A Comparative Study on the Extractions of Partially Impacted Mandibular Third Molars With or Without a Buccal Flap: A Prospective Study

Conventional avulsion versus less traumatic extraction of ankylosed roots with a magnetoelectric device in anterior maxillary areas

The analysis aimed to compare two different single-tooth extraction surgical approaches in anterior maxillary areas of the ankylosed teeth: less traumatic magneto-electrical (mag) versus conventional tooth extraction (con) in minimizing the adverse effects on post-extractive sockets. Parameters of clinical interest such as intra-surgical fracture of the buccal bone plate, presence of postoperative inflammation, and application of stitches were acquired from medical records. The data were subjected to Pearson's χ2 analysis or to Fisher's exact test with significance at 0.05. Sixty-six hopeless maxillary permanent ankylotic teeth were extracted in the same number of patients. In the mag group 2 incisors suffered a fracture. Two patients out of 40 had signs and symptoms of inflammation that resolved completely within 3 days. In the con group 18 out of 26 patients suffered from buccal alveolar fracture. Six of these patients experienced signs of inflamed tissue. The two groups showed significant differences with p-values ≤0.0009 with regards to fracture (2/38 vs. 18/8) and tissue inflammation variables (2/38 vs. 10/16). A significantly different distribution about the presence of sutures was registered between the mag (4/36) and the con (18/8) group with a p-value <0.0001. Mag group seemed to have reduced frequency of fractured and infected post-extractive sites.

Effects of collagen membrane on bone level and periodontal status of adjacent tooth after third molar surgery: a randomized controlled trial

BACKGROUND

The periodontal status and distal bone level of the adjacent second molar can be negatively affected by the surgical extraction of an impacted lower third molar. Absorbable materials have some benefits, including enhancing primary wound coverage and promoting wound healing through isolation, clotting, wound stabilization and haemostasis. This study set out to compare primary and secondary healing and collagen-membrane-based primary healing after surgical removal of partially erupted impacted third molars (3Ms), evaluating the distal alveolar bone level (ABL) and periodontal status of the adjacent second molars (2Ms).

METHODS

Patients who met the inclusion criteria were randomized into three groups: secondary healing (n = 28), primary healing (n = 27) and membrane-based primary healing (n = 29). Digital panoramic radiographs were obtained preoperatively (T1) and three months postoperatively (T2). The distances between the cemento-enamel junctions and the alveolar bone crests on the distal aspects of the adjacent 2Ms were measured using calibrated radiograph measurement software. The pocket depth and plaque index measurements were performed preoperatively and three months postoperatively. The periodontal plaque index (PPI) scores were registered on the distal aspects of the 2Ms, and the mean values were used.

RESULTS

Three of the applied healing types positively affected periodontal pocket depth (PPD) and periodontal index values (p < 0.05). In terms of the ABL of the adjacent 2Ms, primary healing (p < 0.05) and membrane-based primary healing (p < 0.05) had superior results to secondary healing.

CONCLUSION

Membrane use is promising for the distal bone gain and periodontal status of the adjacent 2M.

TRIAL REGISTRATION

This clinical study was registered by the Australian New Zealand Clinical Trials Registry, with the trial number ACTRN12618001551280.

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.

Does Minimal-Invasive Envelope Flap Reduce Side Effects Compared to Conventional Envelope Flap Following Impacted Third Molar Surgery? A Split-Mouth Randomized Clinical Trial

PURPOSE

The surgical removal of impacted third molars can lead to various postoperative consequences, which can be influenced by modifiable factors such as flap design. The present study aimed to determine whether a minimal-invasive envelope flap (MIEF) can reduce surgical consequences and improve life quality compared to conventional envelope flap (CEF) after removing impacted mandibular third molars.

MATERIAL AND METHODS

This single-blinded, cross-over randomized clinical trial was conducted on adult patients with bilateral, symmetrically impacted mandibular third molars. The flap design for surgical removal of the third molar was the primary predictor variable. The primary outcome (pain) and secondary outcome variables (swelling, mouth opening limitation [MOL]) were recorded daily and on the second and seventh days after the surgery, respectively. Wound dehiscence and patients' postoperative quality-of-life scores (PPOQL) were recorded on the seventh day. The data were analyzed by Kolmogorov-Smirnov and paired sample t test using SPSS version 22. The P value < .5 was considered significant.

RESULTS

Sixty-eight impacted third molars of 34 subjects with a mean age of 22 ± 12.9 years (35% females) were followed. The postoperative pain level in the MIEF group at rest (0.80 ± 0.53) and chewing (2.10 ± 1.32) up to fifth day was significantly (P value < .01) lower than CEF group (2.40 ± 1.12 and 3.05 ± 1.13, respectively). The difference did not reach a significant level at rest and chewing on the sixth and seventh days (P value > .05). On the seventh day, the subjects in the MIEF group showed a significantly (P value < .001) lower level of swelling (1.13 ± 0.11) and MOL (8.28 ± 4.17) than the CEF group (3.2 ± 2.1 and 12.67 ± 4.92, respectively). Based on the PPOQL scale, patients in the MIEF group (1.82 ± 1.31) expressed a better recovery period than the CEF group (3.5 ± 2.1) (P value < .001).

CONCLUSIONS

Considering the reduction of pain, swelling, MOL, and wound dehiscence in MIEF cases, the application of MIEF in surgical removal of impacted mandibular third molars can lead to a significant reduction in postoperative consequences and also a noticeable improvement in PPOQL compared to CEF.

Removal of Horizontally Impacted Mandibular Third Molars With Large Root Bifurcations Using a Modified Tooth Sectioning Method

PURPOSE

The purpose of this study was to introduce the method and first results of a modified tooth sectioning technique for the extraction of horizontally impacted mandibular third molars (M3Ms) with large root bifurcation.

PATIENTS AND METHODS

A total of 300 horizontally impacted M3Ms with large root bifurcation in medically healthy patients were included in this prospective study. Patients were divided into 2 groups: the modified method group (test group), in which the M3M was sectioned between the distal root and the remainder of the tooth at the point of root bifurcation; and the conventional method group (control group), in which the M3M was sectioned between the crown and the root at the cementoenamel junction. Operation duration, postoperative reactions, complications, and patient satisfaction were analyzed and compared between the 2 groups.

RESULTS

Each group included 150 M3Ms which were all successfully extracted. Operation durations in the test and control group were 10.48 ± 3.78 and 15.09 ± 4.24 minutes, respectively (P < .05). The test group had significantly better results than the control group with regard to postoperative reactions and complications (P < .05). Patients in the test group had higher satisfaction ratings regarding operation duration and the healing process than those in the control group (P < .05).

CONCLUSIONS

The modified method of tooth sectioning between the distal root and the remainder of the tooth can efficiently eliminate resistance from the bone and adjacent mandibular second molar and allow for just 1 sectioning of the M3M in most cases, which could make the operation straightforward and safe.

Envelope or triangular flap for surgical removal of third molars? A systematic review and meta-analysis

The aim of this systematic review was to compare the triangular and envelope flaps in mandibular third molar surgery with regard to pain, oedema, and trismus. Secondary outcomes assessed were dehiscence, ecchymosis, alveolar osteitis, periodontal condition, and surgical time. The PRISMA guidelines and recommendations in the Cochrane Handbook were followed, and the review was registered before commencement (PROSPERO; CRD42018112373). The literature search was conducted in the Web of Science, PubMed, Virtual Health Library, Cochrane Library, and Scopus databases and in the grey literature; randomized clinical trials, indexed through November 2018 were included. Three reviewers independently examined the studies. Twenty studies were included in the qualitative analysis, of which 18 were included in the meta-analyses. The flap design did not influence pain, oedema, trismus, dehiscence, or osteitis. The triangular flap was associated with a greater occurrence of postoperative ecchymosis (odds ratio 4.58, 95% confidence interval 1.34 to 15.91, I²=0) and lower periodontal probing depth on day 7 postoperative (standardized mean difference -1.36, 95% confidence interval -2.68 to -0.03, I²=88%) when compared to the envelope flap in mandibular third molar surgeries.

Hard Tissue Preservation in Minimally Invasive Mandibular Third Molar Surgery Using In Situ Hardening TCP Bone Filler

Background

Maintenance of hard tissue in the case of impacted third molars (M3M) with close relationship to the mandibular canal is still a surgical challenge which may be overcome using the inward fragmentation technique.

Methods

A consecutive case series of 12 patients required the extraction of 13 impacted M3M with a close relationship to the inferior alveolar nerve (IAN). Via occlusal miniflaps, M3M were exposed occlusal under endoscopic vision and removed by inward fragmentation. All patients received socket preservation with resorbable in situ hardening TCP particles to reduce the risk of pocket formation at the second molar.

Results

All 13 sites healed uneventfully. Bone height was assessed using CBCT cross-sectional reformats pre- and 3 months postoperatively. The bone height was reduced by 1.54 mm lingual (SD 0.88), 2.91 mm central (SD 0.93), and 2.08 mm buccal (SD 1.09). Differences were significant at a 0.05% level. No tissue invagination at the extraction sites was observed.

Conclusions

Major bone defects can be avoided safely using inward fragmentation surgery. The self-hardening bone filler appears to enhance the mineralization of the intrabony defect.

How effective is collagen resorbable membrane placement after partially impacted mandibular third molar surgery on postoperative morbidity? A prospective randomized comparative study

Background

Collagen membranes have some benefits include promoting wound healing through isolation, clot stabilization, wound stability, and hemostasis, enhancing primary wound coverage through its chemotactic ability to attract fibroblasts, and augmenting flap thickness by providing a collagenous scaffold. The purpose of this study was to compare primary and secondary healing and collagen membrane-based primary healing after surgical removal of partial impacted mandibular third molars, evaluating the incidence of postoperative complications and analyzing the swelling, mouth opening, and pain.

Methods

This was a prospective, randomized controlled study. Patients were randomly assigned to three groups: the SC (Secondary closure) group, the PC (Primary closure) group, and the MBPC (membrane based primary closure) group. Data were collected on pain, mouth opening, swelling, and complications experienced by the patients.

Results

There was no statistically significant difference between the groups for the pain (p > 0.05), relatively. The swelling recorded on postoperative days 2 and 7 was lower in the SC group than in the PC (p = 0.046 and 0.00) and in MBPC (p = 0.005 and 0.002) groups, respectively. Mouth opening showed a statistically significant difference between the three groups at day 2 (p = 0.00). Wound dehiscence was shown in 6 patients in the PC (20%) group and 2 patients in the MBPC (6.7%) group. Dry socket was observed 3 patients in the SC group (10%), 2 patients in the PC group (6.7%), and no dry socket in the MBPC group. No cases of infection or postoperative bleeding were encountered.

Conclusions

The secondary closure provides a marked advantage over the primary closure in terms of swelling and mouth opening. However, the absence of alveolitis in the primary closure using the collagen membrane and minimal wound dehiscence, suggests that membrane use may support primary healing in terms of wound healing.

Effect of flap design and duration of surgery on acute postoperative symptoms and signs after extraction of lower third molars: A randomized prospective study

Background. Different surgical variables are assumed to play a role in postoperative course after lower third molar extraction. The aim of study was to assess whether flap design and duration of surgery can influence acute postoperative symptoms and signs after lower third molar extraction.

Methods. Twenty-five patients scheduled for lower third molar extraction were included in this study and randomly assigned to two groups in terms of flap design: group A (envelope flap) and group B (triangular flap). Swelling and trismus were assessed before and after surgery on days 0, 2 and 7. Pain was assessed for seven days after surgery. Maximum postoperative pain was chosen as the main outcome variable. ANOVA was used to assess differences between the groups regarding maximum postoperative pain, trismus and swelling at 2- and 7-day intervals. Pearson's correlation coefficient was used to assess correlation between duration of surgery and postoperative symptoms and signs.

Results. No significant difference was found between the two flap designs for any postoperative symptoms and signs. The duration of surgery was found to be correlated with both trismus (r = -0.44, P = 0.04) and swelling (r = 0.59, P = 0.004) as assessed 2 days after surgery. No associations were found between duration of surgery and maximum postoperative pain and trismus and swelling at 7-day interval.

Conclusion. Within the limits of the present study, the duration of surgery, and not the flap design, affected the acute postoperative symptoms and signs after lower third molar extraction.

Does laterally rotated flap design influence the short-term periodontal status of second molars and postoperative discomfort after partially impacted third molar surgery?

PURPOSE

To assess the influence of the surgical removal of partially impacted third molars (3Ms) and compare the effects of a 3-cornered laterally rotated flap (LRF) with primary closure (flap 1) and an envelope flap with secondary closure (flap 2) on the short-term periodontal status of the adjacent second molars (2Ms). We also assessed the postoperative complications after removal of the partially impacted 3M.

MATERIALS AND METHODS

A split mouth, randomized clinical study was designed. The study sample included patients with bilateral partially impacted 3Ms. The primary predictor variable was the type of flap design (flaps 1 and 2). The primary outcome variable was periodontal status (gingival recession [GR], probing depth [PD], plaque index [PI], and gingival index) of the 2Ms measured preoperatively and 90 days postoperatively. The secondary outcome variables were postoperative complications, including pain, facial swelling, alveolitis, and local wound infection. The other variables included gender, position of the 3Ms, and surgical difficulty. We performed descriptive, comparative, correlation, and multivariate analyses.

RESULTS

The sample included 28 patients aged 18 to 28 years. The GR, PD, and PI values with the flap 2 design were greater than those with the flap 1 design (P < .05). Facial swelling with the flap 1 design was significantly greater than with the flap 2 design on the second postoperative day (P < .05). The pain levels with the flap 1 design were significantly greater than those with the flap 2 design on the first and second postoperative days (P < .05). According to the multivariate regression analyses, flap design was closely related to the periodontal status of the 2Ms and postoperative discomfort.

CONCLUSION

The results of the present clinical study have shown that the flap design in partially impacted 3M surgery considerably influences the early periodontal health of the 2Ms and postoperative discomfort. However, although the 3-cornered LRF design might cause more pain and swelling, it could be the method of choice for partially impacted 3M surgery because of the early periodontal healing.

Prospective double-blind clinical trial evaluating the effectiveness of Bromelain in the third molar extraction postoperative period

OBJECTIVES

To evaluate the anti-inflammatory and analgesic effect of Bromelain (pineapple extract) administered orally in the postoperative after extraction of impacted lower molars.

STUDY DESIGN

This is a prospective, placebo-controlled, unicentric, double-blind study; the sample size was 34 patients. The pre and postoperative outcomes, evaluated on the third (D3) and eighth day (D8), included inflamtion, pain and oral aperture, as well as the need for analgesics. One group received Bromelain 150mg per day for three days and 100mg on days 4 to 7. The other group received placebo in the same dosage. All outcomes werrecorded quantitatively and analyzed with the Mann-Whitney U test for independent samples.

RESULTS

Although there were no statistically significant differences between the treatment groups, a trend towards less inflammation and improved oral aperture was observed in the group that received Bromelain, compared to the group that received placebo. This trend can be attributed completely to random reasons, since there is no statistical difference in the results.

CONCLUSIONS

Further studies are necessary to analyze different administration patterns and doses of Bromelain for the use in the postoperative of impacted third molars.

Endoscopically assisted removal of a lingually displaced third molar adjacent to the inferior alveolar nerve

BACKGROUND

Osteotomy of impacted lower third molars still represents a major trauma because of periosteal flap preparation and buccal bone loss. We present a new occlusal flapless approach for the removal of lingually impacted lower third molars adjacent to the inferior alveolar nerve without lateral or lingual osteotomy.

METHOD

After occlusal exposure under local anesthesia, visualization of the third molar region is obtained from a posterior perspective using support endoscopy. Under magnifying endoscopic visualization, the crown is removed using an inward fragmentation technique. After exposure of the furcation area, the roots are separated and removed via the occlusal cavity.

CONCLUSIONS

Endoscopically assisted removal of mandibular third molars allows the maintenance of the adjacent bone structures and the integrity of the mandibular canal. It is valuable in complex anatomic sites in particular.

Removal of impacted mandibular third molars using an inward fragmentation technique (IFT) - Method and first results

PURPOSE

Conventional surgical extraction of impacted mandibular third molars (M3M) requires a lateral flap reflection in conjunction with lateral bone removal for outward mobilization of the tooth. The aim of this report is to outline a novel inward fragmentation technique (IFT) in conjunction with an occlusal miniflap approach to reduce the amount of bone removal to a minimum.

PATIENTS AND METHODS

Seventeen consecutive patients (7 men and 10 women; mean age 24.4 years, range 18-36 years) required the extraction of 21-impacted M3M with a close relationship to the inferior alveolar nerve (IAN). Occlusal miniflaps were used and only occlusal bone removal was performed to expose the M3M under endoscopic vision. A central space-making cavity was created followed by inward fragmentation and mobilization of the crown and subsequent root removal through the space created.

RESULTS

20 of 21 sites healed uneventfully, one late infection was observed, no permanent neurosensory lesion occurred. The mean preoperative buccal bone height was 15.5 (11-18) mm and the postoperative buccal bone height 14.7 (11-17) mm. On the 2nd day, the mean swelling level was 1.38 (0-2) on a 4 point scale, the pain level was 2.30 (0-5) on a 10 cm VAS, mean pain duration was 2.04 days.

CONCLUSION

An inward fragmentation technique allows preservation of >90% of the buccal bone height adjacent to mandibular third molars and may reduce postoperative morbidity without raising the risk of IAN lesions.