticatory muscle injury.
Wound closure and drains
Bello et al. reported significant reduction in facial
swelling when partial closure of the wound was done
instead of complete closure.36 Pachipulusu and Man-
jula found that secondary closure was superior to pri-
mary closure in terms of postoperative pain, swelling,
and trismus.37 They saw no differences in trismus and
pain between the 2 techniques. Wound closure had no
effect on the periodontal health of the second molar.
Many papers have reported that a drain can reduce
postoperative facial swelling.38-40 Collectively, these
studies show that allowing drainage following the
removal of the third molar has a positive effect in
reducing facial swelling.
Adjunctive measures
Ozone gel. Ozone gel has been reported to have bene-
ficial effects after third molar surgery. It is thought to
enhance oxygen metabolism, induce enzyme prolifera-
tion, and activate the immune response. Combined,
this results in a reduction in postoperative infection,
improved tissue regeneration, and early wound heal-
ing.41 Sivalingam et al. found a significant reduction in
pain, swelling, and trismus in patients using ozone gel
with no significant secondary effects.42 In another ran-
domized clinical trial, Kazancioglu et al. found signifi-
cant decrease in pain but no differences in trismus or
swelling when applying the ozone gel after third molar
surgery.43 Ozone gel promises to be a good coadjutant
therapy following third molar surgery, but its cost does
not make it a popular option for use on a daily basis.
Cryotherapy or ice. External application of ice follow-
ing surgery is simple and used by many clinicians.
Low temperatures cause vasoconstriction and decrease
postoperative swelling. Cryotherapy can diminish
nerve conduction velocity, resulting in an analgesic
effect.44 However, its use following removal of
impacted third molars is controversial. Multiple clini-
cal studies have been inconclusive regarding the effi-
cacy of cryotherapy,45-48 whereas others suggest that it
improves quality of life and reduces pain and swell-
ing.49,50 In a systematic review, do Nascimento-J
unior
et al. reported that cryotherapy may provide a small
benefit in decreasing pain but not on facial swelling
and trismus.51
Platelet-rich plasma and platelet-rich fibrin. The indi-
cations for use of platelet concentrates such as PRP
and PRF have exploded in recent years in modern den-
tistry. Platelets trapped within a fibrin matrix release
growth factors that stimulate angiogenesis,
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&& 2021
mitogenesis, and macrophage activation. Additionally,
it stimulates bone regeneration and remodeling, as well
as cell growth, proliferation, and differentiation.52 PRP
releases its growth factors after a few days, whereas
PRF displays a continual and steady release of growth
factors over a 10-day period.53 The efficiency of local
application of platelet products to minimize the postop-
erative complications after third molar surgery has
been studied widely.
In a prospective randomized clinical trial with 60
patients, Ogundipe et al. noted that PRP gel reduced
pain, swelling, and trismus.54 Other studies have
reported that PRF is effective in diminishing postopera-
tive swelling and pain when applied inside the socket
after third molar surgery.55 Yelamali and Saikrishna
compared the effectiveness of PRP and PRF on the soft
tissue and bone healing of extracted third molar sock-
ets.56 PRF was significantly better in promoting soft
tissue healing and faster regeneration of bone com-
pared to PRP. These results may be related to the pro-
longed and steady release of growth factors of PRF
compared to PRP. Systematic reviews and meta-analy-
ses have had conflicting results when comparing PRP
and PRF on the healing process after third molar sur-
gery. Some studies show no significant findings,57-59
whereas others report diminishing pain, swelling, and
incidence of alveolar osteitis when PRF is locally
applied.60,61
Laser therapy. Laser therapy has been used to treat
dentin hypersensitivity, temporomandibular joint disor-
ders, paresthesia of the inferior alveolar nerve, and tri-
geminal neuralgia.62 A therapeutic laser evokes
cellular biostimulation, which accelerates wound heal-
ing and tissue regeneration, resulting in a reduction in
pain and swelling.63 Ferrante et al. applied low-level
laser therapy (LLLT) intraorally and extraorally after
third molar surgery and reported a reduction in postop-
erative discomfort.64 However, L
opez-Ram
ırez et al.
reported no beneficial effects of LLLT in third molar
surgery.65 Different treatment protocols and laser
parameters in both studies could explain the differen-
ces in their outcomes. Sierra et al. compared the effec-
tiveness of photo biomodulation therapy (PBMT) after
third molar surgery.66 A statistically significant reduc-
tion in swelling and trismus was noticed when a combi-
nation of both extraoral and intraoral PBMT specific
wavelengths were applied. Laser therapy is still experi-
mental; however, promising results are being reported
as new studies arise.
Piezoelectric surgery. Another controversial topic is
the use of piezoelectric versus a conventional rotary
drill to perform third molar surgery. The piezoelectric
technique is based on 2 fundamental concepts:
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Volume 00, Number 00
minimum invasiveness and predictability of the surgi-
cal procedure. Piezoelectric prevents heat and is tissue
selective. Clinically this concept translates into mini-
mal soft tissue damage, decreased pain, and diminished
swelling after surgery.67 Randomized clinical trials and
a meta-analyses comparing both techniques have con-
cluded that rotary instruments are faster than a piezo-
electric technique but piezoelectric surgery is more
effective in reducing pain, swelling, and trismus in
third molar surgery.68-70
THE FUTURE OF THIRD MOLAR SURGERY
The future of third molar surgery is still developing
during present times. Transoral robotic surgery
(TORS) could make a great impact on third molar sur-
gery, just as it has done in procedures such as tonsillec-
tomies, retromolar trigone tumors, and base of tongue
neoplasms.71-73 In those procedures, TORS has pro-
vided excellent 3D visualization and instrument access,
which have allowed successful surgical resections from
cadaver models to human patients. TORS therefore has
the potential to make extraction of third molars easier,
especially in patients with decreased mouth openings.
On the other hand, navigation surgery has already
been successfully employed for complex trauma cases
and retrieval of projectiles or broken needles.74 This
technology can be applied to extraction of third molars,
ideally in cases where third molars have unusual loca-
tions or are closely involved with other structures such
as the inferior alveolar nerve.
CONCLUSION
As science continues to evolve and new discoveries are
made, third molar surgery will continue to flourish and the
new technologies will slowly be embraced to provide the
best treatment to our patients. Throughout history, dentists
and oral and maxillofacial surgeons have overcome the
clinical and technical challenges imposed by the diseases/
conditions we see daily. Surely, the next generation of sur-
geons will continue to incorporate technology into clinical
practice to propose better or more efficient strategies. One
can only imagine what the future holds for us in this
never-ending journey of the pursuit of the best treatment/
cure for our patients.
ACKNOWLEDGMENT
The authors express their gratitude to the librarians at
the University of Puerto Rico, University of Kentucky,
and New York University Langone Health for their
outstanding job with the literature search.
REFERENCES
1. Coppa A, Bondioli L, Cucina A, et al. Paleontology: early Neo-
lithic tradition of dentistry. Nature. 2006;440:755-756.
REVIEW ARTICLE
Sifuentes-Cervantes et al. 7
2. Wynbrandt J. The Excruciating History of Dentistry: Toothsome
Tales and Oral Oddities from Babylon to Braces. New York,
NY: St. Martin's Press; 1998.
3. Aristotle. Minor Works. Cambridge, MA: Harvard University
Press; 1936.
4. Guerini V. A History of Dentistry From the Most Ancient Times
Until the End of the 18th Century. Pound Ridge, NY: Milford;
1969.
5. Gualteri H. In: Acute treatment of diseases of children with vari-
ous observations, Cramer & Perachon; 1727.
6. Grooss KS. In: Cornelis Solingen: A Seventeenth-Century Sur-
geon and His Instruments, Netherlands: Leiden:Museum Boer-
haave; 1990.
7. Kells CE. Impacted lower third molars. Dental Cosmos.
1918;60:101-107.
8. Kells CE. Impacted lower third molars. Dental Cosmos.
1921;63:101-114.
9. Kells CE. Removal of the impacted third molar: stereoscopic
Skiagraphy. Dent Dig. 1904;10:1-17.
10. Winter GB. Principles of Exodontia as Applied to the
Impacted Mandibular Third Molar. A Complete Treatise on
the Operative Technic With Clinical Diagnoses and Radio-
graphic Interpretations. St. Louis, MO: American Medical
Book Comp.; 1926.
11. Mead SV. Incidence of impacted teeth. Int J Orthod.
1930;16:885-890.
12. Thoma KH. The management of malposed inferior third molars.
J Dent Res. 1932;12:175-208.
13. Fry WK. The third molar. Br Dent J. 1933;54:385-388.
14. Fish EW. The removal of the impacted third lower molar. Br
Dent J. 1934;56:225-234.
15. James WW. Operation for the removal of impacted third man-
dibular molars. Br Dent J. 1937;63:450-454.
16. Ward TG. The split bone technique for removal of lower third
molars. Br Dent J. 1956;201:297-304.
17. Kilpatrick H. Removal of impacted third molars utilizing speeds
up to 200,000 R.P.M. Oral Surg Oral Med Oral Pathol.
1958;11:364-369.
18. Kruger GO. Management of impactions. Dent Clin North Am.
1959;3:707-722.
19. Ries Centeno GA. The Impacted Lower Third Molar. Buenos
Aire, Argentina: El Ateneo; 1960.
20. Partsch C. Third report of the Polyclinic for Oral and Dental Dis-
eases of the University of Breslau. Dt Mschr Zahnhk.
1896;14:486-499.
21. Berwick WA. Alternative method of flap reflection. Br Dent J.
1966;121:295-296.
22. Szmyd L. Impacted teeth. Dent Clin North Am. 1971;15:299-
318.
23. Magnus WW, Castner DV, Hiatt WR. An alternative method of
flap reflection for mandibular third molars. Mil Med.
1972;137:232-233.
24. Donlon WC, Truta MP. Minimally invasive third molar surgery.
Int J Oral Maxillofac Surg. 1999;28:57.
25. Nageshwar P. Comma incision for impacted mandibular third
molars. J Oral Maxillofac Surg. 2002;60:1506-1509.
26. Bouloux GF, Steed MB, Perciaccante VJ. Complications of third
molar surgery. Oral Maxillofac Surg Clin North Am.
2012;20:233-251.
27. Ngeow WC, Lim D. Do corticosteroids still have a role in the
management of third molar surgery? Adv Ther. 2016;33:1105-
1139.
28. Herrera-Briones FJ, Prados S
anchez E, Reyes Botella C, et al.
Update on the use of corticosteroids in third molar surgery:
 ARTICLE IN PRESS
ORAL AND MAXILLOFACIAL SURGERY
8 Sifuentes-Cervantes et al.
systematic review of the literature. Oral Surg Oral Med Oral
Pathol Oral Radiol. 2013;116:e342-e351.
29. Pasupathy S, Alexander M. Antibiotic prophylaxis in third molar
surgery. J Craniofac Surg. 2011;22:551-553.
30. Siddiqi A, Morkel JA, Zafar S. Antibiotic prophylaxis in third
molar surgery: a randomized double-blind placebo-controlled
clinical trial using split-mouth technique. Int J Oral Maxillofac
Surg. 2010;39:107-114.
31. Calvo AM, Brozoski DT, Giglio FPM, et al. Are antibiotics nec-
essary after lower third molar removal? Oral Surg Oral Med
Oral Pathol Oral Radiol. 2012;114:S199-S208.
32. Vlcek D, Razavi A, Kuttenberger JJ. Antibiotics in third molar
surgery. Swiss Dent J. 2014;124:294-302.
33. Erdogan O, € Tatlı U, Ust€
€ un Y, et al. Influence of two different
flap designs on the sequelae of mandibular third molar surgery.
Oral Maxillofac Surg. 2011;15:147-152.
34. Baqain ZH, Al-Shafii A, Hamdan AA, et al. Flap design and
mandibular third molar surgery: a split mouth randomized clini-
cal study. Int J Oral Maxillofac Surg. 2012;41:1020-1024.
35. Kirk DG, Liston PN, Tong DC, et al. Influence of two different
flap designs on incidence of pain, swelling, trismus, and alveolar
osteitis in the week following third molar surgery. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 2007;104:e1-e6.
36. Bello SA, Olaitan AA, Ladeinde AL. A randomized comparison
of the effect of partial and total wound closure techniques on
postoperative morbidity after mandibular third molar surgery. J
Oral Maxillofac Surg. 2011;69:e24-e30.
37. Pachipulusu PK, Manjula S. Comparative study of primary and
secondary closure of the surgical wound after removal of
impacted mandibular third molars. Oral Maxillofac Surg.
2018;22:261-266.
38. Ferreira Cerqueira PR, Do Egito Vasconcelos BC, Bessa-
Nogueira RV. Comparative study of the effect of a tube drain in
impacted lower third molar surgery. J Oral Maxillofac Surg.
2004;62:57-61.
39. Kumar B, Bhate K, Dolas RS, et al. Comparative evaluation of
immediate post-operative sequelae after surgical removal of
impacted mandibular third molar with or without tube drain—
split-mouth study. J Clin Diagn Res. 2016;10:ZC46-ZC49.
40. Zandi M. Comparison of corticosteroids and rubber drain for
reduction of sequelae after third molar surgery. Oral Maxillofac
Surg. 2008;12:29-33.
41. Nogales CG, Ferrari PH, Kantorovich EO, et al. Ozone ther-
apy in medicine and dentistry. J Contemp Dent Pract.
2008;1:75-84.
42. Sivalingam VP, Panneerselvam E, Raja KVB, et al. Does topical
ozone therapy improve patient comfort after surgical removal of
impacted mandibular third molar? A randomized controlled trial.
J Oral Maxillofac Surg. 2017;75. 51.e1-51.e9.
43. Kazancioglu HO, Kurklu E, Ezirganli S. Effects of ozone ther-
apy on pain, swelling, and trismus following third molar surgery.
Int J Oral Maxillofac Surg. 2014;43:644-648.
44. Gelesko S, Long L, Faulk J, et al. Cryotherapy and topical mino-
cycline as adjunctive measures to control pain after third molar
surgery: an exploratory study. J Oral Maxillofac Surg. 2011;69:
e324-e332.
45. Van der Westhuijzen AJ, Becker PJ, Morkel J, et al. A random-
ized observer blind comparison of bilateral facial ice pack ther-
apy with no ice therapy following third molar surgery. Int J Oral
Maxillofac Surg. 2005;34:281-286.
46. Zandi M, Amini P, Keshavarz A. Effectiveness of cold therapy
in reducing pain, trismus, and oedema after impacted mandibular
third molar surgery: a randomized, self-controlled, observer-
blind, split-mouth clinical trial. Int J Oral Maxillofac Surg.
2016;45:118-123.
OOOO
&& 2021
47. Greenstein G. Therapeutic efficacy of cold therapy after intraoral
surgical procedures: a literature review. J Periodontol.
2007;78:790-800.
48. Altiparmak N, Bayram B, Diker N, et al. Efficacy of ice pack
therapy after impacted third molar surgery: a randomized con-
trolled clinical trial. Turkiye Klinikleri Journal of Dental Scien-
ces. 2017;24:19-25.
49. Ibikunle AA, Adeyemo WL. Oral health related quality of life
following third molar surgery with or without application of ice
pack therapy. Oral Maxillofac Surg. 2016;20:239-247.
50. Laureano Filho JR, De Oliveira e Silva ED, Camargo IB, et al.
The influence of cryotherapy on reduction of swelling, pain and
trismus after third-molar extraction: a preliminary study. J Am
Dent Assoc. 2005;136:774-778.
51. do Nascimento-J
unior EM, dos Santos GMS, Tavares Mendes
ML, et al. Cryotherapy in reducing pain, trismus, and facial
swelling after third-molar surgery: systematic review and meta-
analysis of randomized clinical trials. J Am Dent Assoc.
2019;150:269-277.
52. Gassling V, Douglas T, Warnke PH, et al. Platelet-rich fibrin
membranes as scaffolds for periosteal tissue engineering. Clin
Oral Implants Res. 2010;21:543-549.
53. Kobayashi E, Fl€uckiger L, Fujioka-Kobayashi M, et al. Compar-
ative release of growth factors from PRP, PRF, and advanced-
PRF. Clin Oral Investig. 2016;20:2353-2360.
54. Ogundipe OK, Ugboko VI, Owotade FJ. Can autologous plate-
let-rich plasma gel enhance healing after surgical extraction of
mandibular third molars? J Oral Maxillofac Surg.
2011;69:2305-2310.
55. Ozgul O, Senses F, Er N, et al. Efficacy of platelet rich fibrin in
the reduction of the pain and swelling after impacted third molar
surgery: randomized multicenter split-mouth clinical trial. Head
Face Med. 2015;26:37.
56. Yelamali T, Saikrishna D. Role of platelet rich fibrin and platelet
rich plasma in wound healing of extracted third molar sockets: a
comparative study. J Maxillofac Oral Surg. 2015;14:410-416.
57. Al-Hamed FS, Tawfik MAM, Abdelfadil E, et al. Efficacy of
platelet-rich fibrin after mandibular third molar extraction: a sys-
tematic review and meta-analysis. J Oral Maxillofac Surg.
2017;75:1124-1135.
58. Barona-Dorado C, Gonz
alez-Regueiro I, Mart
ın-Ares M, et al.
Efficacy of platelet-rich plasma applied to post-extraction
retained lower third molar alveoli. A systematic review. Med
Oral Patol Oral Cir Bucal. 2014;1:e142-e148.
59. do Canellas JVS, Ritto FG, Medeiros PJD. Evaluation of postop-
erative complications after mandibular third molar surgery with
the use of platelet-rich fibrin: a systematic review and meta-anal-
ysis. Int J Oral Maxillofac Surg. 2017;46:1138-1146.
60. Xiang X, Shi P, Zhang P, et al. Impact of platelet-rich fibrin on
mandibular third molar surgery recovery: a systematic review
and meta-analysis. BMC Oral Health. 2019;19:1-10.
61. He Y, Chen J, Huang Y, et al. Local application of platelet-rich
fibrin during lower third molar extraction improves treatment
outcomes. J Oral Maxillofac Surg. 2017;75:2497-2506.
62. Amarillas-Escobar ED, Toranzo-Fern
andez JM, Mart
ınez-Rider
R, et al. Use of therapeutic laser after surgical removal of
impacted lower third molars. J Oral Maxillofac Surg.
2010;68:319-324.
63. Coluzzi DJ, Convissar RA. Lasers in clinical dentistry. Dent Clin
North Am. 2004;48:xi-xii.
64. Ferrante M, Petrini M, Trentini P, et al. Effect of low-level laser
therapy after extraction of impacted lower third molars. Lasers
Med Sci. 2013;28:845-849.
65. L
opez-Ram
ırez M, V
ılchez-P
erez MA,
Gargallo-Albiol J, et al.
Efficacy of low-level laser therapy in the management of pain,
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Volume 00, Number 00
facial swelling, and postoperative trismus after a lower third
molar extraction. A preliminary study. Lasers Med Sci.
2012;27:559-566.
66. Sierra SO, Deana AM, Bussadori SK, et al. Choosing between
intraoral or extraoral, red or infrared laser irradiation after
impacted third molar extraction. Lasers Surg Med. 2016;48:511-
518.
67. Keyhan SO, Fallahi HR, Cheshmi B, Mokhtari S, Zandian D,
Yousefi P. Use of piezoelectric surgery and Er:YAG laser: which
one is more effective during impacted third molar surgery? Max-
illofac Plast Reconstr Surg. 2019;41:1-10.
68. Sortino F, Pedulla E, Masoli V. The piezoelectric and rotatory
osteotomy technique in impacted third molar surgery: compari-
son of postoperative recovery. J Oral Maxillofac Surg.
2008;66:2444-2448.
69. Basheer SA, Jay Govind R, Daniel A, et al. Comparative study
of piezoelectric and rotary osteotomy technique for third molar
impaction. J Contemp Dent Pract. 2017;1:60-64.
70. Magesty RA, Galv~ao EL, de Castro Martins C, et al. Rotary
instrument or piezoelectric for the removal of third molars: a
meta-analysis. J Maxillofac Oral Surg. 2017;16:13-21.
REVIEW ARTICLE
Sifuentes-Cervantes et al. 9
71. O'Malley BW, Weinstein GS, Snyder W, Hockstein NG. Transo-
ral robotic surgery (TORS) for base of tongue neoplasms. Laryn-
goscope. 2006;116:1465-1472.
72. Durmus K, Apuhan T, Ozer E. Transoral robotic surgery for ret-
romolar trigone tumours. Acta Otorhinolaryngol Ital.
2013;33:425-427.
73. Weinstein GS, O'Malley BW, Snyder W, Sherman E, Quon H.
Transoral robotic surgery: radical tonsillectomy. Arch Otolar-
yngol Head Neck Surg. 2007;133:1220-1226.
74. Demian N, Pearl C, Woernley TC, Wilson J, Seaman J. Surgical
navigation for oral and maxillofacial surgery. Oral Maxillofac
Surg Clin North Am. 2019;31:531-538.
Reprint requests:
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Paseo Dr. Jose Celso Barbosa,
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