Randomized clinical study comparing Piezoelectric Surgery with conventional rotatory osteotomy in mandibular third molars surgeries

PurposeThe aim of this study was to evaluate the performance and to assess the postoperative sequel and quality of life after removal of impacted mandibular third molars using piezoelectric surgery compared with conventional rotatory osteotomy.Patients and methodsA single blinded, randomized, control clinical study was performed. Sixty-three patients (44 males, 19 females) who presented with bilaterally asymptomatic impacted mandibular third molars were included in this analysis. Each patient was treated, at two separate sessions approximately 4 weeks apart, with a conventional rotatory hand piece on one side of the mandible and a piezoelectric device on the contralateral side. Patients were followed up on postoperative days 1, 3, 5, 7, and 15 to rate the pain, swelling and trismus. Inferior alveolar nerve paresthesia was evaluated up to 12 months postoperatively.ResultsThe severity of the pain, trismus and swelling using the piezosurgery were significantly different from the rotary group. In both groups, pain was most intense and peaked during the first post-operative day, while swelling and trismus reached peak levels on the third postoperative day. The piezoelectric procedure resulted in a significantly longer procedural duration compared to the rotatory surgery (P < 0.001).ConclusionPiezoelectric surgery is considered a viable alternative technique compared to the conventional rotary systems and can improve a patient’s quality of life. Thus, piezoelectric surgery might be a preferred modality for patients undergoing complicated surgical extraction of impacted lower third molars.     

Influence of two different flap designs on the sequelae of mandibular third molar surgery

Purpose

The aim of this study was to compare the influence of triangular and envelope flaps on trismus, pain, and facial swelling after mandibular third molar surgery.

Methods

Twenty healthy patients with bilateral, symmetrically impacted mandibular third molars were included in this double-blinded, prospective, cross-over, randomized study. The patients were operated with envelope flap on one side and triangular flap on the other side. Trismus was determined by measuring maximum interincisal opening, and facial swelling was evaluated using a tape measuring method. Pain was determined using visual analog scale (VAS) and recording the number of pain pills taken.

Results

The facial swelling measurements and VAS scores were lower in the envelope flap group compared to the triangular flap group. There was no significant difference between the two flap designs in operation time, maximum interincisal opening, and the number of analgesics taken.

Conclusion

Envelope flap yields to less facial swelling and reduced VAS scores in comparison to triangular flap. There is no clinical difference in trismus between the two flap designs. Despite the higher VAS scores with triangular flap, no additional doses of analgesics were required in triangular flap.     

Comparison of corticosteroids and rubber drain for reduction of sequelae after third molar surgery

Introduction

For reducing edema, trismus, and pain after impacted tooth surgery, some protocols are proposed but their relative effectiveness is controversial.

Purpose

The goal of this study was to evaluate and compare the effects of corticosteroids and rubber drain on the postoperative complications of impacted molar surgery.

Patients and methods

This study was carried out on 22 patients with bilateral symmetrical mandibular impacted third molars. For surgical removal of impacted teeth on one side of these patients, either rubber drain (11 cases) or perioperative corticosteroids (11 cases) were used (study group). The contralateral impacted teeth were removed routinely without using any drug or drain (control group). Facial edema, trismus, and pain perception of the study and control groups were recorded on the second and seventh postoperative days.

Results and discussion

This study showed that perioperative steroids reduce the trismus, facial swelling, and the severity of pain after third molar surgery. This study also revealed that the use of the drain reduces facial pain and trismus but has no effect on the facial swelling after impacted tooth surgery. Comparing the steroid and drain groups, we found that perioperative corticosteroids are more effective than the surgical drain in reducing postoperative pain and edema, but their effects on trismus are similar.     

Rotary Instrument or Piezoelectric for the Removal of Third Molars: a Meta-Analysis

Aim

The aim of this systematic review and meta-analysis was to compare, in the lower third molar surgery, the osteotomy techniques with rotary instruments and piezoelectric motors.

Methods

An electronic search was conducted using the following databases: Pubmed, Web of Science, and the Cochrane Oral Health Group Trials Register. Inclusion criteria were: studies in humans, randomized or nonrandomized, comparing the extraction of third molars that required osteotomy and/or odontosection with rotary instrument and osteotomy and/or odontosection with piezoelectric motor assistance. The analysis and inclusion of articles was performed by two reviewers independently. An evaluation of the quality of articles and data extraction was carried out.

Results

From a total of nine hundred seventy four (974) trials, eleven articles were included in the qualitative analysis, and seven were included in the quantitative analysis. Rotary instruments were faster than the piezoelectric surgery (95 % CI 0.34 to 1.16). The piezoelectric surgery showed better results when compared with roatry instruments when trismus was assessed in 2 (95 % CI 0.65 to 1.69), 3 (95 % CI 0.63 to 1.67) and 5 (95 % CI 0.03 to 2.26) days after surgery. Seven days after surgery, there were no differences between the techniques (95 % CI (?0.022) to (?1.49)).

Conclusion

The piezoelectric surgery was effective in reducing pain, swelling and trismus in third molar surgery, but the same requires greater surgical time than the rotary instruments.

     

Eventuality of Dexamethasone Injected Intra-massetrically on Post Operative Sequel Following the Surgical Extraction of Impacted Mandibular Third Molars: A Prospective Study

Objective

The objective of the study was to compare the efficacy of dexamethasone given intra-massetrically via intra buccal approach on postoperative sequele after surgical extraction of impacted mandibular third molars.

Methodology

Twenty patients, each of who required surgical extraction of a single impacted mandibular third molar under local anesthesia, were randomly set apart to one of the two groups of ten each. The experimental group received dexamethasone 8 mg injected to the masseter muscle intra buccally and the control group did not receive any steroid. Facial swelling and maximal inter-incisal distance were measured by an independent examiner preoperatively, and at 4th h, on the day of surgery, 2 and 7 postoperative days. Pain was measured from the patient’s response to a visual analogue scale.

Results

Patients were of the age range 18–40 years. Dexamethasone group showed significant reduction in swelling and pain compared with the control group at all intervals. Dexamethasone injected into the masseter muscle via intra buccal approach resulted in significantly less trismus than control on day one postoperatively.

Conclusion

Dexamethasone 8 mg given intra-massetrically through intra buccal approach is an effective way of minimizing swelling, trismus, and pain following surgical extraction of impacted mandibular third molars. It offers a simple, safe, painless, non-invasive and cost-effective treatment.

     

Comparative study of primary and secondary closure of the surgical wound after removal of impacted mandibular third molars

Aim

Aim of the study is to compare the primary and secondary healing after surgical removal of impacted mandibular third molars, in terms of swelling, severity of pain, trismus, and periodontal healing between two types of closure.

Materials and methods

A total of 60 patients, divided into two groups randomly: group A, with 30 patients in which primary closure was done; group B, with 30 patients in which secondary closure was done. A comparison between two groups was done in terms of postoperative pain, swelling, trismus at first, third, and seventh postoperative days, and periodontal healing near adjacent second molar after 6 months.

Results

The swelling and pain in group A were greater than that in group B, with a statistically significant difference (p <?0.05). Mouth opening is greater in group B compared to group A. There is no significant difference in periodontal healing in between two groups after 6 months. Complication like alveolar osteitis was noted in 1 patient (3.3%) in group B.

Conclusion

We conclude that secondary closure was better than primary closure in terms of postoperative pain, swelling, and trismus. Irrespective of any closure technique, there is no difference in terms of periodontal healing.

     

Effects of intra-space injection of Twin mix versus intraoral-submucosal,intramuscular, intravenous and per-oral administration of dexamethasone on post-operative sequelae after mandibular impacted third molar surgery: a preliminary clinical comparative study

Introduction

A prospective randomised double-blind study was undertaken to compare the effects of intra-space injection of ‘Twin mix’ versus intraoral-submucosal, intramuscular, intravenous and per-oral administration of dexamethasone on post-operative sequelae after mandibular impacted third molar surgery.

Material and methods

A randomised double-blind clinical trial was conducted on 60 patients with class II position B impaction of mandibular third molars. Sixty transalveolar extractions were performed prospectively with ten patients randomly allocated to each of the six study groups (group T: intra-space injection of Twin mix; group S: submucosal dexamethasone; group M: intramuscular dexamethasone; group V: intravenous dexamethasone; group O: per-oral dexamethasone; group C: control group, no dexamethasone). A ten-point visual analogue scale was used to assess the overall pain intensity/patient discomfort, and specific facial measurements were recorded to assess the post-operative facial swelling. Maximal mouth opening was compared pre and post-operatively to assess the trismus.

Results

Mean operative visual analogue scale scores did not show statistical variation, and post-operative visual scores indicated better patient comfort in the steroid groups with statistically significant difference between group T and the control group on the first, third and the seventh post-operative day. Mean increase in distances between tragus and soft tissue menton to assess facial swelling showed strong statistically significant difference between the first and the third post-operative day between the control group and group T (p value <0.0001). Association of trismus was found less with the steroid treatment groups when compared to the control group.

Conclusion

Steroid groups had a better clinical outcome with improved quality of life post-operatively when compared to the nonsteroid study group. Intra-space injection of dexamethasone in pterigomandibular space as Twin mix was found to have similar clinical effects as conventional methods of administering steroids via intraoral-submucosal, intramuscular, intravenous and per-oral routes. This, however, is a small study which would now benefit from larger numbers.     

Comparison of Primary and Secondary Closure of the Surgical Wound After Removal of Impacted Mandibular Third Molars

Aims and Objectives

This comparative study compares the primary and secondary healing after surgical removal of impacted mandibular third molars, evaluating and monitoring the extent of swelling and severity of pain and trismus.

Materials and Methods

60 patients (37 females, 23 males; age range 18–40 years) were included in the series. The patients were randomly subdivided into 2 groups of 30 each. All the patients were operated by the same operator under same clinical conditions. Group 1 had 30 patients who underwent primary closure. Group 2 had 30 patients who underwent secondary closure. Pain, swelling and trismus were evaluated for 1st, 3rd and 7th days after surgery with a VAS scale.

Results

An analysis of immediate findings showed that the patients with primary closure experienced significantly greater pain, swelling and trismus than that was experienced by patients with secondary closure. When the subsequent findings were analyzed there was statistically significant difference in pain, swelling and trismus experienced between both the groups.

Conclusion

The findings of this study suggest that the procedure of choice after removal of impacted mandibular third molars is a secondary closure and healing by secondary intention. A secondary closure appears to minimize the postoperative edema, pain and trismus and thus contributes to enhanced patient comfort.     

Pre-Emptive Analgesia with Ketamine for Relief of Postoperative Pain After Surgical Removal of Impacted Mandibular Third Molars

Purpose

In this study we assessed the clinical efficacy of sub-mucosal injection of ketamine at sub-anesthetic dose of 0.5 mg/kg on post-operative pain, swelling and trismus following surgical extraction of impacted mandibular third molars.

Methods

Forty bilaterally symmetrical impacted mandibular third molars in 20 patients who required surgical removal were included in the study. Within the same individual, one of the sites received a test medication whereas the other site was used as control. All patients received nerve blocks with local anesthetic (2 % lignocaine hydrochloride with 1:80,000 adrenaline); the Test group received sub-mucosal infiltration of 0.5 mg/kg of ketamine hydrochloride (without preservative) around the impacted mandibular third molar and along the incision line, while the Placebo group received normal saline infiltration, 10 min before placement of the incision.

Results

The pain scores on VAS at 30 min, 1, 4, 12 h and 1 day post-operatively was significantly lower in the Test group than in the Placebo group (p < .05). With respect to facial swelling and mouth opening the Test group and Placebo group showed overall no statistically significant difference (p > .05) on the 1st, 3rd and 7th post-operative days.

Conclusion

The sub-mucosal injection of 0.5 mg/kg ketamine administered before surgical removal of impacted mandibular third molars was found to be effective in significantly reducing post-operative pain for the first 24 h.

     

Pseudoaneurysm of the facial artery occurred after mandibular sagittal split ramus osteotomy

Introduction

Pseudoaneurysms are caused by rupture of arteries with extravasation of blood. The compressed perivascular tissue forms the wall of aneurysmal sac. Pseudoaneurysm directly related with surgical procedure of sagittal split ramus osteotomy (SSRO) was reported quite rarely especially related with facial artery during the vertical osteotomy.

Case report

SSRO was carried out for a 19-year-old male; the patient visited the emergency room with notable swelling 3 weeks after the surgery. We experienced severe intra-oral bleeding with surgical exploration. Angiography revealed a pseudoaneurysm of the right facial artery that might be related with vertical osteotomy over lateral cortex of the mandibular body during orthognathic surgery. This implies that the minor vascular trauma from vertical osteotomy of the mandibular body during the conventional orthognathic surgery might cause later development of pseudoaneurysm.     

2种切开翻瓣法拔除下颌智牙的临床效果分析

目的 比较2种不同切开翻瓣法拔除水平阻生下颌第三磨牙的临床效果。方法选取水平阻生下颌第三磨牙患者400 例,随机分为A、B 2组。A组200 例,采用远中切口翻瓣法;B组200 例,采用常规角形切口翻瓣法,观察2组病例拔牙时间、干槽症发生率、术后疼痛、面部肿胀、开口受限等情况,应用SPSS 13.0软件包对数据进行统计学分析。结果A组手术时间比B组长。术后第3天,A组面部肿胀及开口受限均较B组轻,2组患者的疼痛程度无显著差异。术后第7天,2组术后疼痛、面部肿胀及开口受限无显著差异。结论远中切口法翻瓣较角形切口法明显减少患者术后肿胀及开口受限的程度。     

Single dose of diclofenac or meloxicam for control of pain, facial swelling,and trismus in oral surgery

Background

Postoperative pain associated with removal of mandibular third molars has been documented from moderate to severe during the first 24 hours after surgery, with pain peaking between 6 and 8 hours when a conventional local anesthetic is used. Dental pain is largely inflammatory, and evidence-based medicine has shown that nonsteroidal anti-inflammatory drugs are the best analgesics for dental pain. The aim of this study was to compare the analgesic, anti-inflammatory and anti-trismus effect of a single dose of diclofenac and meloxicam after mandibular third molar extraction.

Material and Methods

A total of 36 patients were randomized into two treatment groups, each with 18 patients, using a series of random numbers: Group A, was administered 100 mg of diclofenac; and Group B, 15 mg of meloxicam. Drugs were administered orally 1 hour prior to surgery. We evaluated pain intensity, analgesic consumption, swelling, as well as trismus.

Results

The results of this study showed that patients receiving 15 mg of meloxicam had less postoperative pain (P=0.04) and better aperture than those receiving 100 mg of diclofenac (P=0.03). The meloxicam group presented less swelling than diclofenac group; however, significant statistical differences were not observed.

Conclusions

Data of this double-blind, randomized, parallel-group clinical trial demonstrated that patients receiving 15 mg of preoperative meloxicam had a better postoperative analgesia and anti-trismus effect compared with who were given 100 mg of diclofenac after third molar extractions. Key words:Diclofenac, meloxicam, dental pain, trismus, third molar surgery.     

Oral dexamethasone decreases postoperative pain,swelling, and trismus more than diclofenac following third molar removal: a randomized controlled clinical trial

Purpose

The aim of this study was to compare the anti-inflammatory potential of two pharmacotherapy protocols based on the parameters of pain, trismus, and swelling, after extraction of third molars.

Methods

Thirty patients selected with symmetrical impaction of third molars were submitted to surgical procedures in both sides in different times. For one group, dexamethasone was used for 3 days, and for another group diclofenac sodium was also used for the same period. The main variables analyzed were the visual analogue pain scale (VAS), but others were also analyzed such as swelling and trismus, which were submitted to statistical analysis.

Results

The results had no difference regarding the length of procedures (p = 0.986) and the pain in the immediate and 4-h postoperative period (p = 0.723 and 0.541). The rescue analgesic consumption was higher (p < 0.05) when using the protocol with diclofenac sodium. The variables mouth opening (p < 0.05) and swelling (p < 0.05) were significantly better when using the protocol with dexamethasone in the postoperative period.

Conclusions

Medical protocol with the use of dexamethasone in the postoperative period was more effective in controlling pain, trismus, and swelling, after the extraction of third molars, when compared to diclofenac sodium.

     

Effects of tube drain with primary closure technique on postoperative trismus and swelling after removal of fully impacted mandibular third molars.

OBJECTIVE: Surgical removal of impacted mandibular third molars with primary wound closure may result in postoperative edema, facial swelling, pain, and restriction of mouth opening. The type of closure may be a cause of these complications. The aim of this study was to compare the effects of placement of a surgical tube drain before primary closure with the effects of primary closure alone after removal of fully impacted mandibular third molars. METHOD AND MATERIALS: The study group included 13 patients aged 15 to 39 years with bilateral fully impacted mandibular third molars. The insertion of a small surgical tube drain before primary closure (drain group) was compared to a simple primary closure procedure (no drain group) after removal of the impacted third molars in a randomized crossover design. The duration of the operation was recorded. Patients were evaluated 1, 2, 3, and 7 days postoperatively for facial swelling and trismus. RESULTS: The facial swelling experienced by the drain group was significantly less than that experienced by the no drain group. The degree of trismus was greater in the no drain group than in the drain group, but the difference was not statistically significant. CONCLUSION: Use of a surgical drain, especially after removal of fully impacted third molars, will reduce postoperative facial swelling.     

The stability of bilateral sagittal ramus osteotomy and vertical ramus osteotomy after bimaxillary correction of class III malocclusion

Introduction

The purpose of this retrospective cephalometric study was to compare the stability of bilateral sagittal split osteotomy (BSSO) with extra-oral vertical ramus osteotomy (VRO) after correction of class III malocclusion by means of bimaxillary orthognathic surgery.

Methods

The sample comprised 51 consecutively treated patients, 38 females and 13 males, with a mean age of 19.1 years. All had a one-piece Le Fort I osteotomy with maxillary advancement and mandibular setback. VRO was performed in 30 cases, and BSSO was performed in 21 cases. Lateral cephalograms were obtained before surgery, within 1 week of surgery and 1 year after surgery.

Results

The mean forward movement of the maxilla was 5.6 mm in both groups (p < 0.001). The mean horizontal surgical change in the VRO group was 4.4 mm (p < 0.001), and in the BSSO group it was 5.4 mm (p < 0.001). In the VRO group, the horizontal relapse was 1.2 mm (p < 0.001), and in the BSSO group, it was 1.4 mm (p < 0.001).

Conclusion

There was no difference in the stability between the BSSO and VRO groups. The average relapse in the whole sample was 26% of the surgical movement.     

Comparison of periapical radiography and limited cone-beam computed tomography in mandibular molars for analysis of anatomical landmarks before apical surgery

Introduction

The purpose of the present study was to evaluate the detectability and dimensions of periapical lesions, the relationship of the mandibular canal to the roots of the respective teeth, and the dimension of the buccal bone by using limited cone-beam computed tomography (CBCT) in comparison to conventional periapical (PA) radiographs for evaluation of mandibular molars before apical surgery.

Methods

The study comprised 38 molars with 75 roots. The type of PA lesion as diagnosed on PA radiographs was compared with the type of lesion seen on sagittal and coronal CBCT sections. The distances of the apices of the first mandibular molars and basal border of the PA lesion to the coronal lining of the mandibular canal were assessed with PA radiographs and corresponding sagittal and coronal CBCT images. Furthermore, coronal CBCT images were used to measure the distance from the apices to the buccal bone surface and the corresponding width of the cortical bone plate.

Results

Of 58 detected PA lesions, 15 (25.9%) lesions diagnosed with sagittal CBCT slices were missed with PA radiography. The distance between the apices and the upper border of the mandibular canal was only measurable in 24 of 68 radiographs (35.3%) by using PA images. The cortical bone wall had a mean thickness of 1.7 mm, whereas the total buccal bone wall (cortical and spongious) measured 5.3 mm on average.

Conclusions

The present study highlights the advantages of using limited CBCT for treatment planning in mandibular molars before apical surgery.     

Oral health-related quality of life following third molar surgery with or without application of ice pack therapy

Aim

To evaluate the effect of ice pack therapy on oral health-related quality of life (OHRQoL) following third molar surgery.

Methods

All consecutive subjects who required surgical extraction of lower third molars and satisfied the inclusion criteria were randomly allocated into two groups. Subjects in group A were instructed to apply ice packs directly over the masseteric region on the operated side intermittently after third molar surgery. This first application was supervised in the clinic and was repeated at the 24-h postoperative review. Subjects in group A were further instructed to apply the ice pack when at home every one and a half hours on postoperative days 0 and 1 while he/she was awake as described. Group B subjects did not apply ice pack therapy. Facial swelling, pain, trismus, and quality of life (using Oral Health Impact Profile-14 (OHIP-14) instrument) were evaluated both preoperatively and postoperatively. Postoperative scores in both groups were compared.

Results

A significant increase in the mean total and subscale scores of OHIP-14 was found in both groups postoperatively when compared with preoperative value. Subjects who received ice pack therapy had a better quality of life than those who did not. Subjects whose postoperative QoL were affected were statistically significantly higher in group B than in group A at all postoperative evaluation points (P < 0.05). Statistically significant differences were also observed between the groups in the various subscales analyzed, with better quality of life seen among subjects in group A.

Conclusions

Quality of life after third molar surgery was significantly better in subjects who had cryotherapy after third molar than those who did not have cryotherapy. Cryotherapy is a viable alternative or adjunct to other established modes of improving the quality of life of patients following surgical extraction of third molars.

     

A prospective randomized double-blind study to assess the latency and efficacy of Twin-mix and 2 % lignocaine with 1:200,000 epinephrine in surgical removal of impacted mandibular third molars: a pilot study

Introduction

A prospective randomized double-blind study was conducted to assess the latency and duration of pterygomandibular nerve block with a mixture of 1.8 ml 2 % lignocaine with 1:200,000 epinephrine and 1 ml of 4 mg dexamethasone and its impact on postoperative sequelae of surgical extraction of impacted mandibular third molars.

Material and methods

The study was conducted as a prospective randomized double-blind clinical trial on 20 patients with bilateral impaction of mandibular third molars. A total of 40 interventions were included for the study, 20 with 2 % lignocaine with 1:200,000 epinephrine (study group C, control) and 20 with the twin-mix (study group T, twin-mix), with a gap of 1 month between two interventions in a single patient. After injection of the anesthetic solution, the time to anesthetic effect, duration of anesthesia, and the need to re-anesthetize the surgical site were recorded. A 10-point visual analog scale (VAS) was used to assess the overall pain intensity while injecting the study drug, during surgery, and in the postoperative period. pH of the test anesthetic solutions was also determined using a pH meter.

Results

Twin-mix was found to be more basic than 2 % lignocaine with 1:200,000 epinephrine. Mean VAS value for the pain/sting on local anesthetic injection/block was less in study group T. Time of onset of the local anesthetic was significantly less for the study group T, 51?±?17.5 s when compared with patients in study group C (P less than 0.0001). The duration of soft tissue anesthesia was longer for all the patients in the study group T. On comparative evaluation between study group C and study group T, patients in the control group had more sever swelling and reduction in mouth opening in the postoperative period.

Discussion

The addition of dexamethasone to lignocaine and its administration as an intra-space injection significantly shortens the latency and prolongs the duration of the soft tissue anesthesia, with improved quality of life in the postoperative period after surgical extraction of mandibular third molars.     

Efficacy of adjuvant laser therapy in reducing postsurgical complications after the removal of impacted mandibular third molars: A systematic review update and meta-analysis

Background

The authors updated a previously published systematic review to assess the effects of low-level laser therapy (LLLT) on reducing complications after the removal of impacted mandibular third molars.

Effect of the suture technique on postoperative pain,swelling and trismus after removal of lower third molars: A randomized clinical trial

Background

To evaluate the intensity of pain, swelling and trismus after the removal of impacted lower third molars comparing two different suture techniques of the triangular flap: the complete suture of the distal incision and relieving incision and the partial suture with only one suture knot for closure of the corner of the flap and the closure of the distal incision, without suturing the relieving incision.

Material and Methods

A prospective, randomized, crossover clinical trial was conducted in 40 patients aged from 18 to 45 years who underwent surgical extraction of impacted lower third molars at the Department of Oral Surgery in the Odontological Hospital of the University of Barcelona during the year 2011. Patients were randomly divided in 2 groups. Two different techniques (hermetical closure and partial closure of the wound) were performed separated by a one month washout period in each patient. Postoperative pain, swelling and trismus were evaluated prior to the surgical procedure and also at 2 and 7 days post operatively.

Results

No statistically significant differences were observed for pain (p<0.06), trismus (p<0.71) and swelling (p<0.05) between the test and the control group. However, the values of the three parameters related to the test group were lower than those for the control group.

Conclusions

Partial closure of the flap without suturing the relieving incision after surgical extraction of lower third molars reduces operating time and it does not produce any postoperative complications compared with complete closure of the wound. Key words: Third molar, surgical flaps, suture techniques, postoperative pain, swelling, trismus.