The Effect of Different Flap Closure Techniques on Postoperative Morbidity: A Randomized Controlled Trial for Impacted Third Molar Surgery
Phase: NA
Conditions: Impacted Mandibular Third Molar, Postoperative Morbidity, Oral Surgery
Sponsor: Recep Tayyip Erdogan University

STUDY PROTOCOL 
1. Project Title: The Effect of Different Flap Closure Techniques on Postoperative Morbidity: A 
Randomized Controlled Study for Impacted Third Molar Surgery 
2. Significance of the Project: This study aims to evaluate the relationship between different flap 
closure techniques (surgical drain, cyanoacrylate, sutureless technique, and conventional 
suturing) and postoperative complications such as pain, swelling, and trismus, as well as the 
physical monitoring of wound healing and potential changes in patients’ quality of life following 
the surgical extraction of impacted mandibular third molars. 
3.1 Background and Rationale: 
Surgical extraction of impacted mandibular third molars (IMTM) is one of the most commonly 
performed oral surgical procedures worldwide [1]. These surgeries are of great significance for both 
patients and surgeons, as frequently occurring postoperative complications can negatively affect the 
quality of life of individuals undergoing the procedure [2]. The primary reason for impaired quality 
of life following IMTM surgery is the exaggerated inflammatory response, including bleeding, pain, 
swelling, and trismus. 
To minimize these symptoms, various studies have focused on preoperative and postoperative 
medications, laser therapy, acupuncture, kinesitherapy, cryotherapy, and ozone therapy as 
complementary treatments [3-8]. In addition to the reported pharmacologic and complementary 
approaches, studies have also examined different surgical techniques aimed at the same goal, 
including various flap types, anesthesia methods, interalveolar agents, use of drainage tubes, tissue 
adhesives, surgical sutures, and sutureless techniques [6,9-13]. 
After IMTM extraction, the mucoperiosteum may be allowed to heal either primarily (hermetically 
closed) or secondarily (leaving a small opening at the surgical site). Intraoral placement of a surgical 
drain has been proposed as a procedure that could reduce postoperative discomfort and facilitate 
drainage of blood, serum, or potential necrotic tissue and debris [14]. Although some clinical studies 
have analyzed the effect of drainage, results remain inconsistent, and further randomized studies are 
needed [6,14]. 
In recent years, tissue adhesives have gained popularity as a potential method to address the 
complications mentioned above. Currently, cyanoacrylate is the most widely used tissue adhesive. 
Its high tensile strength, rapid polymerization, biocompatibility, hemostatic properties, ease of 
application, and bacteriostatic characteristics make it an attractive option for oral surgical procedures. 
It is non-resorbable in the oral cavity and detaches from the oral mucosa over 7–10 days [15]. 
However, there are only a limited number of clinical studies evaluating postoperative surgical 
outcomes such as pain, swelling, trismus, and healing when comparing cyanoacrylate and sutures for 
flap closure in IMTM surgery [10,15]. 
Primary or secondary healing has been a subject of debate in the literature, with conflicting views 
regarding its effect on postoperative outcomes. Some surgeons advocate for primary suturing of 
extraction sockets after IMTM surgery, stating that it effectively controls bleeding, prevents 
contamination of the surgical site, improves healing quality and speed, and offers cost advantages 
[16,17]. Other surgeons prefer the sutureless technique, arguing that it facilitates drainage of 
inflammatory exudate, minimizes postoperative tension in surrounding soft tissues, and reduces the 
risk of infection and inflammatory reaction [13]. Additionally, empirical observations suggest that 
most primarily closed wound edges tend to separate and eventually heal secondarily. A review of the 
literature reveals numerous studies with conflicting results evaluating these techniques individually 
[18-20]. However, there are relatively few studies comparing these techniques directly. 
Considering all these perspectives, the present study aims to compare the effects of primary flap 
closure using surgical drains, cyanoacrylate, sutureless techniques, and conventional sutures on 
postoperative complications following impacted mandibular third molar surgery. 
15.08.2025

References 
1. Falci SGM, Guimarães MTBÁ, Al-Moraissi EA et al (2022) Top 100 cited publications in the 
field of third molar surgery: a biblio metric analysis. J Stomatol Oral Maxillofac Surg 123:e489–
e498. https://doi.org/10.1016/j.jormas.2022.07.007  
2. Duarte-Rodrigues L, Miranda EFP, Souza TO et al (2018) Third molar removal and its impact on 
quality of life: systematic review and meta-analysis. Qual Life Res 27:2477–2489. https://doi.org/ 
10.1007/s11136-018-1889-1  
3. Alcântara CEP, Falci SGM, Oliveira-Ferreira F et al (2014) Pre emptive effect of dexamethasone 
and methylprednisolone on pain, swelling, and trismus after third molar surgery: a split-mouth 
randomized 
triple-blind 
clinical 
trial. 
Int 
J 
Oral 
Maxillofac 
Surg 
43:93–98. 
https://doi.org/10.1016/j.ijom.2013.05.016  
4. Bianchi de Moraes M, Gomes de Oliveira R, Raldi FV et al (2020) Does the low-intensity laser 
protocol affect tissue healing after third molar removal? J Oral Maxillofac Surg 78:1920.e1-1920. 
e9. https://doi.org/10.1016/j.joms.2020.05.018  
5. Armond ACV, Glória JCR, Dos Santos CRR et al (2019) Acupuncture on anxiety and 
inflammatory events following surgery of mandibular third molars: a split-mouth, randomized, triple-
blind 
clinical 
trial. 
Int 
J 
Oral 
Maxillofac 
Surg 
48:274–281. 
https://doi. 
org/10.1016/j.ijom.2018.07.016  
6. Menziletoglu D, Guler AY, Basturk F, Isik BK (2020) Compari son of surgical drain placement 
with use of kinesiologic tape on postoperative pain, swelling, and trismus in impacted mandibular 
third 
molar 
surgery. 
J 
Oral 
Maxillofac 
Surg 
78:1919.e1-1919.e7. 
https://doi.org/10.1016/j.joms.2020.06.023  
7. Kjærgaard Larsen M, Kofod T, Starch-Jensen T (2021) The use of cryotherapy in conjunction with 
surgical removal of mandibular third molars: a single-blinded randomized controlled trial. J Oral 
Maxillofac Res 12:e2. https://doi.org/10.5037/jomr.2021.12402  
8. Glória JCR, Douglas-de-Oliveira DW, Silva E, LDA et al (2020) Influence of ozonized water on 
pain, oedema, and trismus dur ing impacted third molar surgery: a randomized, triple blind clinical 
trial. BMC Oral Health 20:41. https:// doi. org/ 10. 1186/ s12903-020-1029-5  
9. Costa S-M, Ribeiro B-C, Gonçalves A-S et al (2022) Double blind randomized clinical trial 
comparing minimally- invasive envelope flap and conventional envelope flap on impacted lower 
third molar surgery. Med Oral Patol Oral Cir Bucal 27:e518–e524. https:// doi. 
org/10.4317/medoral.25425  
10. Santmartí-Oliver, M., Bazal-Bonelli, S., Sánchez-Labrador, L., Beca-Campoy, T., Pérez-
González, F., Cobo-Vázquez, C. M., Madrigal Martínez-Pereda, C., & Meniz-García, C. (2024). 
Cyanoacrylate versus suture as flap closure methods in mandibular third molar surgery: a split-mouth 
randomized controlled clinical study. Medicina oral, patologia oral y cirugia bucal, 29(4), e458–
e467. https://doi.org/10.4317/medoral.26375 3  
 
11. Yamashita K, Kibe T, Shidou R et al (2020) Difference in the effects of lidocaine with 
epinephrine and prilocaine with fely pressin on the autonomic nervous system during extraction of 
the impacted mandibular third molar: a randomized controlled trial. J Oral Maxillofac Surg 
78:215.e1-215.e8. https:// doi. org/ 10. 1016/j. joms.2019.09.019  
12. Canellas JVDS, Fraga SRG, Santoro MF et al (2020) Intrasocket interventions to prevent alveolar 
osteitis after mandibular third molar surgery: a systematic review and network meta-analysis. J 
Craniomaxillofac Surg 48:902–913. https:// doi. org/ 10. 1016/j. jcms.2020.06.012  

13. Takadoum S, Douilly G, de Boutray M et al (2022) Sutureless socket technique after removal of 
third molars: a multicentric, open, randomized controlled trial. BMC Oral Health 22:256. 
https://doi.org/10.1186/s12903-022-02287-y  
14. Genc, A., Cakarer, S., Yalcin, B. K., Kilic, B. B., Isler, S. C., & Keskin, C. (2019). A comparative 
study of surgical drain placement and the use of kinesiologic tape to reduce postoperative morbidity 
after 
third 
molar 
surgery. 
Clinical 
oral 
investigations, 
23(1), 
345–350. 
https://doi.org/10.1007/s00784-018-2442-x  
15. Gonçalves, M. W. A., Souza, M. R. F., Becheleni, M. T., Galvão, E. L., Al-Moraissi, E. A., & 
Falci, S. G. M. (2023). Does cyanoacrylate have the best postoperative outcomes after third molar 
extractions when compared to conventional sutures? A systematic review and meta-analysis. 
Heliyon, 10(1), e23058. https://doi.org/10.1016/j.heliyon.2023.e23058  
16. Falci, S. G. M., Guimarães, M. T. B. Á., Canarim, N. M., Falci, S. E., Martins, O. B. L., de Souza, 
G. M., & Galvão, E. L. (2024). Comparison of suture and sutureless techniques on postoperative 
complications after third molar surgery: a systematic review. Clinical oral investigations, 28(1), 115. 
https://doi.org/10.1007/s00784-024-05518-4  
17. Sen, A., Dhupar, V., & Akkara, F. (2024). Analysing inflammatory responses after mandibular 
third molar extraction: a comparison of suture-less and multiple suture techniques. Oral and 
maxillofacial surgery, 28(4), 1587–1594. https://doi.org/10.1007/s10006-024-01287-2  
18.Kumar MS, Natta S, Shankar G, Reddy SHK, Visalakshi D, Se shiah G V. Comparison between 
silk sutures and cyanoacrylate ad hesive in human mucosa- a clinical and histological study. J Int 
Oral Heal. 2013;5:95-100.  
19. Joshi AD, Saluja H, Mahindra U, Halli R. A comparative study: efficacy of tissue glue and sutures 
after impacted mandibular third molar removal. J Maxillofac Oral Surg. 2011;10:310-5.  
20. Oladega AA, James O, Adeyemo WL. Cyanoacrylate tissue adhe sive or silk suture for closure 
of surgical wound following removal of an impacted mandibular third molar: a randomized 
controlled study. J Cranio-Maxillofacial Surg. 2019;47:93-8. 
 
3.2. Study Methodology 
The study sample will be selected from patients presenting to the Department of Oral, Dental, and 
Maxillofacial Surgery at Recep Tayyip Erdoğan University Faculty of Dentistry with complaints 
related to impacted mandibular third molars between August 2025 and December 2025. The sample 
size has been determined based on a power analysis, and 148 patients aged 18–40 years will be 
included in the study regardless of gender. The study will be designed as a prospective, randomized 
controlled, single-blind clinical trial. The researcher responsible for postoperative evaluations will 
be blinded to patient group assignments. All patients will receive detailed information regarding the 
surgical procedure and potential complications. Written and verbal informed consent will be obtained 
from all participants before the study. 
Patients will be randomly assigned to groups after verbal and written information is provided, 
according to the inclusion and exclusion criteria listed below: 
Inclusion Criteria: 
 
Patients aged 18–40 years 
 
Patients without any systemic disease (ASA-I) 
 
Patients with impacted mandibular third molars requiring extraction, with bone and/or mucosal 
retention, and in similar positions (Pell & Gregory Class 2, Position B; Winter classification: 
vertical and mesioangular) 

Exclusion Criteria: 
 
ASA II, III, or IV patients 
 
Known allergy to anesthetic solutions 
 
Known acrylic allergy 
 
Pregnant or breastfeeding women 
 
Tobacco use ≥10 cigarettes per day 
 
Alcohol consumption 
 
Patients using antiplatelet agents 
 
Patients using anticoagulants 
 
Patients with coagulation disorders 
 
Patients with immunosuppressive diseases or receiving immunosuppressive therapy 
 
Patients with acute pain or infection 
Patients included in the study will be randomly assigned to one of four study groups using a 
computer-assisted simple randomization method after receiving the verbal explanation. The written 
form of the verbal patient information is provided below. 
Patient Information on Flap Closure Techniques 
1. Drain Application 
A small drain (a thin, soft plastic tube placed along the wound edge to reduce postoperative 
fluid accumulation and swelling) will be inserted into the extraction site to facilitate removal 
of excess fluid. This method may help reduce edema and infection risk. The drain is typically 
removed within 24–48 hours and may cause mild discomfort in some patients. 
2. Periacryl® (Biological Adhesive) Application 
The tissue adhesive (Periacryl®) is applied to approximate the wound edges. Its application is 
rapid and generally improves patient comfort. In some cases, fragmentation of the adhesive 
may be delayed, or a foreign body sensation may occur. 
3. Sutureless Technique (Secondary Wound Healing) 
The extraction site is allowed to heal naturally without any sutures or closure materials. 
Healing may be slower with this technique, but in some cases, it is considered sufficient. 
Patients must maintain careful oral hygiene. 
4. Primary Suture (Sutured Closure) 
Wound edges are approximated and held together with sutures. This method generally allows 
faster epithelial healing. Temporary discomfort such as swelling or suture irritation may occur. 
The flap closure technique applied will vary according to the assigned group. In all groups, the 
surgical procedure will be standardized, with the only difference being the wound closure 
method. Follow-up measurements will include edema, mouth opening limitation, pain levels, 
wound healing, and quality of life. 
Patients will be divided into four groups as described above: 
 
Group 1: Surgical Drain Group 
 
Group 2: Cyanoacrylate Group 
 
Group 3: Sutureless Technique 
 
Group 4: Conventional Suturing Technique 

In Group 1, after tooth extraction, the flap will be repositioned to its original position, and the 
horizontal incision will be sutured. A 2-mm diameter, 2-cm long plastic tube drain will be placed in 
the buccal vertical incision between the first and second molars and fixed to the vestibular mucosa. 
The drain will be removed 2 days after surgery [1]. 
In Group 2, the flap will be repositioned and cyanoacrylate (PeriAcryl®90 High Viscosity Dental 
Cyanoacrylate, Canada) applied along the wound edges. Once the edges are securely positioned, a 
layer of cyanoacrylate will be spread along the incision up to the mesial side of the mandibular second 
molar to ensure proper closure and sealing. After 30–60 seconds for adequate polymerization, the 
procedure will be completed according to the manufacturer’s instructions [2]. 
In Group 3, intraoral compresses will be applied for 15 minutes, and the flap will be repositioned 
and maintained with jaw pressure. If bleeding or inadequate flap repositioning occurs, sutures may 
be used in a limited fashion only at the vertical incision [3]. 
In Group 4, the vertical section distal to the second molar and the horizontal incision will be closed 
with 3/0 braided, non-absorbable silk sutures (Doğsan®, Istanbul, Turkey). 
All patients will undergo mandibular third molar surgery according to a standardized surgical 
procedure; the only difference will be the flap closure method at the end of the procedure. To ensure 
unbiased assessment of postoperative outcomes, the researcher performing postoperative evaluations 
will be blinded to the patient group assignments. 
Measurement of Outcomes: 
 
Trismus: Maximum Interincisal Opening (MIO) will be measured using a caliper between the 
upper and lower central incisors in millimeters [4] (Figure 1). 
 
Edema: Using a flexible ruler, measurements will be taken from the corner of the mouth to the 
tragus, from the pogonion to the tragus (anteroposterior), and from the lateral canthus to the 
mandibular angle (superoinferior). The arithmetic mean of three measurements will be recorded 
in millimeters [5,6] (Figure 2). Trismus and edema will be assessed at preoperative (Pre-op), 
postoperative Day 2 (D2), and postoperative Day 7 (D7). 
 
Pain: Patients will record their pain level on a Visual Analog Scale (VAS) from 0 to 10 [5] at 
preoperative (Pre-op), 6 hours post-extraction (D0), and daily at 10:00 a.m. for 7 days 
postoperatively (D1–D7) (Figure 3). 
 
Wound Healing: Wound healing will be evaluated on Day 2 (D2) and Day 7 (D7) according 
to the method described by Madrazo-Jiménez et al. [7] (Figure 4). 
 
Quality of Life: The General/Geriatric Oral Health Assessment Index (GOHAI), developed by 
Atchison et al. (1990) and validated in Turkish by Ergül et al. (2008), will be used (Table 1) 
[8,9]. GOHAI contains 12 questions on functional limitation, aesthetics, chewing efficiency, 
food selection, social impact, pain, and medication use. A trained interviewer will administer 
the questionnaire, and scores will be categorized as follows: 1–20: very poor, 21–30: poor, 31–
40: moderate, 41–50: good, 51–60: very good. GOHAI will be administered on postoperative 
Day 10 (D10) to detect potential differences in quality of life between groups. 

 
Fig. 1: Maximum Interincisal Opening 
 
Fig. 2: Measurements for Quantifying Edema 
 
AB: Distance from corner of the 
mouth to the tragus 
 
AC: Distance from pogonion to tragus 
 
EF: Distance from lateral canthus to 
gonion 
 
 
Fig. 3: Visual Analog Scale (VAS) 
 
 
 
 
Fig. 4: Wound Healing Assessment Criteria 
 

Item 
No 
Question 
Response Scale 
(1–5) 
1 
How often did you limit the types or amounts of food you ate due to 
problems with your teeth or dentures? 
1: Never – 5: 
Always 
2 
How often did you have difficulty biting or chewing foods such as hard meat 
or apples? 
1: Never – 5: 
Always 
3 
Were you able to swallow comfortably? 
1: Never – 5: 
Always 
4 
How often did your teeth or dentures prevent you from speaking as you 
wished? 
1: Never – 5: 
Always 
5 
Were you able to eat anything without discomfort? 
1: Never – 5: 
Always 
6 
How often did the condition of your teeth or dentures limit your interaction 
with other people? 
1: Never – 5: 
Always 
7 
How often were you satisfied or happy with the appearance of your teeth, 
gums, or dentures? 
1: Never – 5: 
Always 
8 
How often did you use medication to relieve pain or discomfort around your 
mouth? 
1: Never – 5: 
Always 
9 
How often were you worried or concerned about problems with your teeth, 
gums, or dentures? 
1: Never – 5: 
Always 
10 
How often did you feel tense or uncomfortable because of your teeth, gums, 
or dentures? 
1: Never – 5: 
Always 
11 
How often did you feel uncomfortable eating in front of others due to 
problems with your teeth or dentures? 
1: Never – 5: 
Always 
12 
How often were your teeth or gums sensitive to hot, cold, or sweet foods? 1: Never – 5: 
Always 
 
Table 1: General/Geriatric Oral Health Assessment Index (GOHAI) 
 
 
 
 
 
 
 
 
 
 
 
 
Always (5) 
 
 
 
 
 
 
 
 
 
 
Frequently (4) 
Sometimes (3) 
Rarely (2) 
Never (1) 
 
 
 
 
 
 

Surgical Procedure 
All surgical procedures will be performed under local anesthesia. Local anesthesia will be administered 
using a 2 ml solution containing 80 mg articaine + 0.01 mg adrenaline per 2 ml, via inferior alveolar 
nerve block and buccal nerve block. Following this, a full-thickness mucoperiosteal envelope flap will 
be elevated using a No. 15 scalpel, following horizontal and buccal releasing incisions. Procedures such 
as removal of buccal bone and, if necessary, sectioning of the tooth will be carried out using a surgical 
micromotor with tungsten carbide or steel round burs under saline irrigation. After removing the bone 
tissues that retain the impacted tooth, cleavage points will be created between the tooth and cortical bone 
at the mesial and buccal aspects, and the tooth will be extracted from the alveolar socket using a Bein 
elevator. Debris, bone fragments, and epithelial remnants in the alveolar socket will be removed after 
tooth extraction. The alveolar socket will be irrigated with 0.9% isotonic sodium chloride solution 
(physiological saline), and wound edges will be closed primarily using 3/0, 18 mm, 75 cm silk sutures 
with a 3/8 cutting needle, achieving hemostasis. 
Postoperatively, all patients will be prescribed the following medications for 7 days starting from the 
first day after surgery until suture removal: 875 mg amoxicillin + 125 mg clavulanic acid twice daily at 
12-hour intervals, 25 mg dexketoprofen trometamol twice daily, and 120 mg (0.12%) chlorhexidine 
gluconate + 150 mg (0.15%) benzydamine hydrochloride three times daily. 
Statistical Analysis 
The adequate sample size was determined based on a power analysis performed using the G*Power 
software, resulting in a total of 148 patients, with 37 cases in each group. Data will be presented using 
descriptive statistics, including mean and standard deviation. Non-parametric tests, including Spearman, 
Kruskal-Wallis, Mann-Whitney U, and Wilcoxon tests, will be used to analyze intergroup and intragroup 
differences. Repeated measures ANOVA will be conducted using parametric testing. Statistical 
significance will be set at P < 0.05, and all analyses will be performed using IBM SPSS Statistics version 
25. 
References 
1. Menziletoglu, D., Guler, A. Y., Basturk, F., & Isik, B. K. (2020). Comparison of Surgical Drain 
Placement With Use of Kinesiologic Tape on Postoperative Pain, Swelling, and Trismus in Impacted 
Mandibular Third Molar Surgery. Journal of oral and maxillofacial surgery : official journal of the 
American 
Association 
of 
Oral 
and 
Maxillofacial 
Surgeons, 
78(11), 
1919.e1–1919.e7. 
https://doi.org/10.1016/j.joms.2020.06.023  
2. Santmartí-Oliver, M., Bazal-Bonelli, S., Sánchez-Labrador, L., Beca-Campoy, T., Pérez-González, 
F., Cobo-Vázquez, C. M., Madrigal Martínez-Pereda, C., & Meniz-García, C. (2024). Cyanoacrylate 
versus suture as flap closure methods in mandibular third molar surgery: a split-mouth randomized 
controlled clinical study. Medicina oral, patologia oral y cirugia bucal, 29(4), e458–e467. 
https://doi.org/10.4317/medoral.26375  
3. Takadoum, S., Douilly, G., de Boutray, M., Kabani, S., Maladière, E., Demattei, C., & Lapeyrie, P. 
(2022). Sutureless socket technique after removal of third molars: a multicentric, open, randomized 
controlled trial. BMC oral health, 22(1), 256. https://doi.org/10.1186/s12903-022-02287-y  
4. Mariani, P., Menditti, D., Russo, D., & Laino, L. (2023). Evaluation of the effectiveness of tube drain 
on postoperative discomfort in mandibular third molar surgery: prospective randomized split-mouth 
study. 
Acta 
odontologica 
Scandinavica, 
81(7), 
528–533. 
https://doi.org/10.1080/00016357.2023.2205934 10  
5. Sen, A., Dhupar, V., & Akkara, F. (2024). Analysing inflammatory responses after mandibular third 
molar extraction: a comparison of suture-less and multiple suture techniques. Oral and maxillofacial 
surgery, 28(4), 1587–1594. https://doi.org/10.1007/s10006-024-01287-2  

6. Ristow, O., Hohlweg-Majert, B., Stürzenbaum, S. R., Kehl, V., Koerdt, S., Hahnefeld, L., & Pautke, 
C. (2014). Therapeutic elastic tape reduces morbidity after wisdom teeth removal--a clinical trial. 
Clinical oral investigations, 18(4), 1205–1212. https://doi.org/10.1007/s00784-013-1067-3  
7. Madrazo-Jiménez, M., Rodríguez-Caballero, Á., Serrera-Figallo, M. Á., Garrido-Serrano, R., 
Gutiérrez-Corrales, A., Gutiérrez-Pérez, J. L., & Torres-Lagares, D. (2016). The effects of a topical gel 
containing chitosan, 0,2% chlorhexidine, allantoin and despanthenol on the wound healing process 
subsequent to impacted lower third molar extraction. Medicina oral, patologia oral y cirugia bucal, 
21(6), e696–e702. https://doi.org/10.4317/medoral.21281  
8. Atchison, K. A., & Dolan, T. A. (1990). Development of the Geriatric Oral Health Assessment Index. 
Journal of dental education, 54(11), 680–687.  
9. Ergül, S., & Akar, G. C. (2008). Reliability and validity of the Geriatric Oral Health Assessment 
Index in Turkey. Journal of gerontological nursing, 34(9), 33–39. https://doi.org/10.3928/00989134-
20080901-05  
 
4. Parameters to be Evaluated 
a. 
Where 
and 
by 
whom 
the 
parameters 
will 
be 
assessed 
The study will be conducted at the Department of Oral, Dental, and Maxillofacial Surgery, Faculty of 
Dentistry, Recep Tayyip Erdoğan University. In this study, the extraction of impacted teeth will be 
performed by Res. Asst. İsmail Burak Halat, and patient group randomization will be carried out using 
computer-assisted simple randomization. Preoperative, intraoperative, and postoperative monitoring of 
the patient groups will be conducted by Res. Asst. Müberra Keskin. 
b. Which parameters are routine for the patient group and which are specific to the study 
The study aims to comparatively evaluate four different flap closure techniques (conventional suturing, 
surgical drain, cyanoacrylate tissue adhesive, and sutureless technique) that are routinely used after 
mandibular impacted third molar extraction. Based on the collected data, possible differences in 
postoperative complications and quality of life will be identified. 
c. 
Estimated 
study 
duration, 
start 
and 
end 
dates 
4 months, from 15.08.2025 to 15.12.2025 
5. Number and characteristics of patients/volunteers to be included in the study 
Patients will be selected from those presenting to the Department of Oral, Dental, and Maxillofacial 
Surgery, Faculty of Dentistry, Recep Tayyip Erdoğan University, with complaints regarding impacted 
mandibular third molars. The sample size was determined based on a power analysis, and 138 patients 
aged 18–40 years, regardless of gender, will be included. All patients will be provided with detailed 
information regarding the surgical procedure and possible complications. Written and verbal informed 
consent will be obtained from all patients prior to the study. 
6. Inclusion and Exclusion Criteria 
Inclusion Criteria: 
 
Patients aged 18–40 years 
 
Patients without any systemic disease (ASA I) 
 
Patients with impacted mandibular third molars indicated for extraction, with bone and/or 
mucosal retention, in a similar position (Pell & Gregory classification: Class 2, Position B; 
Winter classification: vertical and mesioangular) 
Exclusion Criteria: 
 
Patients classified as ASA II, III, or IV 
 
Patients with known allergy to anesthetic solutions 

 
Patients with acrylic allergy 
 
Pregnant or breastfeeding women 
 
Individuals with tobacco use of 10 or more cigarettes per day 
 
Patients who consume alcohol 
 
Patients using antiplatelet agents 
 
Patients using anticoagulants 
 
Patients with coagulation disorders 
 
Patients with immunosuppressive disease or receiving immunosuppressive therapy 
 
Patients with acute pain or infection 
7. Criteria for withdrawal of volunteers/patients and follow-up of withdrawn participants 
Participation in the study is voluntary. Volunteers may refuse to participate or withdraw from the study 
at any time without any penalty or loss of rights. Refusal to accept the methods used during the procedure 
will result in exclusion from the study. No follow-up period will be applied for participants who 
withdraw or are withdrawn from the study. 
8. Criteria for terminating participation in the study 
 
Failure to attend scheduled appointments on time 
 
Noncompliance with physician instructions