Mandibular fracture after third molar removal.

PURPOSE: Mandibular fracture after impacted lower third molar removal is a rare, but major, complication. The factors leading to a mandibular fracture secondary to third molar removal are analyzed retrospectively. PATIENTS AND METHODS: Six patients who suffered from a mandibular fracture as a complication after third molar removal were examined clinically and radiographically. RESULTS: All fractures occurred an average of 14 days postoperatively. The patients were 42 to 50 years old and were all fully dentulous. All grades of tooth impaction were included. CONCLUSIONS: The major risk factor for this complication seems to be advanced age in combination with a full dentition. The degree of tooth impaction is less important. Preexisting bone lesions weaken the mandible and further predispose to a fracture.     

Mandibular third molar removal: patient preferences, assessments of oral surgeons and patient flows

Mandibular third molar removal is one of the most common treatments conducted at oral and maxillofacial surgery clinics in Sweden. During the 1980's and 1990's, 20-25,000 mandibular third molars were removed annually which represents about 60% of the total operation volume. Removals performed in private specialist clinics and general dental clinics are not included in these figures. The aims of the present studies on mandibular third molars were to: 1) study values that reflect patients' preferences about possible outcomes of removal and non-removal; 2) make comparisons between Sweden and Wales with respect to patient's preferences; 3) study assessments of oral surgeons' indications for molars to be removed; 4) describe patient flows in the care process of removal. The multi-attribute utility (MAU) method was used to quantify patients' preferences about outcomes following removal and non-removal. Whilst there were clear cultural and economic differences between the Swedish and the Welsh, there was a high degree of correlation in patients' ranking of the different outcomes for patients from the two countries (rs = 0.93, P<0.001). Generally, situations describing the outcomes of non-removal had a higher ranking than those describing the outcomes of removal i.e. patients seemed to prefer non-removal. Oral surgeons at seven specialist clinics registered data for 666 patients i.e. patient age and sex, the angular position and extent of eruption of the molar and whether or not there was an associated disease related to the molar proposed for removal. The indication for the removal was assessed on a Visual Analogue Scale (VAS), and the recorded results found to show a great variety. The mean VAS for removal of molars without disease was significantly lower than that for molars with associated disease. The differences between the mean VAS for molars with one disease compared with molars with two or three diseases were not significant. The patients' age was the only factor that had a significant effect on the assessment of the indication for molars without disease. The indication was higher for patients of the youngest age group than for patients of the oldest age group (P<0.05). In four specialist units in southern Sweden, the patient flows (the number of visits and what the visits comprise of) was registered for 361 patients. All details were recorded from arrival of the referral to the unit to performed mandibular third molar surgery. Eight different patient flows were found. The number of patient visits varied from one to three. For about 60 percent of the patients, attached radiographs to the referral were considered not appropriate and had to be completed, e.g. to be retaken. For a minority of the patients, the radiographic examination was completed at the radiological clinic included in the specialist unit and, in the oral and maxillofacial clinic for the others. The number of patient visits seemed not to depend on whether the attached radiographs were judged to be appropriate or not. In conclusion: Patient preferences seem to be more stable than the preferences of oral surgeons across the boundaries. Patients prefer outcomes of third molar non-removal as compared to outcomes following removal. Different patient flows may influence the cost-effectiveness in mandibular third molar surgery.     

Oral hygiene and postoperative pain after mandibular third molar surgery

OBJECTIVE: The purpose of this study was to evaluate the association between oral hygiene before surgery and pain, inflammation, and trismus after the surgical removal of 190 impacted lower third molars. STUDY DESIGN: Patient hygiene was assessed by the simplified oral hygiene index. The maximum active interincisal oral opening was determined before surgery by using a millimeter scale, from the upper incisive edge to the lower incisive edge. Pain and inflammation were in turn recorded in written form by each patient 2, 6, and 12 hours after the operation and every day thereafter for 7 days. RESULTS: Maximum postoperative pain was recorded 6 hours after extraction, with peak inflammation after 24 hours. The patients with the poorest oral hygiene reported higher pain levels throughout the postoperative period and more analgesic consumption in the first 48 hours. In contrast, oral hygiene appeared to exert no influence on either trismus or inflammation. CONCLUSIONS: Poor oral hygiene before the surgical removal of 190 impacted lower third molars is correlated with greater postoperative pain.     

改良三角瓣对下颌第三磨牙拔除术后并发症的影响及其临床应用

目的 通过对比改良三角瓣与传统三角瓣对下颌近中阻生第三磨牙拔除术后并发症的影响,探讨改良三角瓣的临床应用.方法 选取110例门诊就诊需要拔除第三磨牙的患者,随机分为2组:改良三角瓣组和传统三角瓣组,记录患者术后2、7d的疼痛程度、肿胀程度和张口受限程度,进行组间比较.结果 术后2d,改良三角瓣组的肿胀程度(Z=-3.432)和张口受限程度(t=19.188)均小于传统三角瓣组,其差异有统计学意义(P＜0.05),但术后7d无此差别(P＞0.05).而在疼痛程度方面,两者在术后2d和术后7d均未看到明显差异(P＞0.05).结论 与传统三角瓣相比,改良三角瓣早期并发症更轻,熟练掌握后操作更容易,值得推广.     

Mandibular third molar and inferior alveolar canal

Purpose

The purpose of this study was to determine the incidence of Inferior Alveolar Nerve (IAN) damage after surgical removal of lower third molars, to identify the cause and to construct a predictive model to assess the risk of IAN injury.

Materials and methods

Patients were selected from the out patient department after proper clinical and radiological evaluation of mandibular third molars. 50 mandibular third molars of 50 different patients were removed under local anaesthesia. Standardized data collection including the patient’s name, age, gender, proximity of inferior alveolar nerve were recorded.

Results

A total 6% of the operated sides demonstrated impairment of labial sensation and vast majority of these disturbances subsided completely within six weeks.

Conclusion

For IAN we found Patient’s age, the development of roots, the degree of impaction and the radiographic position of the nerve canal to be significantly correlated to sensory deficit.     

Age as a risk factor for third molar surgery complications.

PURPOSE: The purpose of this study was to estimate the frequency of complications after third molar (M3) surgery, with age as the primary risk factor. PATIENTS AND METHODS: This was a prospective cohort study of a sample of subjects having at least 1 M3 extracted as part of the American Association of Oral and Maxillofacial Surgeons' Age-Related Third Molar Study. The predictor variables were categorized as demographic, health status, anatomic, and pathological. The outcome variable was overall complications, including both intraoperative and postoperative complications. Appropriate univariate and bivariate statistics were computed. A multiple logistic regression model was used to evaluate the simultaneous effects of multiple covariates. RESULTS: The study sample was comprised of 4,004 subjects having a total of 8,748 M3s removed. The mean age was 39.8 +/- 13.6 years, with 245 subjects (6.1%) age 25 and younger. Approximately half of the subjects were female. The overall complication rate was 19%. In bivariate analyses, age above 25 years, gender, American Society of Anesthesiologists classification, number of preoperatively identified risk factors for complication, impaction level of M3, evidence of periodontal disease, preoperative infection, and evidence of any pathology associated with M3 were associated with complications (P 25 years) appears to be associated with a higher complication rate for M3 extractions.     

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.

     

Preoperative ketorolac has a preemptive effect for postoperative third molar surgical pain

There is uncertainty regarding the role of preemptive analgesia in preventing postoperative pain. Most previous studies were of parallel design completed under general anesthesia with many confounding inter-patient's variables. The present study evaluated the efficacy of preemptive ketorolac in a crossover design in patients undergoing bilateral mandibular third molar surgery. This was a double blind, randomized, placebo-controlled study where 34 patients had each of their identical impacted mandibular third molars removed under local anesthesia on two occasions. Each patients acted as their own control; one side was pretreated with intravenous ketorolac 30 mg before surgery followed by placebo injection after surgery, and for the other side, the patient was given placebo injection before surgery and post-treated with intravenous ketorolac 30 mg after surgery. The difference in postoperative pain between pretreated and post-treated side in each patient was assessed by four primary end-points: pain intensity as measured by a 100-mm visual analogue scale hourly for 12 h, time to rescue analgesic, postoperative analgesic consumption, and patient's global assessment. Throughout the 12-h investigation period, patients reported significantly lower pain intensity scores in the ketorolac pretreated sides when compared with the post-treated sides (P = 0.003). Patients also reported a significantly longer time to rescue analgesic (8.9 h versus 6.9 h, P = 0.005), lesser postoperative analgesic consumption (P = 0.007) and better global assessment for the ketorolac pretreated sides (P = 0.01). Pretreatment with intravenous ketorolac has a preemptive effect for postoperative third molar surgery and extended the analgesia by approximately 2 h.     

Preoperative intravenous tramadol versus ketorolac for preventing postoperative pain after third molar surgery

The objective of this study was to compare the analgesic efficacy of a single-dose of preoperative intravenous tramadol versus ketorolac in preventing pain after third molar surgery. Sixty-four patients undergoing elective third molar surgery were randomly assigned into one of the two groups (32 in each group): Group I received tramadol 50 mg, and Group 2 received ketorolac 30 mg intravenously preoperatively before the surgery. After injection of the study drugs, a standard intravenous sedation technique was administered and the impacted third molars were removed under local anaesthetic. The difference in postoperative pain was assessed by four primary end-points: pain intensity as measured by a 100-mm visual analogue scale hourly for 12 h, median time to rescue analgesic, postoperative acetaminophen consumption, and patient's global assessment. Throughout the 12-h investigation period, patients reported significantly lower pain intensity scores in the ketorolac versus tramadol group (P = 0.05, Mann-Whitney U-test). Patients also reported significantly longer median time to rescue analgesic (9.0 h versus 7.0 h, P = 0.007, log rank test), lesser postoperative acetaminophen consumption (P = 0.02, Mann-Whitney U-test) and better global assessment (P = 0.01, chi2 test) for the ketorolac versus tramadol group. Preoperative intravenous ketorolac 30 mg is more effective than tramadol 50 mg in the prevention of postoperative dental pain.     

Nerve damage and third molar removal

The surgical removal of lower third molars endangers both the lingual and inferior alveolar nerves. Patients sustaining an injury to either of these nerves must be managed correctly, and this requires a diagnosis of the injury type and regular monitoring of the recovery of sensation. Surgical intervention for a damaged inferior alveolar nerve is not usually indicated but may be undertaken: if the nerve is completely divided and the severed ends are misaligned; if a bony fragment has compressed the mandibular canal; or if the patient suffers from persistent neuropathic pain. In contrast, after injury to the lingual nerve, if sensory testing demonstrates no neural recovery within 3-4 months, exploration of the injury site and microsurgical repair of the damaged nerve is indicated.