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Alveolar Expansion Technique for Extraction of Third Molars (Wisdom Teeth)

Posted on 21. Apr, 2012 by wisdom.

An interesting study titled “Comparison of an alveolar expansion technique and buccal guttering technique in the extraction of mandibular third molar. A pilot study,” appeared in the Open Journal of Stomatology (vol 1, pages 103-108, 2011) written by Babatunde O. Akinbami and Lukcy I. Ofomala from Nigeria.

As stated in the abstract the background for this study was

“The over-ambitious use of surgical drills for almost every case of third molar impaction is on the increase in most established oral surgery centers. The purpose of this study was to assess and compare the severity of post operative symptoms of swelling and pain that accompany the use of surgical drill in the buccal guttering technique and the non application of drill in an alveolar expansion technique.”

The authors open in the introduction by discussion how bone around impacted third molar teeth is usually dense and can require the use of cutting drills which can cause vibration and friction.

A total of 10 patients were included in the study. Five patients had the guttering technique performed on the right side and alveolar expansion technique on the left side, 3 patients had the alveolar expansion technique performed on the right side and buccal guttering technique of the left side, and the final 2 cases served as control.

Periapical x-rays were taken to assess the root configuration to the inferior alveolar nerve bundle and impaction against the adjacent second molar. Each patient was given 2% lidocaine with 1:80,000 epinephrine.

The authors discuss how many techniques have been used to remove impacted third molars (wisdom teeth). The authors state

“Other techniques like therapeutic agenesis of the tooth bud using electrocautery, laser energy and use of sclerosing agents have been tried in lower mammals and animals but no human clinical studies are available to attest the validity of these later techniques.”

This study found that most patients included preferred the alveolar expansion technique to reduce the use of drills. The authors point out that it is possible to remove wisdom teeth without using drills.

Near the end of the study the authors state

“The alveolar expansion technique is however, better applicable in younger patients with less dense bone, patients with soft tissue impacted third molar, vertically or mesially impacted tooth with sufficient space for the elevator to move the tooth into, when there is no impaction against the second molars and in cases of close proximity of the neurovascular bundle with enough clearance around the tooth. Absolute contraindications of the use of this technique include high bone density, completely buried tooth/tooth with high Winter’s red line, horizontal impaction associated with impaction against the second molar, distal or vertical impaction with part of the tooth buried under the ascending ramus, anteriorly extended external oblique ridge and in patients with very low pain threshold.”

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Third Molar Morbidity Among Troops Deployed

Posted on 24. Mar, 2012 by wisdom.

A few articles have been recently released in late 2010 discussing third molars (wisdom teeth) among those serving in the military.

Guidelines from NICE and SIGN as stated over at http://www.teethremoval.com/wisdomteeth.html due state that those who have a certain occupation such as in the armed forces should certainly strongly consider having wisdom teeth removed before they cause problems due to not being able to easily have access to dental treatment.

A paper was put out in December 2010 titled “The Impact of Retained Third Molars on the Deployed Airman.” It is over at this link here.

The article is written by Robert E. Langsten and William J. Dunn and states that as many as 22% of all emergency department visits at a deployed Expeditionary Medical Support facility can be attributed to dental problems.

The article mentions how there is no reliable method to predict when asymptomatic partially erupted third molars will become painful. Thus Air Force dental providers should carefully consider that not every medical facility in theater has an oral surgeon on staff and that air evacuation/transport of these patients can be expensive and time consuming.

The article recommends that each patient should be questioned as to whether or not they have noticed pain in any third molars.

It further recommends that more research on how much time and money is needed to treat patients who present with symptoms of their retained wisdom teeth in the theatre. Further methods for predicting future problems of impacted third molars requires research.

Another article appeared in August 2010 titled ” Third molar-related morbidity in deployed Service personnel,” by J. Combes and et al. in the British Dental Journal (209, E6).

This article said that access to dental surgeons in the theatre is not always possible. It further stated that some of the patients in the study had documented evidence of pericoronitis yet did not have the wisdom teeth extracted. Some patients required transport by helicopter when presenting with symptoms in theatre and some were not able to receive prompt treatment.

Hence it is important that service personnel are asked about their third molars prior to deployment and to complete treatment if necessary.

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Evidence Base for Oral and Maxillofacial Surgery Journals

Posted on 17. Mar, 2012 by wisdom.

An interesting articled titled “The evidence base for oral and maxillofacial surgery: 10-year analysis of two journals,” appeared in the January 2012 edition of the British Journal of Oral and Maxillofacial Surgery (vol. 50, issue 1, pages 45-48) wirrten by Amandip Sandhu.

The author opens by discussing an editorial in the Lancet in 1996 which discussed how there is a lack of scientific rigor in surgical research.

The author states

“There is a well established hierarchy of levels of evidence, and the medical community considers that meta-analyses and randomised controlled trials (RCTs) are the most scientifically stringent means of investigating the efficacy of one intervention against another. Other grades of evidence (in increasing weakness of level of evidence) are case controlled studies, comparative studies, case series, correlation studies and expert committee reports, and the clinical experiences of respected authorities.”

The author evaluated articles published in both the British Journal of Oral and Maxillofacial Surgery and the International Journal of
Oral and Maxillofacial Surgery between January 1999 and December 2009. The author looked at the abstract of every article and looked at the article in full if the abstract was not sufficient for analysis.

The author looked at 3294 articles and 1 meta-analysis and 68 randomized controlled trials (2%) were present.

The author points out how if one recommends involvement in a randomized controlled trial there must be a uncertainty about the benefit or harm from the intervention. Further using sham surgery as a control has issues.

The author briefly mentions the National Institute for Health and Clinical Excellence (NICE) and a brief discussion of the Cochrane Collaboration is made in which the author states that reviews relevant to oral and maxillofacial surgery consists of weak evidence.

The author than goes on to discuss the Impact Factor and how it should be interpreted with care.

The author states

“The latest [impact factors] IFs for the International Journal and the British Journal (2009) are 1.444 (2008: 1.487), and 1.327 (2008: 0.787), respectively. For comparison, the five medical journals in 2009 with the highest IFs were the New England Journal of Medicine (IF 50.017), the Journal of the American Medical Association (IF 31.171), The Lancet (IF 28.409), Annals of Internal Medicine (IF 17.457), and the British Medical Journal (IF 12.827).”

The author ends by saying

“Although the number of RCTs is comparable with other related specialties, in common with other surgical disciplines more effort is required to carry out better quality, ethical research if we are to provide patients with the best possible evidence for our interventions, given the recognised difficulties in carrying out such research.”

A table with the results of the analysis is presented in the article. A total of 618 of the 1715 (36%) BJOMS articles reviewed and 481 of the 1579 (31%) of the IJOMS articles reviewed consisted of case series which were by far the highest type of papers in the journals.

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Using Computed Tomograph (CT) To Lower the Incidence of Wisdom Teeth Removal Nerve Injuries

Posted on 25. Feb, 2012 by wisdom.

A question that everyone who has wisdom teeth wants to know these days is the following: “If you use Computed Tomography (CT) can it lower the risk of developing a nerve injury from having wisdom teeth removed?”

Three authors from Spain (Sanmarti-Garcia, Valmaseda0-Castellon, Gay-Escoda) recently conducted a study asking this question titled “Does Computed Tomography Prevent Inferior Alveolar Nerve Injuries Caused by Lower Third Molar Removal?” appearing in the Journal of Oral and Maxillofacial Surgery (vol 70, pages 5-11, 2012).

The issue is as stated by the authors is that

“panoramic radiography alone cannot identify the buccolingual position of the mandibular canal and the 3M roots.”

Computed tomography (CT) is able to show this information. Even so an estimated 40% of cases show superposition of the roots and the mandibular canal. Hence many of the potential CTs performed may potentially add additional costs and exposes patients to additional radiation without in some cases adding any clinically useful information to the pre-surgical picture.

The authors state

“the utility of CT in the extraction of a 3M is questionable because in most cases it does not modify the surgical technique, it seems to have a low positive predictive value for IAN injury (not much higher than panoramic radiography because the incidence of IAN injury is very low), and it does not always correctly identify the mandibular canal. Unfortunately, although many reports have insisted on the advantages of CT imaging for determining the relation between the lower 3M and the IAN, there have been no reports in the dental literature showing any decrease of the prevalence or severity of IAN resulting from preoperative CT scanning.”

As stated in literature the incidence of inferior alveolar nerve (IAN) injury from wisdom teeth removal is roughly 0.5% to 8%.

The results of the study were

“…CT examinations per se do not seem to significantly decrease the prevalence of IAN injuries”

The study states that sample size is a concern for adequate statistical power but states that using the typical alpha of 0.05 and beta of 0.2 would have required many more hundreds of patients that what was used in the study.

Another potential issue with the study raises is that of selection bias where patients who have a CT performed and show a clear risk may not extract the wisdom teeth.

The authors state that the debate about whether to perform a CT scan for third molar extractions is still open.

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Perioperative Information for Third Molar (Wisdom Teeth) Removal

Posted on 11. Feb, 2012 by wisdom.

A recent study titled “An Evaluation of Patients’ Knowledge About Perioperative Information for Third Molar Removal,” appears in the Journal of Oral and Maxillofacial Surgery (vol. 70, pages 12 – 18, 2012).

The study attempts to look at what patients know about third molar (wisdom teeth) removal before having surgery performed. The study was conducted by authors in Brazil and Kentucky (United States).

The study explains on being nervous and anxious before having wisdom teeth removed can actually cause a longer surgery, more potential swelling, and even more pain.

Hence there is incentive for the surgeon and the surgical team to help produce a calming environment for patients to help reduce anxiety which can lead to potentially better outcomes.

The study had 67 patients which included 43 female and 24 males who had 1 or more wisdom tooth removed. The patients presented to an ambulatory environment between August 2009 and April 2010 in Brazil. One surgeon interviewed each patient and this surgeon was blinded as in did not know about the patient’s past tooth extraction experience(s).

In this study 25 of the patients had previous tooth extraction experience. Most of the wisdom teeth were extracted for orthodontic reasons. Other reasons for the removal of the wisdom teeth included pericoronitis, pain, difficult to clean, caries (cavities), malocclusion, periodontitis, and in 4% of the cases as a preventative measure.

Discussions in the study mention other studies which discuss how many patients like to have a consultation on a separate day than on the day of the surgery. A trustworthy and professional relationship is important to be formed between patient and doctor.

The study showed that patients who had previous extraction experience showed more interest and knowledge about the possibility of a preoperative medication taken before surgery.

Even so, the study also showed that surgeons should not assume that those who have previous extraction experience have greater knowledge about dental extractions.

The second to last paragraph of the study states:

“Although some referrers may be able to educate the patient, it is the role of the surgeon to educate the patient and to build up a rapport and engender trust at the first consultation. The referrers may not give the correct information, leading to a case of mixed messages being given to the patient and adding to the confusion and mistrust.”

The study identified that the 2 areas patients have the most misconceptions about include whether or not a medication should be taken preoperatively and what type of hygiene (cleaning) should be done after surgery.

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