Current thinking in lower third molar surgery

IS Intra-masseteric Dexamethasone Better than Intra-deltoid Injection in Reducing Post-operative Sequelae Following Impacted Third Molar Surgery?: A Randomized Clinical Study

Aim

The post-operative sequelae of third molar surgical extractions need to be controlled in order to reduce patient morbidity. Dexamethasone is a well-researched drug which has established its merit as an anti-inflammatory agent. The aim of this randomized clinical study was to compare the patient-centric outcomes after pre-emptive intramuscular injection of dexamethasone into the masseter and deltoid, respectively.

Materials and Methods

The outcomes measured were pain, facial swelling and mouth-opening postoperatively on Day 1, 3 and 7. The subjects were randomly divided into two groups. Group 1 received an intra-oral injection of 8 mg of dexamethasone into the masseter muscle and a placebo injection of distilled-water into the deltoid muscle 2 h before surgical removal of impacted mandibular third molar. Group 2 received an intra-oral placebo injection of distilled-water into masseter muscle and an 8 mg injection of dexamethasone into deltoid muscle.

Results

On comparison, Group 1 patients experienced statistically significant less pain (VAS score on day 1, 3, and 7), facial swelling (day 1, 3), and restricted mouth-opening (day 1, 3).

Conclusion

The study concluded that pre-emptive dexamethasone injection, at masseter or deltoid, is helpful in reducing post-operative sequelae of mandibular third molar extraction. However, the immediate post-operative outcomes were found to be better mitigated when the injection was administered locally into masseter muscle.

Wisdom Tooth Extraction Training for Dental Students: Step-by-Step or All-in-One?

Aims/Background For inexperienced dental students, impacted wisdom tooth extraction is a complex procedure involving a series of intricate steps. This study compared the effectiveness of step-by-step and all-in-one teaching methods for dental students learning impacted wisdom tooth extraction, by evaluating their practical abilities, understanding, and learning satisfaction. Methods Fifty dental students were randomly assigned to either a step-by-step teaching group (Group S) or an all-in-one teaching group (Group A) for impacted wisdom tooth extraction training. Their skills were assessed using the Assessment of Competency in Exodontia Skills (ACES) scoring system, and their theoretical knowledge was tested in a test. The students also completed a questionnaire to gauge their satisfaction regarding the teaching method received. Results The students in Group S demonstrated superior performance in clinical procedures compared to Group A, evidenced by the significantly higher ACES scores (p < 0.05). There was no significant difference in theoretical exam scores between the two groups (p > 0.05). The students in Group S reported higher general satisfaction (p < 0.05), suggesting a preference for the step-by-step approach. The results also showed that satisfaction toward hands-on practice and teaching sessions significantly contributed to general satisfaction, while satisfaction with mastery of clinical skills did not. Conclusion The step-by-step teaching method was more effective in improving students' clinical skills and augmenting their satisfaction during impacted wisdom tooth extraction training. Our findings support the use of incremental learning approaches in dental education to enhance both clinical competencies and students' learning experiences.

Efficacy of Ketorolac Tromethamine Diluted Saline Irrigant on Postoperative Sequelae in Patients Undergoing Lower Third Molar Impaction Surgery: A Prospective Clinical Study

Background Lower third molar surgery is very commonly performed for minor oral surgery by an oral and maxillofacial surgeon. One of the main chief complaints that patients report back to the clinic after getting their lower third molar impaction surgery is immediate postoperative pain. In our study, we have compared the efficacy of ketorolac tromethamine diluted saline solution over plain saline solution used as an irrigant in reducing postoperative swelling and pain. Aim The aim of the current study is to analyse the efficiency of ketorolac tromethamine diluted saline solution over normal saline without any drug dilution in reducing postoperative sequelae like pain and swelling after surgical removal of the lower third molar. Materials and methods This study was carried out at the Department of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, from April 2023 to July 2023. The study included 50 individuals who wanted to prophylactically get the lower third molar removed surgically. These participants were divided into two groups. One group received ketorolac diluted saline irrigant while the other group received plain saline (0.9% NaCl) as irrigant. Postoperatively, pain and swelling were evaluated in both groups. Both pain and swelling were measured preoperatively, postoperatively after 48 hours, and postoperatively after seven days. The swelling was measured using a 4-point measuring scale, and pain measurement was done using a 10-point visual analogue scale. Statistical analysis was done using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 23.0, Armonk, NY). For the comparison of continuous variables between the two groups, an unpaired t-test was used. The normality of the results obtained was checked using the Shapiro-Wilk test. The results were considered statistically significant if the P-value was less than 0.05. Results Based on the results obtained it was found that participants who were included in the ketorolac saline group had comparatively lower postoperative pain scores than participants in the plain saline group and this was statistically significant (P=0.001). Postoperative swelling was also comparatively lower in the ketorolac tromethamine saline group but the results were not statistically significant at the end of day 7 (P=0.09). Conclusion Upon observing the cumulative results obtained, we conclude that ketorolac saline (10mg/100mL) was more efficacious in terms of pain reduction than the regular saline solution in impacted lower third molar surgery.

Development of a risk prediction model for surgical site infection after lower third molar surgery

BACKGROUND

There is little evidence regarding risk prediction for surgical site infection (SSI) after lower third molar (L3M) surgery.

METHODS

We conducted a nested case-control study to develop a multivariable logistic model for predicting the risk of SSI after L3M surgery. Data were obtained from Hokkaido University Hospital from April 2013 to March 2020. Multiple imputation was applied for the missing values. We conducted decision tree (DT) analysis to evaluate the combinations of factors affecting SSI risk.

RESULTS

We identified 648 patients. The final model retained the available distal space (Pell & Gregory II [p = 0.05], Pell & Gregory III [p < 0.01]), depth (Pell & Gregory B [p < 0.01], Pell & Gregory C [p < 0.01]), surgeon's experience (3-10 years [p = 0.25], <3 years [p < 0.01]), and simultaneous extraction of both L3M [p < 0.01]; the concordance-statistic was 0.72. The DT analysis demonstrated that patients with Pell and Gregory B or C and simultaneous extraction of both L3M had the highest risk of SSI.

CONCLUSIONS

We developed a model for predicting SSI after L3M surgery with adequate predictive metrics in a single center. This model will make the SSI risk prediction more accessible.

Outcomes of Coronectomy and Total Odontectomy of Impacted Mandibular Third Molars

OBJECTIVE

The aim of this research was to evaluate the surgical complications and neurosensory deficits after coronectomy and the complete removal of mandibular third molars.

METHODS

The study sample included patients requiring surgical removal of mandibular third molars. A coronectomy was conducted on 220 teeth showing signs of close proximity to the inferior alveolar canal. A complete extraction was performed on 218 teeth with no risk signs. The patients were evaluated at 1 week and 1, 3, 6, 12, and 24 months after surgery for pain, swelling, neurologic deficit, dry socket, postoperative bleeding, infection, root migration, and eruption.

RESULTS

No significant difference was noted in pain and swelling; however, bleeding and dry socket were significantly higher in the odontectomy group (P = .017). The inferior alveolar nerve deficit was higher in the odontectomy group (3.7%) than the coronectomy group (0.5%) (P = .017). The percentage and distance of root migration of coronectomised teeth at 3, 6, and 12 months were 60% (2.37 ± 0.96 mm), 66% (3.35 ± 0.86 mm), and 74% (3.85 ± 0.93 mm), respectively.

CONCLUSIONS

Coronectomy is a safe procedure and should be performed when the roots are closely associated with the mandibular canal. Although root migration is common, the likelihood of root exposure is low and roots rarely need removal.

Does Betamethasone Injection Into the Pterygomandibular Space Affect the Postoperative Outcomes of Impacted Lower Third Molar Surgery?

BACKGROUND

Pain, swelling, and trismus are common outcomes following impacted lower third molar surgery.

PURPOSE

The purpose of the study was to evaluate the effect of betamethasone injection into the pterygomandibular space on the aforementioned sequelae of third molar surgery.

STUDY DESIGN, SETTING, AND SAMPLE

A split-mouth, double-blind, randomized clinical trial was conducted on 40 patients with symmetrical bilateral impacted lower third molars. The surgeries were performed at an outpatient clinic under local anesthesia.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

The predictor variable is the steroid treatment. The experimental group received a 1 mL (6 mg) betamethasone injection into the pterygomandibular space, while the control group received a normal saline.

MAIN OUTCOME VARIABLE(S)

The primary outcome variable was postoperative pain assessed using a visual analog scale. The secondary outcome variables were the number of analgesic tablets consumed, facial swelling, and trismus.

COVARIATES

The age and sex of the patients, the direction of impaction, and the duration of surgery were recorded.

ANALYSES

Comparisons between the groups were carried out using an unpaired t test. An analysis of variance test was used to assess intragroup differences. The significance was considered at P ≤ .05.

RESULTS

Of the 265 patients initially screened for study enrollment, the final sample included 40 subjects, with a mean age of 28.3 years (±7.4), 28 (70%) were mal and 12 (30%) were female. There was no significant difference between the two groups concerning postoperative pain or the number of consumed analgesic tablets. However, the betamethasone group exhibited significantly reduced facial swelling and increased mouth opening. On the first postoperative day, the visual analog scale pain score did not significantly differ between the betamethasone group (6.0 ± 1.7) and the control group (6.8 ± 1.4), with a P value of 0.112. On the first postoperative day, facial swelling measured 4.2 ± 1.3 mm in the betamethasone group compared to 6.0 ± 0.9 mm in the control group (P < .001). Mouth opening in the betamethasone group was 30.8 ± 6.7 mm, while in the control group, it measured 21.9 ± 5.5 mm (P < .001).

CONCLUSION AND RELEVANCE

Local betamethasone has no effect on pain after third molar surgery, but facial swelling and trismus are significantly reduced.

Risk assessment of inferior alveolar nerve injury after wisdom tooth removal using 3D AI-driven models: A within-patient study

OBJECTIVE

To compare a three-dimensional (3D) artificial intelligence (AI)- driven model with panoramic radiography (PANO) and cone-beam computed tomography (CBCT) in assessing the risk of inferior alveolar nerve (IAN) injury after mandibular wisdom tooth (M3M) removal through a within-patient controlled trial.

METHODS

From a database of 6,010 patients undergoing M3M surgery, 25 patients met the inclusion criteria of bilateral M3M removal with postoperative unilateral IAN injury. In this within-patient controlled trial, preoperative PANO and CBCT images were available, while 3D-AI models of the mandibular canal and teeth were generated from the CBCT images using the Virtual Patient Creator AI platform (Relu BV, Leuven, Belgium). Five examiners, who were blinded to surgical outcomes, assessed the imaging modalities and assigned scores indicating the risk level of IAN injury (high, medium, or low risk). Sensitivity, specificity, and area under receiver operating curve (AUC) for IAN risk assessment were calculated for each imaging modality.

RESULTS

For IAN injury risk assessment after M3M removal, sensitivity was 0.87 for 3D-AI, 0.89 for CBCT versus 0.73 for PANO. Furthermore, the AUC and specificity values were 0.63 and 0.39 for 3D-AI, 0.58 and 0.28 for CBCT, and 0.57 and 0.41 for PANO, respectively. There was no statistically significant difference (p>0.05) among the imaging modalities for any diagnostic parameters.

CONCLUSION

This within-patient controlled trial study revealed that risk assessment for IAN injury after M3M removal was rather similar for 3D-AI, PANO, and CBCT, with a sensitivity for injury prediction reaching up to 0.87 for 3D-AI and 0.89 for CBCT.

CLINICAL SIGNIFICANCE

This within-patient trial is pioneering in exploring the application of 3D AI-driven models for assessing IAN injury risk after M3M removal. The present results indicate that AI-powered 3D models based on CBCT might facilitate IAN risk assessment of M3M removal.

The effect of individual drilling sleeves on the precision of coronectomy tooth sections. An in vitro 3D-printed jaw model experiment

OBJECTIVES

The aim of this in vitro study was to evaluate the effect of a 3D-printed drill sleeve (DS) on the precision and duration of coronectomy sections.

MATERIALS AND METHODS

Thirty-six trainees and oral surgeons performed 72 coronectomy cuts in a 3D-printed, entirely symmetric mandible model. Coronectomy was performed freehand (FH) on one side and with a DS on the other side. The occurrence of "too superficial" (≥ 4 mm unprepared lingual tooth tissue) and "too deep" (drilling ≥ 1 mm deeper as tooth contour) cuts and sectioning times were registered.

RESULTS

In 7 cases, the sections were "too deep" with FH, while none with DS (OR: 18.56; 95%CI: 1.02-338.5; p = 0.048). The deviation between virtually planned and real cut depths was significantly greater in the FH group (1.91 ± 1.62 mm) than in DS group (1.21 ± 0.72 mm) (p < 0.001). A total of 18 "too superficial" buccolingual sections occurred with FH, while 8 cases with DS (OR: 3.50; 95%CI: 1.26-9.72; p = 0.016). Suboptimal sections did not correlate with experience (p = 0.983; p = 0.697). Shortest, suboptimal drillings were most frequently seen distolingually (OR: 6.76; 95% CI: 1.57-29.07; p = 0.01). In the inexperienced group, sectioning time was significantly longer with FH (158.95 ± 125.61 s vs. 106.92 ± 100.79 s; p = 0.038).

CONCLUSIONS

The DS effectively reduced tooth sectioning times by less experienced colleagues. Independently from the level of experience, the use of DS obviated the need for any preparation outside the lingual tooth contour and significantly decreased the occurrence of "too superficial" cuts, leaving thinner unprepared residual tooth tissue lingually.

CLINICAL RELEVANCE

Coronectomy sections may result in lingual hard and soft tissue injury with the possibility of damaging the lingual nerve. The precision of the buccolingual depth-control can be improved, while surgical time can be reduced when applying a drilling sleeve.

The perception and practice of routine lingual flap retraction in lower third molar surgery among oral and maxillofacial surgeons in Nigeria

Background

Lingual nerve injury is a known complication of mandibular third molar (M3M) surgery, and retraction of the lingual flap is reported to reduce the incidence of this complication. However, there is no global consensus on the routine retraction of lingual flap.

Aim

The aim of the study was to assess the perception and practice of lingual flap retraction amongst oral and maxillofacial surgeons in Nigeria.

Materials and Methods

This cross-sectional national survey was conducted amongst 122 oral and maxillofacial surgeons in Nigeria from January 2023 to March 2023 using a validated, structured, self-administered questionnaire. The questionnaire had three sections and 14-item questions. Section A consists of the sociodemographic questions, Section B comprises questions on perception towards lingual flap retraction, whereas Section C consists of questions on the practice of lingual flap retraction. These questionnaires were deployed as an online survey and as hard copies. Both qualitative and quantitative data were analysed. A critical probability level (P < 0.05) was used as the cut-off level for statistical significance.

Results

Most of the participants (47.6%) belong to the age group of 31-40 years. The male-to-female ratio was 6:1. Only 12 (9.8%) participants had a positive perception towards routine lingual flap retractions following M3M surgery. Perception of lingual flap retraction was found not to be associated with the demographic variables of the participants (P > 0.05). A total of 95 participants (77.9%) did not raise nor retract the lingual flap during lower third molar surgery. The rate of practice of lingual flap retraction during third molar surgery was not influenced by any of the factors studied (P > 0.05).

Conclusion

The majority of oral and maxillofacial surgeons in Nigeria do not agree that routine retraction of the lingual flap is necessary to reduce lingual nerve injury and majority, too, do not practice this in their management of impacted lower third molar.

Efficacy of Dexamethasone Diluted Saline Irrigant on Postoperative Sequelae in Patients Undergoing Lower Third Molar Surgery: A Prospective Clinical Study

Background Third molar impaction surgery is one of the most common yet challenging procedures done as a part of minor oral surgery. Years of research and improvisation of techniques have been done, yet there are still a lot of postoperative sequelae after surgical removal of the impacted tooth. In our study, we have compared the efficacy of dexamethasone diluted saline solution over plain saline solution used as an irrigant in the reduction of postoperative sequelae for lower third molar surgery. Aim The aim of the study was to evaluate the efficacy of dexamethasone diluted saline solution over plain saline solution in the reduction of postoperative sequelae for lower third molar surgery. Materials and methods The research was conducted at Saveetha Dental College and Hospital in the Department of Oral and Maxillofacial Surgery. The study consisted of 48 individuals, 24 of whom had dexamethasone saline as an irrigant (8 mg of dexamethasone was diluted in 100 ml of plain saline) (Group 1), and 24 in whom plain saline was used as an irrigant (Group 2) in the lower third molar surgery. Patients were evaluated postoperatively for pain and swelling. The postoperative swelling was measured on postoperative day two and day seven. Postoperative pain was measured on day two, day four, and day seven after surgery using a visual analog scale. Data were analyzed using SPSS (IBM Corp., Armonk, NY) with P-values less than 0.05 considered statistically significant. The statistical test used to compare the outcomes between the two groups was the independent samples t-test. Results It was found that study participants in the dexamethasone saline irrigation group reported statistically significantly lesser pain than participants receiving plain saline irrigation on day two (P = 0.001), day four (P = 0.001), and day seven (P = 0.001), respectively. Also, there was a reduction in swelling among participants in the dexamethasone saline irrigation group when compared to the normal saline irrigation group, which was statistically significant (P = 0.001) on day two, while the postoperative swelling was not statistically significant on day seven (P = 0.08) between the two study groups. Conclusion Based on the results obtained, it can be concluded that dexamethasone saline solution (8 mg/100 mL) was more effective as an irrigant in reducing the postoperative sequelae than regular saline solution in the lower third molar surgery.

Extraction of impacted mandibular third molars in close proximity to the inferior alveolar canal with coronectomy-miniscrew traction to avoid nerve injury

OBJECTIVES

Extraction of impacted mandibular third molars (IMTMs) is the most common surgery performed in the Department of Oral and Maxillofacial Surgery. Inferior alveolar nerve (IAN) injury is a rare but severe complication, and the risk is significantly higher in cases of IMTM near the inferior alveolar canal (IAC). The existing surgical method to extract such IMTMs is either not safe enough or is time-consuming. A better surgical design is needed.

MATERIALS AND METHODS

From August 2019 to June 2022, 23 patients underwent IMTM extraction by Dr. Zhao at Nanjing Stomatological Hospital, Affiliated Hospital of Medical School, Nanjing University, and were found to have IMTMs in close proximity to the IAC. Due to high IAN injury risk, these patients underwent coronectomy-miniscrew traction to extract their IMTMs.

RESULTS

The time between coronectomy-miniscrew insertion and complete removal of the IMTM was 32.65 ± 2.110 days, which was significantly shorter than that of traditional orthodontic traction. Two-point discrimination testing revealed no IAN injury, and no injury was reported by patients during follow-up. Other complications, such as severe swelling, severe bleeding, dry socket, and limited mouth opening, were not observed. Postoperative pain levels were not significantly higher in the coronectomy-miniscrew traction group than in the traditional IMTM extraction group.

CLINICAL RELEVANCE

For IMTMs that are in close proximity to the IAC and must be extracted, coronectomy-miniscrew traction is a novel approach to minimize the risk of IAN injury in a less time-consuming way with a lower possibility of complications.

Risk Factors for Delayed-Onset Infection after Mandibular Wisdom Tooth Extractions

Wisdom tooth extraction is one of the most commonly performed procedures by oral maxillofacial surgeons. Delayed-onset infection (DOI) is a rare complication of wisdom tooth extraction, and it occurs ~1–4 weeks after the extraction. In the present study, risk factors for DOI were investigated by retrospectively analyzing the cases of 1400 mandibular wisdom tooth extractions performed at Kagawa University Hospital from April 2015 to June 2022. Inclusion criteria were patients aged >15 years with a wisdom tooth extraction per our procedure. The exclusion criteria were patients with insufficient medical records, a >30-mm lesion around the wisdom tooth shown via X-ray, colonectomy, radiotherapy treatment of the mandible, the lack of panoramic images, and lesions other than a follicular cyst. The DOI incidence was 1.1% (16 cases), and univariate analyses revealed that the development of DOI was significantly associated with the Winter classification (p = 0.003), position (p = 0.003), hypertension (p = 0.011), and hemostatic agent use (p = 0.004). A multivariate logistic regression analysis demonstrated that position (OR = B for A, 7.75; p = 0.0163), hypertension (OR = 7.60, p = 0.013), and hemostatic agent use (OR = 6.87, p = 0.0022) were significantly associated with DOI development. Hypertension, hemostatic use, and position were found to be key factors for DOI; long-term observation may thus be necessary for patients with these risk factors.

Does surgical removal of mandibular third molar influence the periodontal status of the adjacent second molars? A systematic review

Objective: This study aimed to assess the influence of mandibular third molar surgical removal on the periodontal status of adjacent second molars and to investigate the potential impact of the flap design. Methods: A systematic review of the literature, registered in PROSPERO, has been carried out from Pubmed and Scopus databases following PRISMA guidelines from January 2010 to January 2022. PICO method was used to select the relevant articles. Studies comparing the periodontal status of the second molar before and after mandibular third molar removal were considered. Results: Twenty-three studies involving 1067 patients were included. The two main parameters studied were periodontal pocket depth and clinical attachment level. The envelope flap and the triangular flap were the most commonly used flap techniques. Periodontal health of adjacent second molar was maintained or improved in most of the included studies. The flap design did not seem to have a significant influence either. Conclusion: Avulsion of impacted third molar in healthy young adults does not impair the periodontal health of adjacent second molars. Further studies, with higher levels of evidence, are needed to confirm these results and to identify possible risk factors (such as age, impaction depth or periodontal disease) responsible for poorer healing.