Postoperative evaluation of Er:YAG laser, piezosurgery, and rotary systems used for osteotomy in mandibular third-molar extractions

Temperature variations during bone removal procedures similar to third molar extraction using different instruments

Bone removal is commonly used in the extraction of third molars and the heat generated during the process can interfere with the repair of bone. The aim of this study was to evaluate the temperature variation presented in bone removal performed with a high-speed turbine (400000 rpm), implant motor with straight piece (100000 rpm), low-speed micromotor (20000 rpm) and piezoelectric saw (30 kHz) in pig mandibles. For this, bone removal was carried out around 20 posterior teeth, under constant saline solution irrigation with a syringe and needle. In addition, the time required to perform bone removal was recorded. The results indicated a mean (SD) temperature variation of 0.96 °C (0.6 °C) for the high-speed turbine, 1.38 °C (0.5 °C) with the implant motor, 2.22 °C (0.7 °C) for the low-speed micromotor and 2.90 °C (1.3 °C) for the piezoelectric saw. The conventional variance was calculated discounting the variation of time used for bone removal around the teeth. There was a statistically significant difference in temperature variation between the high-speed turbine vs the micromotor (p = 0.009) and the high speed micromotor vs the piezoelectric saw (p = 0.04). We conclude that there is a statistically significant difference in temperature variation between the instruments used in oral and maxillofacial surgery, with higher rotation speeds resulting in the lowest temperature variations and a reduced surgical time.

Comparative Study of the Surgical Excision of Impacted Mandibular Third Molars Using Surgical Burs and an Erbium-Doped Yttrium Aluminum Garnet (Er:YAG) Laser

Background The use of lasers has increased in the field of dentistry in recent years. However, in the field of oral and maxillofacial surgery, the use of lasers has been largely restricted to soft tissue, and less focus is placed on the use of lasers for hard tissues. Aim The present study aimed to comparatively evaluate the efficacy of a erbium-doped yttrium aluminum garnet (Er:YAG) laser for cutting the bone while removing the impacted mandibular third molar with the use of a surgical bur. Methods The study assessed 80 subjects undergoing removal of impacted mandibular third molars. The subjects were recruited from the Department of Oral and Maxillofacial Surgery, Luxmi Bai Institute of Dental Sciences and Hospital, Patiala, Punjab, India. They were randomly divided into two groups, each consisting of 40 subjects. Group I used an Er:YAG laser to remove the bone, while Group II used a surgical bur. Assessments and comparisons were made for complications, wound healing, trismus, edema, bleeding, and pain. Results The study examined the efficacy of the Er:YAG laser for cutting the bone and extracting the impacted mandibular third molars using a surgical bur in two groups of 80 patients each. When the laser was used in place of a surgical bur, Group I patients experienced less edema, bleeding, and discomfort; nevertheless, the difference was not statistically significant. Time taken by laser for bone cutting was significantly higher compared to the surgical bur. In Group I (laser), trismus existed for a longer time. For mouth opening, the preoperative mouth opening was comparable in the two groups with p = 0.87. Conclusion Pain, hemorrhage, and edema were lesser, and the time required for bone cutting was substantially longer in the laser group. Apart from these, laser-assisted intra-oral bone cutting should be preferred because of its less invasive nature, simpler procedure, and simpler osteotomy when compared to traditional surgical burs and also in anxiety-prone patients.

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.

Comparison of Manual (2D) and Digital (3D) Methods in the Assessment of Simulated Facial Edema

BACKGROUND

An edema assessment following dental surgeries is essential to improving the dental surgeon's technique and, consequentially, patient comfort.

PURPOSE

Two-dimensional (2D) methods are limited in analyzing 3-dimensional (3D) surfaces. Currently, 3D methods are used to investigate postoperative swelling. However, there are no studies that directly compare 2D and 3D methods. The goal of this study is to directly compare 2D and 3D methods used in the assessment of postoperative edema.

STUDY DESIGN AND SAMPLE

The investigators implemented a prospective, cross-sectional study with each subject serving as its own control. The sample was composed of dental student volunteers without facial deformities.

PREDICTOR VARIABLE

The predictor variable is the method used to measure edema. After simulating edema, manual (2D) and digital (3D) techniques were used to measure edema. The manual method used direct facial perimeter measurements. The two digital methods were photogrammetry using a smartphone (iPhone 11, Apple Inc, Cupertino, California), and facial scanning with a smartphone application (Bellus3D FaceApp, Bellus3D Inc, Campbell, California) [3D measurements] MAIN OUTCOME VARIABLE: The coefficient of variation (CV) (CV = standard deviation /mean) was used to assess homogeneity of edema measurements.

ANALYSIS

The Shapiro-Wilk and equal variance tests were applied to assess data homogeneity. Next, one-way analysis of variance was performed, followed by a correlation analysis. Finally, the data were submitted to Tukey's test. The statistical significance threshold was set at 5% (P < .05).

RESULTS

The sample was composed of 20 subjects aged 18-38 years. The CV showed higher values using the manual (2D) method (47%; 4.88% ± 2.99), compared with the photogrammetry method (18%; 8.55 mm ± 1.52) and the smartphone application (21%; 8.97 mm ± 1.93). A statistically significant difference was observed between the manual method values and those of the other two groups (P < .001). There was no difference between the facial scanning and photogrammetry groups (3D methods) (P = .778) CONCLUSION AND RELEVANCE: Both digital measuring methods (3D) demonstrated greater homogeneity than the manual method in analyzing facial distortions caused by the same swelling simulation. Therefore, it can be affirmed that digital methods may be more reliable that manual methods for assessing facial edema.

Three-dimensional facial swelling evaluation of pre-operative single-dose of prednisone in third molar surgery: a split-mouth randomized controlled trial

BACKGROUND

Facial swelling, pain, and trismus are the most common postoperative sequelae after mandibular third molar (M3M) surgery. Corticosteroids are the most used drugs to reduce the severity of inflammatory symptoms after M3M surgery. This study aimed to evaluate the effect of a single pre-operative dose of prednisone on pain, trismus, and swelling after M3M surgery.

METHODS

This study was designed as a split-mouth randomized, controlled, triple-blind trial with two treatment groups, prednisone (PG) and control (CG). All the parameters were assessed before the extraction (T0), two days (T1), and seven days after surgery (T2). Three-dimensional evaluation of facial swelling was performed with Bellus 3D Face App. A visual analogue scale (VAS) was used to assess pain. The maximum incisal distance was recorded with a calibrated rule to evaluate the trismus. The Shapiro-Wilk test was used to evaluate the normal distribution of each variable. To compare the two study groups, the analysis of variance was performed using a two-tailed Student t-test for normal distributions. The level of significance was set at a = 0.05. Statistical analysis was conducted using the software STATA (STATA 11, StataCorp, College Station, TX).

RESULTS

Thirty-two patients were recruited with a mean age of 23.6 ± 3.7 years, with a male-to-female ratio of 1:3. A total of 64 M3Ms (32 right and 32 left) were randomly assigned to PG or CG. Surgery time recorded a mean value of 15.6 ± 3.7 min, without statistically significant difference between the groups. At T1, PG showed a significantly lower facial swelling compared to CG (PG: 3.3 ± 2.1 mm; CG: 4.2 ± 1.7 mm; p = 0.02). Similar results were recorded comparing the groups one week after surgery (PG: 1.2 ± 1.2; CG: 2.1 ± 1.3; p = 0.0005). All patients reported a decrease in facial swelling from T1 to T2 without differences between the two groups. At T1, the maximum buccal opening was significantly reduced than T0, and no difference between PG (35.6 ± 8.2 mm) and CG (33.7 ± 7.3 mm) (p > 0.05) was shown. Similar results were reported one week after surgery (PG: 33.2 ± 14.4 mm; CG: 33.7 ± 13.1 mm; p > 0.05). PG showed significantly lower pain values compared to CG, both at T1 (PG: 3.1 ± 1.5; CG: 4.6 ± 1.8; p = 0.0006) and T2 (PG: 1.0 ± 0.8; CG: 1.9 ± 1.4; p = 0.0063).

CONCLUSION

Our results showed that pre-operative low-dose prednisone administration could reduce postoperative sequelae by improving patient comfort after M3M surgery and reducing facial swelling two days and one week after surgical procedures.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov - NCT05830747 retrospectively recorded-Date of registration: 26/04/2023.

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.

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.

Is the Er: YAG Laser Effective in Reducing Pain, Edema and Trismus After Removal of Impacted Mandibular Third Molars? A Meta-Analysis

PURPOSE

Removal of impacted third molars, can be associated with complications such as pain, edema, trismus, that can increase the morbidity of this procedure. The purpose of this study is to determine whether the Er: YAG laser is effective in reducing pain, swelling and trismus compared to rotary instruments in removing impacted lower third molars (3 LM`s).

METHODS

For this systematic review the searches were carried out independently by 2 researchers and the articles were selected according to the inclusion and exclusion criteria previously established. The predictor variable was the study group (Er: YAG laser versus rotatory instruments). The main outcome was the analysis of post-operative pain, edema and trismus after third molars extractions. Data analysis included the risk of bias evaluation (RoB 2 Cochrane) and meta-analysis with random effects I² based heterogeneity and 95% confidence.

RESULTS

In the initial results, 1,371 articles were found and 6 RCT were selected to compose this study. A total of 299, 3 LM`s were removed, 126 with the Er: YAG laser, 142 with a drill and 31 with a piezoelectric instrument. The results of this meta-analysis showed that in the laser group there was a significant reduction in edema (1.82 [CI95% = -3.06 to -0.57] cm (P = .004)) and complications (P = .0004), a slight reduction in pain after 2 days (P = .030) and there was no variation in trismus (P = .200) when compared to the drill group. The surgery and/or osteotomy time was shorter in the drill group. Only 1 study presented low risk of bias.

CONCLUSIONS

The Er: YAG laser has been shown to be effective in reducing edema, pain and complications in impacted lower third molar surgeries. however due to the lack of standardization in Er: YAG laser therapy, new controlled and standardized studies should be performed with the aim of proving the efficacy of this therapeutic modality.

Comparison of Submucosal With Intramuscular or Intravenous Administration of Dexamethasone for Third Molar Surgeries: A Systematic Review and Meta-Analysis

Objective: The study aimed to review evidence on the efficacy of submucosal (SM) administration vs. intravenous (IV) or intramuscular (IM) route of injections of dexamethasone for improving outcomes after mandibular third molar surgery.

Methods: PubMed, Embase, CENTRAL, and Google Scholar were searched for randomized controlled trials (RCTs) up to 20th May 2021. Early (2–3 days) and late (7 days) outcomes were compared between SM vs. IV or IM dexamethasone. Quality of evidence was assessed based on GRADE.

Results: Thirteen trials were included in the systematic review and 10 in the meta-analysis. Meta-analysis indicated a significant reduction in early pain with IV dexamethasone but no such difference for late pain compared to the SM group. There was no difference in early and late swelling scores between the SM and IV groups. Pooled analysis indicated no significant difference in early and late trismus between SM and IV groups. Comparing SM with IM dexamethasone, there was no significant difference in early and late pain scores. Swelling in the early and late postoperative periods was not significantly different between the two groups. There was no significant difference in early and late trismus between SM and IM groups. The quality of evidence was low for all outcomes.

Conclusion: Low-quality evidence suggests that SM infiltration of dexamethasone results in similar outcomes as compared to IV or IM administration of the drug after third molar surgeries. Further high-quality RCTs are needed to corroborate the current conclusions.