Piezoelectric bone surgery for impacted lower third molar extraction compared with conventional rotary instruments: a systematic review, meta-analysis, and trial sequential analysis

A comparative analysis of postoperative morbidity and alveolar bone regeneration following surgical extraction of ımpacted lower third molar teeth using piezosurgery and conventional ınstruments: a split-mouth clinical ınvestigation

BACKGROUND-OBJECTIVE(S)

This randomized, split-mouth study aimed to compare postoperative complications following the surgical extraction of impacted lower third molars using piezosurgery versus conventional rotary instruments.

MATERIALS AND METHODS

Twenty-one patients, aged 18-35 years, with bilaterally and symmetrically impacted lower third molars, were randomly assigned to undergo extraction using piezosurgery on one side and conventional rotary instruments on the other.

RESULTS

The piezosurgery method required a longer operation time. However, it resulted in quicker resolution of postoperative swelling by the 7th day compared to the conventional method, where swelling persisted longer. Mandibular angle-tragus measurements were significantly higher with the conventional method on the 1st, 3rd, and 7th postoperative days. Although mouth opening decreased significantly after piezosurgery, it returned to preoperative levels by the 7th day, outperforming the conventional method. Postoperative pain was notably higher with the conventional method during the first four days but showed no significant difference from the 5th day onward. Alveolar bone healing was significantly better with piezosurgery at the 3rd and 6th months. Temporary paresthesia occurred in one patient from the conventional group, resolving within four weeks. Neither method resulted in alveolar osteitis.

CONCLUSION(S)

Within the study's limitations, piezosurgery demonstrated a reduction in postoperative discomfort, suggesting its advantage in enhancing patient recovery following lower third molar extractions.

CLINICAL SIGNIFICANCE

Piezosurgery, when used appropriately, can reduce postoperative complications compared to conventional methods. Clinicians should be aware of its indications, benefits, and potential challenges. Trial registration This study was registered as a clinical trial to the ClinicalTrials.gov, and the registration ID is NCT06262841 ( https://clinicaltrials.gov/study/NCT06262841 ).

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.

A comprehensive classification for impacted cuspids and bicuspids with a proposal for Difficulty Index Categorization: a single center evaluation of 4165 cases

BACKGROUND

The aim of the current study was to propose a classification of impacted cuspids, and bicuspids based on their spatial position in the maxillary and mandibular arches and their radiological appearance.

METHODS

This prospective study was conducted including all the patients who reported to our center for extractions, orthodontic treatment, missing permanent cuspids/bicuspids, removal of third molar teeth. All patients who reported within a time frame of 6 months were enrolled in the study. Orthopantomogram was advised for all the patients as a part of diagnostic work up. The panoramic radiographs and clinical data were reviewed and patients with evidence of impacted bicuspids and cuspids were included in the study and were advised to undergo a cone beam computed tomography to evaluate the 3-dimensional position of the impacted teeth. Treatment plan was decided based on the position of the impacted teeth and feasibility for orthodontic movement. Standard surgical protocol was followed for all the patients. The duration of the procedure from the time of incision till the suturing were tabulated and the difficulty of extraction was correlated with the current Difficulty Index to validate the same.

RESULTS

A total number of 4165 patients were enrolled in the study and based on the inclusion and exclusion criteria, 3680 patients were excluded and 487 patients with impacted cuspids/bicuspids were included in the study. A total number of 231 patients had impacted maxillary cuspids and bicuspids and 256 cases had impacted mandibular cuspids/bicuspids. Amongst the 256 mandibular cuspid and bicuspid that were impacted, 62% were in position C while the rest of 38% were in position B. More than ⅓ of the teeth which were in position C had transmigrated (35%). Seventy-three percent of the maxillary teeth were in position C and 69% of these teeth were either transmigrated (29%), or were horizontally (38%) placed in the alveolus or inverted (2%). The rest of the 31% were found to be either mesially inclined or vertical. The average Difficulty Index for maxillary teeth was 8 and mandibular teeth was 9. Mandibular cuspids and bicuspids in position B and C took longer time for surgical removal compared to the maxillary teeth and this was statistically significant.

CONCLUSIONS

The proposed clinical classification on impacted mandibular cuspids and bicuspids provides a structured approach to plan the treatment based on the 3-dimensional position of the teeth in the arch.

Application of an ultrasonic bone knife combined with a dental electric motor in the extraction of mandibular middle and low impacted teeth

OBJECTIVE

To investigate the clinical application of an ultrasonic bone knife (UBK) combined with a dental electric motor (DEM) in the extraction of mandibular middle and low impacted teeth.

METHODS

From January 2022 to May 2023,200 patients with wisdom teeth were randomly divided into three groups: experimental group A (UBK combined with DEM), experimental group B (UBK combined with high-speed turbine mobile phone (HSTMP)), and the control group (bone chisel split crown (BCSC)). The operation time, psychological state during operation, pain, swelling, limitation of mouth opening and other complications on the first, second and third days after operation were recorded.

RESULTS

The operation time of experimental group A (EAG) (12.95 ± 2.12) minutes was shorter than that of experimental group B (EBG) (17.06 ± 2.25) minutes and the control group (CG) (23.43 ± 2.18) minutes, and the difference was statistically significant (P < 0.05). The psychological state of the EAG was significantly lower than that of the EBG and CG (P < 0.05). The postoperative pain, swelling, limitation of mouth opening and complications in the EAG were significantly lower than those in the EBG and CG (P < 0.05).

CONCLUSION

UBK combined with DEM in the extraction of mandibular middle and low obstructed teeth has good results, good prognosis, high safety, short operation time, better psychological status of patients, low postoperative pain, swelling, mouth opening restriction and complication rate, and is currently the preferred extraction method.

Endoscopic visualization of the inferior alveolar nerve associated with somatosensory changes after impacted mandibular third molar extraction

The aim of this study is to assess the relationship between somatosensory functional changes and inferior alveolar nerve (IAN) exposure after impacted mandibular third molars (M3M) removal. We recruited 35 patients who underwent impacted M3M extraction near the IAN. The M3Ms were extracted by combined endoscopy, piezosurgery, and contra-angle high-speed turbine handpiece. All IAN canal perforations and exposed regions were recorded and measured by endoscopy after extraction and on cone-beam computed tomography (CBCT) images before extraction. The patients were followed up 1, 7, and 35 days after surgery. A standardized quantitative sensory testing (QST) battery was performed on the lower lip skin. All of 35 cases had exposed IAN on CBCT images, 5 of which had no exposed IAN under endoscopy. For the other 30 cases, the endoscopy-measured IAN length and width were shorter than the CBCT measurements (P < 0.001). The warm and mechanical detection thresholds (MDT) on the operation side were significantly higher than the contralateral side after surgery (P < 0.05). Thermal sensory limen, MDT, and cold pain threshold were strongly correlated with the exposed IAN length and MDT also with the exposed IAN width one day after surgery. In conclusion, it was found that not all exposed IAN in CBCT images were real exposure after surgery. The intraoperative exposed IAN endoscopic measurements were smaller than by CBCT and strongly correlated with some QST parameters.

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.

Comparison between Magneto-Dynamic, Piezoelectric, and Conventional Surgery for Dental Extractions: A Pilot Study

This pilot split-mouth study aimed to evaluate and compare early postoperative discomfort and wound healing outcomes in post-extraction sockets after dental extraction performed with a Magnetic Mallet (MM), piezosurgery, and conventional instruments (EudraCT 2022-003135-25). Twenty-two patients requiring the extraction of three non-adjacent teeth were included. Each tooth was randomly assigned to a specific treatment (control, MM, or piezosurgery). Outcome measures were the severity of symptoms after surgery, wound healing assessed at the 10-days follow-up visit, and the time taken to complete each procedure (excluding suturing). Two-way ANOVA and Tukey’s multiple comparisons tests were performed to evaluate eventual differences between groups. There were no statistically significant differences between the compared methods in postoperative pain and healing, and no additional complications were reported. MM required significantly less time to perform a tooth extraction, followed by conventional instruments and piezosurgery, in increasing order (p < 0.05). Overall, the present findings suggest the use of MM and piezosurgery as valid options for dental extractions. Further randomized controlled studies are needed to confirm and extend this study’s results, facilitating the selection of the optimal method for an individual patient depending on the patient’s needs and preferences.

Computer-Guided Osteotomy with Simultaneous Implant Placement and Immediately Loaded Full-Arch Fixed Restoration: A Case Report

Aim: This case report aims to illustrate a clinical protocol that allows for the rehabilitation of patients requiring extensive osteotomy, simultaneous implant placement, and full-arch, screwed-in prosthetics in one session. This protocol allows for the improvement of the aesthetics and functionality of the fixed implant-supported prosthesis through the preoperative planning of all surgical procedures, including osteotomy, and of the prosthesis through the application of 3D-printing technology for the creation of surgical templates and prostheses. Methods: This case report concerns a 72-year-old patient, ASA1, who, following diagnosis, the establishment of a treatment plan, and the provision of informed consent, opted for an immediate, full-arch rehabilitation of the lower arch. The digital planning stage started with the correct positioning of the fixtures. The proper bone levels were found and used to guide the creation of the provisional screwed-in prothesis. Two templates with the same supports (landmarks/pins) were then 3D-printed: a positioning template, including a slit to assist the surgeon during the osteotomy, and a surgery template to assist the surgeon during the implants’ positioning. A screwed-in prosthesis encased in resin C&B MFH (NEXTDENT®, Soesterberg, The Netherlands) was delivered. Minimal occlusal adjustments were performed. Results: In a single clinical session, through careful planning and the pre-operative 3D printing of a prosthesis, a temporary implant-supported prosthetic rehabilitation was possible in a case that required an extended osteotomy. Clinically, the correspondence between the virtual design phase and the final realization was consistent. At a functional level, the provisional prosthesis required minimal occlusal adjustments and the DVO values obtained in the immediate post-operative period were found to be comparable to those of the virtual design. By planning the final position of the bone and the implants in advance, it was possible to deliver a full-arch prothesis with proper implant emergence, occlusal vertical dimensions, and occlusal relationship. Conclusion: This fully digital protocol allows the clinician to preview and plan the osteotomy and implant surgery as well as the delivery of the temporary, immediately loaded, complete, fixed prosthesis in patients who are candidates for post-extraction surgery with the need for severe osteotomy.

3D-printed titanium surgical guides for extraction of horizontally impacted lower third molars

OBJECTIVES

This prospective study introduced a digitally designed sectioning guide and evaluated its feasibility for the extraction of horizontally impacted lower third molars.

MATERIALS AND METHODS

This study included 38 horizontally impacted lower third molars, randomly divided into experimental and control groups. The teeth were extracted using a 3D-printed titanium surgical guide in the experimental group; free-hand extractions were performed in the control group. The surgical duration, tooth sectioning duration, cortical bone perforation, and postoperative complications, including pain, swelling, trismus, dry socket, infection, and hemorrhage, were evaluated.

RESULTS

Although not statistically significant, guided surgery tended to reduce the number of tooth sectioning steps compared to free-hand extractions. There were no cases of cortical bone perforation in the experimental group. Although the surgical duration was greater in the experimental group (p < 0.05), there were no differences in postoperative pain, swelling, and trismus. There were no cases of postoperative infection and hemorrhage in either group.

CONCLUSIONS

3D-printed titanium surgical guides had superior accuracy and safety compared to free-hand surgery. Further studies with larger sample sizes are required to verify these findings.

CLINICAL RELEVANCE

The template improved the safety of tooth sectioning during impacted lower third molar surgery and resulted in a more predictable extraction. The narrow sectioning groove could fit comfortably with hypertrophic soft tissues in the posterior mandible.

Piezoelectric Surgery Is Effective in Reducing Pain, Swelling, and Trismus After Removal of Impacted Lower Third Molars: A Meta-Analysis

PURPOSE

Surgery of impacted lower third molars may be associated with postoperative complications. The aim of this study is to determine whether piezoelectric surgery is effective in reducing pain, swelling, and trismus compared to conventional rotary instruments during extraction of impacted lower third molars.

METHODS

For this systematic review, the searches were performed independently by 2 researchers. Randomized clinical trials that used the piezoelectric instrument for the removal of impacted lower third molars in humans were included. The predictor variable was the study group (piezo surgery vs rotary instruments). The main outcome was the analysis of postoperative pain, swelling, and trismus. Data analysis included risk of bias assessment (RoB 2 Cochrane) and meta-analysis with heterogeneity based on random effects I² and 95% confidence interval.

RESULTS

In the initial results, 956 articles were revised and after applying inclusion/exclusion criteria, the final sample was composed of 18 publications, all being randomized clinical trials. The results of this meta-analysis demonstrated a significant reduction in pain scores with a Cohen's d of -0.95 [CI 95% = -1.23 to -0.67] of high clinical impact (P < .001). In the piezo group there was a significant increase in mouth opening of 4.29 [CI 95% = 2.33 to 6.25] mm (P < .001). Regarding swelling, Tragus-Ang and Go-eye, both showed a significant reduction in the piezo group (P < .001). There was a significant increase of 7.32 [CI 95% = 4.40 to 10.24] minutes in the piezo group (P < .00001), and none of the studies showed a significant risk of bias.

CONCLUSIONS

Piezo proved to be effective in reducing pain, swelling, and trismus in third molar surgeries even with longer surgical time, but due to the lack of standardization in primary studies regarding swelling, new, controlled and standardized studies should be carried out with the objective of proving the effectiveness of this therapeutic modality in the reduction of postoperative swelling.

Automated Periotome versus Conventional Periotome in Intra-Alveolar Extraction of Sheep Jaw: An In Vitro Study

Background

Atraumatic dental extraction is the way forward in modern dentistry. This study aims to compare the effectiveness of automated periotome with conventional periotome with regard to operating time, postoperative gingival laceration, and bone and tooth structure fractures.

Methods

This is an in vitro study of forty posterior teeth of sheep mandibles. Ten sound healthy mandibles were selected, and each mandible was then divided into two quadrants with two teeth in each quadrant. Teeth were then extracted by conventional periotome for the first group (one quadrant) and by automated periotome for the second group (other quadrants). A statistically significant P value is set at below 0.05 with a 95% confidence interval.

Results

No bone fracture was seen in any of the cases of automated periotome with a significance of 0.004 when compared to the fractures seen in seven cases in the conventional group. Whereas comparing the other parameters among the different groups did not show any significant difference.

Conclusion

It is worthwhile to use the automated periotome in simple extractions, especially when implants are considered in the treatment plan.

A Pilot Randomized Controlled Clinical Trial Comparing Piezo Versus Conventional Rotary Surgery for Removal of Impacted Mandibular Third Molars

Background: The extraction of impacted mandibular third molars is a frequent dental surgery, interfering with patients’ quality of life. Ultrasonic surgery is an alternative to osteotomy with conventional rotary instruments. This study compares postoperative signals and symptoms after extracting impacted mandibular third molars using ultrasonic surgery or conventional rotary osteotomy. Methods: A pilot randomized controlled clinical trial was conducted. Thirty patients were randomly divided into the test group (ultrasonic technique) and a control group (conventional rotatory technique). All surgeries were timed. Swelling parameters, trismus and paraesthesia were evaluated on the day of surgery and the third, fifth and seventh postoperative days. Intraoperative bleeding was evaluated during surgery. Postoperative pain was evaluated daily by the patient through a visual analogue scale and the number of ingested analgesics. Results: Pain, swelling and trismus present beneficial results with the ultrasonic technique but without statistical significance. Intraoperative bleeding was significantly lower with ultrasonic surgery (t(28) = 3.258; p = 0.003). Operating time was significantly higher in extractions involving osteotomy and cutting crown and roots either with the conventional technique (p = 0.020) or ultrasonic technique (p = 0.039). Regardless of the surgical difficulty, no statistically significant results were detected between techniques regarding the procedure duration. Conclusions: The beneficial postoperative signs and symptoms make ultrasonic surgery a favourable therapeutic option, especially when the integrity of noble anatomical structures is the most important risk factor. Further studies with larger samples are needed to support the use of piezosurgery as a valid option for impacted mandibular third molar extraction.

Comparing the Effect of Facial Compression Bandage to That of Systemic Dexamethasone on Postsurgical Sequels after Extraction of Impacted Mandibular Third Molars: A Split-mouth Randomized Clinical Trial

AIM: The present study aimed to compare the clinical efficiency of facial pressure bandage, to that of intramuscular injection of dexamethasone (8 mg) on postsurgical sequels (swelling, pain, and trismus) of extraction of impacted mandibular third molar. METHODS: The study implemented a randomized split-mouth design. Patients with symmetrical bilateral impacted molars were eligible for the present trial. Sides were randomly assigned to two groups: pressure bandage group and dexamethasone group. The evaluated postsurgical sequels were extraoral swelling, trismus, and pain after 48 h and 7 days. RESULTS: The study included 42 impacted third molars (n = 42) in 21 patients with a mean age of 23.4 years. Most participants were females (66.7%). The mean postoperative swelling rates after 48 h and 7 days in pressure bandage group were found to be comparable to those of dexamethasone group. No significant difference was found in the mean rates of postoperative trismus between study groups after 48 h and 7 days. Differences in mean pain level scores between the pressure bandage group and dexamethasone group were statistically insignificant after 48 h and 7 days. CONCLUSION: The study findings showed that the effect of the pressure bandage was comparable to dexamethasone effect on the postsurgical sequels after surgical extraction of impacted mandibular third molars.

Piezoelectric Bone Surgery. Overview in Applications and Proof of Feasibility in Hand and Plastic Surgery

PURPOSE

Piezoelectric bone surgery was already extensively used in a number of surgical procedures ranging from dental to maxillofacial surgery. The authors aimed to determine whether piezosurgery was suitable and advantageous for performing osteotomies in Hand and Plastic reconstructive surgery.

METHODS

The authors overviewed a variety of applications for Piezosurgery^® Device, from Mectron, in bone reconstructive surgery with over the last 8 years. An overall number of 156 bone cutting procedures in adults and children was described at the phalanges, metacarpal bones and distal radius level, as well as in bone graft harvesting and bone remodeling following carpal scaphoid nonunion, scapho-lunate bone-ligament-bone reconstruction and fibula free flap in maxillofacial defects.

RESULTS

The consolidation rate was 87.5% in scaphoid nonunion grafting and fixation. Bone healing was achieved in all other cases. No intra-operative complications were recorded.

CONCLUSION

Piezosurgery^® allowed high precision in bone cutting as well as custom-made graft and surface roughness were obtained, while preserving nerves, vessels and tendons integrity. The instrument may be handling moved into the surgical space in absence of vibrations, with a clear view onto the bone. The mechanical and biological characteristics of the piezoelectrical effect perfected this technique as an effective and useful instrument in Hand and Plastic surgery. The selective bone cutting properties avoided injuries to the surrounding soft tissues and thermal damage of the bony cells. Best advantages were described in feasibility and flexibility for intra-articular osteotomies, custom-made grafts and reconstructive microsurgical techniques.

Low-level laser therapy using laser diode 940 nm in the mandibular impacted third molar surgery: double-blind randomized clinical trial

Background

The effect of low-level laser therapy (LLLT) on pain mitigation following the third molar surgery is still controversial. The absence of a standard method for using laser among the studies is related to the types of sample selection, sample size, control, and LLLT parameters, which make pain mitigation following surgery more controversial. Therefore, this study aimed to determine the effect of LLLT on reducing pain, swelling, and trismus following the mandibular impacted third molar surgery.

Methods

This study was performed on 25 healthy subjects. After the surgery, amoxicillin 500 mg was prescribed every 8 h for a 7-day period besides oral Ibuprofen (Gelofen) 400 mg every 12 h for a 3-day period. The intraoral Laser diode 940 nm was applied immediately after suture on the tested side, while on the placebo side, a fiber tip was used with no laser radiation following surgery. Eventually, the pain score was evaluated by VAS index from the 1st to the 7th-day post-surgery and then analyzed by SPSS 24.

Results

The results indicate that the mean swelling and trismus before, during, 2 days after, and 7 days after the intervention did not differ significantly between the two studied groups. However, the results show that on the sixth and seventh days, the pain was significantly lower in the intervention group compared to the control group.

Conclusions

The results suggest that although the pain, swelling, and trismus following surgery were lower on the radiated side, only pain was found to be significant on the radiated side (p < 0.05).

The registration number of the clinical trial in a Primary Registry in the WHO Registry Network is IRCT20141209020258N110 and the date of retrospective registration is 04/05/2019. The related URL is https://www.irct.ir/trial/36321.