Current perspectives on the surgical management of mandibular third molars in the United Kingdom: the need for further research

The Role of Cyanoacrylate after Mandibular Third Molar Surgery: A Single Center Study

BACKGROUND

The management of the surgical wound of partially impacted mandibular third molar surgery has a great impact on recovery as well as on food impact retention. The present study used clinical parameters and health-related quality of life (HRQL) to compare outcomes of cyanoacrylate application versus traditional suture of third molar impaction surgery.

METHODS

This was a retrospective observational study of subjects scheduled for outpatient third molar surgery. Each participant signed an informed consent agreement. Inclusion criteria were as follows: presence of at least one partially impacted mandibular third molar, confirmed with a preoperative panoramic radiograph. Exclusion criteria were the following: smoking, diagnosed diabetes mellitus. Between June 2020 and September 2023, a total of 78 patients of mean age 31.14 years old (range 21-40 years, standard deviation 9.14), were included in this study-38 patients were male, 40 patients were female. A group of patients received traditional silk suture (G1 = 41 patients), while the second group (G2 = 37 patients) received hemostasis performed with fibrin sponge and, after complete soaking of the sponge, the application of cyanoacrylate gel on the blood clot and suture with one 2/0 stitch in order for recovery for secondary closure. The following parameters were measured: HRQL, average pain (AP), maximum pain (MP), complication score (CS), facial swelling (FS), and erythema.

RESULTS

For HRQL parameters, oral disability was found to be significantly higher in G1 while AP was significantly higher in G2 (p < 0.05). AP was higher in G2 (p = 0.0098), as well as MP (p = 0.001). No differences were found with regards to CS (p = 0.0759). FS and erythema were higher in G1 (p < 0.0001 for facial swelling, and p = 0.0001 for erythema).

CONCLUSIONS

on the basis of this study, the use of cyanoacrylate after mandibular third molar surgery appears to be useful in order to reduce postoperative oral disability, facial swelling, and erythema after tooth extraction, with increased average and medium pain: clinicians may consider its use in selected cases.

Microbiological Retention on PTFE versus Silk Suture: A Quantitative Pilot Study in Third Molar Surgery

Background: Mandibular third molar (M3M) removal and management of postoperative complications represent a common matter of interest in oral and maxillofacial surgery. This potential quantitative study assessed the ability of two types of surgical sutures, Silk and polytetrafluoroethylene polymer (PTFE), to carry aerobic and anaerobic bacteria on wounds after mandibular third molar surgery, with a collection of the stitches at the suture removal and study in the laboratory on the basis of colony-forming units. Methods: This prospective quantitative study sampled a total of 10 consecutive healthy patients for mandibular third molar surgery at the Oral Surgery School, Dentistry and Dental Prosthodontics, Department of Medical Biotechnologies, University of Siena, Siena, Italy. The mean age of the patients was 31 years (range 25–40 years), seven patients were male and three patients were female. Inclusion criteria were: presence of a partially impacted mandibular third molar. Exclusion criteria were: smoking and diabetes mellitus. Extraction of the mandibular third molar was performed under local anesthesia: after the third molar surgery, two sutures were applied on the surgical site distally to the second mandibular molar: one single 3/0 silk stitch; one single 3/0 PTFE stitch. No sutures were applied on the release incision. Sutures were removed after 7 days and were immediately conserved and sent to the laboratory to be rated on the basis of colony-forming units (CFUs). CFUs were evaluated and reported on GraphPad Prism and transformed into its base 10 logarithm. Data were analyzed with a non-parametric Wilcoxon test, and p-values < 0.05 were evaluated as statistically significant. Results: All the patients attended the suture removal date, and all the sutures were present in the site. None of the surgical sites presented dehiscence. No stitch loss was reported, and no patient reported mouth washing or tooth brushing in the surgery site. All interventions were uneventful and no major complications were reported after M3M surgery. Bacterial retention resulted as statistically greater in silk sutures rather than PTFE sutures, both in Brain Heart Infusion samples (p = 0.003) and Wilkins-Chalgren anaerobe samples (p = 0.002). Conclusions: We found the PTFE suture to be superior to the silk suture in a reduction in the bacterial biofilm in both aerobic and anaerobic evaluations after M3M surgery.

Association of the Inferior Alveolar Nerve Position and Nerve Injury: A Systematic Review and Meta-Analysis

Background: We aimed to compare the relationship between the buccal and lingual positions of the inferior alveolar nerve canal (IAC) relative to the lower third molar (LM3) and the rate of the inferior alveolar nerve (IAN) injury. Methods: A systematic search was performed in the following databases: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Journals@Ovid. No language or publication status restrictions were set. The publication year was set from 2009 to 2021. The process of meta-analysis was performed by Review Manager software (Cochrane Collaboration). Results: A total of 1063 articles were initially searched and full texts of 53 articles were read, and 11 satisfactory articles were found. There was a statistical difference between the rate of IAN injury and the lingual position and buccal position of the IAC relative to the LM3 roots (OR, 4.96; 95% CI, 2.11 to 11.62; p = 0.0002), with high heterogeneity (p = 0.001, I² = 65%). Conclusion: A statistical difference was found in the rate of IAN injury between cases where the IAC was positioned buccally and lingually of the LM3 roots. The IAC was at a relatively higher risk of damage in third molar extraction when it was located on the lingual position of the LM3 roots.

Current thinking in lower third molar surgery

The removal of lower third molar teeth is one of the most common surgical procedures performed worldwide, but many concepts in this surgery have been unclear and have engendered different opinions. This paper aims to review current thinking in certain pertinent aspects of this surgery to update the reader on the most current research and synthesise it to make clinical recommendations. Topics covered include preoperative imaging, timing of removal, flap design, lingual retraction, coronectomy, lingual split, closure techniques, and use of antibiotics, steroids, and drains.

Clinical negligence claims in oral and maxillofacial surgery over the last 10 years

According to NHS Resolution, the cost of harm from clinical activity in the last year was £8.3 billion. The steady increase in litigation within the National Health Service (NHS) has led to concerns being raised regarding the sustainability of the NHS, the increasing practice of defensive medicine, and the psychological impact on healthcare professionals. To our knowledge, litigation within oral and maxillofacial surgery has not been investigated in the UK since 2010, therefore our aims were to identify the trends within our specialty and the common reasons for negligence claims over the last 10 years. A freedom of information request was made to NHS Resolution for all clinical negligence claims from 2010 to 2020. A total of 1,122 claims were registered and the total for damages paid was £32,631,131. The claims were categorised by the primary injury and further divided into groups of cause codes. Four types of primary injury comprised 65.4% (n = 734) of all negligence claims and were as follows: additional or unnecessary operations (n = 313, 27.9%), unnecessary pain (n = 156, 13.9%), nerve damage (n = 139, 12.4%), and dental damage (n = 126, 11.2%). The damages associated with nerve damage were the costliest, with a total of £8,033,737 being paid. The significant increase in the number and cost of clinical negligence claims is concerning. The lessons from these claims must be shared and implemented to reduce the burden on the NHS, and ensure that we are providing a high quality of care with improved patient outcomes.

Coronectomy of mandibular third molars: a systematic literature review and case studies

BACKGROUND

Extraction of mandibular third molars (M3M) close to the inferior alveolar nerve (IAN) has a higher risk of neurological disturbance. This review aims to evaluate the evidence supporting the use of the coronectomy technique compared to complete extraction for such M3Ms. Case studies by a specialist oral and maxillofacial surgeon are included to illustrate clinical practice.

METHODS

Three databases (Cochrane Library, Embase, PubMed) were searched (November 2020). Additional articles were sought by hand searching the reference list of included articles. All studies published in English comparing outcomes of coronectomy with complete extraction with at least 50 subjects and 6 months follow-up were included.

RESULTS

Of the six included studies, five reported a lower rate of IAN disturbance after coronectomy compared with complete extraction. There were no reported cases of lingual nerve disturbance. Other outcomes of coronectomy such as pain, infection, alveolar osteitis were either similar or lower compared to complete extraction. There were high rates of root migration but low rates of exposure and reoperation. Follow-up protocols varied considerably.

CONCLUSIONS

There is medium quality evidence to support the option of coronectomy for high risk M3M cases. Further studies to develop follow-up protocols to assist general dental practice is warranted.

Printed titanium implants in UK craniomaxillofacial surgery. Part I: access to digital planning and perceived scope for use in common procedures

This first part of a two-part study examines perceived applications for and barriers to using printed titanium in light of current caseloads, funding pathways, and use of digital planning. It aims to demonstrate the scope for printed titanium in modern practice and to guide industry about the needs of UK surgeons. A cross-sectional study over 14 weeks was performed electronically with support from the British Association of Oral and Maxillofacial Surgeons (BAOMS) and a national trainee-led recruitment team. Ethics approval was obtained at the lead centre. A total of 132 participants joined the study (70% consultants, 25% specialty registrars, and 5% other), approximating a 29% response rate from consultant/registrar BAOMS members throughout mainland UK. Eighty-eight per cent used CAD-CAM design, with highly variable funding/access, design/manufacturing workflows (in-house/outsourced). Eighty-eight per cent were involved with trauma, 61% with orthognathic, and 52% with oncology-reconstruction surgery. Favourite applications for printed titanium were orbital floor repair (89%) and free-flap jaw reconstruction (87%). Most participants also cited maxillary/zygomatic osteotomies and cranioplasty (range 61%-73%). Although a popular application (78%), the evidence base in temporomandibular joint surgery is limited. Those performing orthognathic surgery perceived more indications than those who did not (p=0.013). Key barriers included cost, turnaround time and logistics, and the need to be trained in traditional techniques. Printed titanium was useful for both common and niche procedures, but was specifically limited in emergency trauma. Most surgeons had experience in CAD-CAM surgery but technical understanding appeared unclear. Limiting factors included variable funding and production pathways, perceived costs, and logistics, but in-house design can minimise them. In part II, we quantify perceived benefits and limitations and whether surgeons' understanding and knowledge are sufficient to rationalise them.