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P36 Risk factors associated with injury to the inferior alveolar and lingual nerves following third molar surgery
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Posters / British Journal of Oral and Maxillofacial Surgery 48 (2010) S25–S55
P35 The physics forceps – a breakthrough in dental extraction technology N.J. Perkins1 , H.M. Perez2 , C.E. Misch3 , R. Golden4 . 1 St. Helen’s Dental Practice, Cockermouth, Cumbria, UK; 2 OMFS, University of Detroit Mercy Dental School; 3 Oral Implantology, Temple University; 4 GDP, Detroit, Michigan, USA In recent years there has been an increased emphasis on the atraumatic removal of teeth, especially with regard to immediate placement of dental implants. The Physics Forceps are the latest innovation in dental extraction technology, and they provide an efficient means for atraumatic dental extractions. They were invented by Dr. Richard Golden in 2004, and have subsequently evolved to their current patented ‘beak and bumper’ design. Physics Forceps utilize the biomechanical principles of a first class lever, creep and favourable stress distribution. The application of the Physics Forceps involves 6 stages: (1) separation of the gingival attachment from the tooth (e.g. using a periotome); (2) placement of the ‘beak’ onto a secure palatal/lingual application point (root surface); (3) placement of the ‘bumper’ (with single-use plastic sleeve attached) onto the buccal aspect of the alveolus at the level of the mucogingival junction (this acts as a fulcrum; braces and protects the buccal plate); (4) application of a steady slow rotational force (facilitates creep in the periodontium) using only wrist movement for 30–40 seconds; (5) occlusal elevation of the tooth a few millimetres from its socket; (6) delivery of the tooth using a haemostat/rongeurs/conventional forceps. Lower molars (dependent on root morphology) may need sectioning to allow for a more predictable extraction. As with any new technique there is a learning curve for operators in making the transition from conventional forceps to Physics Forceps, especially the effective use of wrist movement. Physics Forceps represent an important addition to the armamentarium for atraumatic exodontia. P36 Risk factors associated with injury to the inferior alveolar and lingual nerves following third molar surgery W. Jerjes, T. Upile, P. Shah, F. Nhembe, D. Gudka, P. Kafas, E. McCarthy, S. Abbas, S. Patel, Z. Hamdoon, J. Abiola, M. Vourvachis, M. Kalkani, M. Al-Khawalde, R. Leeson, B. Banu, J. Rob, M. El-Maaytah, C. Hopper. UCLH Head and Neck Centre, UK Objective: Earlier reports, including a preliminary study within the same unit, have shown that the surgeon’s experience is one of the most influential factors in determining the likelihood of both permanent inferior alveolar nerve (IAN) and lingual nerve (LN) paraesthesia, following third molar surgery. The effect of this and other factors influencing such prevalence are being assessed in this study. Study design: This prospective study involved 3236 patients who underwent surgical removal of impacted third molars. Patients’ demographics and radiological parameters were recorded along with the grade of the treating surgeon. The prevalence of IAN and LN paraesthesia at 1 month, 6 months and 18–24 months postoperatively were also traced. Results: At one month postoperatively, the incidence of IAN paraesthesia was 1.5% and the LN was 1.8%. These figures decreased over time and 18–24 months postoperatively, the incidence of permanent dysfunction of the IAN was 0.6% and LN was 1.1%. With regards to the inferior alveolar nerve paraesthesia, risk factors included the patient’s age (26–30 years),
horizontally impacted teeth, close radiographic proximity to the inferior alveolar canal (IAC) and treatment by trainee surgeons. With regards to the lingual nerve, risk factors included male patients, distoangular impactions, close radiographic proximity to the IAC and treatment by trainee surgeons. Conclusion: One of the main risk factors of developing permanent sensory dysfunction is related to the surgical skills/experience of the operator. Other factors are associated with the type of impaction and the radiographic proximity of the tooth to the inferior alveolar nerve. P37 Odontogenic infection complicated by cervical pan-fascial space gas forming infection P. Naredla, G. Gillan, H. Djani, S. Rice, P. Hardee. Whipps Cross University Hospital NHS Trust, UK Introduction: Tissue space infections in the head and neck owing to odontogenic cause are well documented. Material: We present an unusual case of a 42 years old male patient who attended with a fluctuant swelling in left face and neck which was preceded by pain in lower left second molar. There was subtle crepitus on the left side of the neck on palpation. The primary focus was an abscess of the lower left second molar. CT scans of the head and neck revealed collection of pus and pockets of gas in the soft tissues consistent with gas forming sepsis. Results: Following incision and drainage foul smelling pus yielded a growth of mixed aerobes and anaerobes. Conclusion: This type of abscess with putrefaction of tissues and gas formation can be a characteristic feature of mixed anaerobic infections. P38 Before you reach for the bleach . . . H. Chaudhury, T. Wildan, S. Popat, R. Anand, D. Dhariwal. The John Radcliffe Hospital, UK Introduction: Endodontic treatment forms an essential part of routine general dental practice. Sodium hypochlorite is the most commonly used irrigant in endodontics due to its ability to dissolve organic soft tissue in the root canal system and its action as a powerful antimicrobial agent. However, if the sodium hypochlorite comes into contact with vital tissues it can cause severe inflammation and tissue necrosis. Even though these complications are supposedly very rare, four affected patients were seen in our unit in a four month time period. Case report: These cases are outlined in this paper and they highlight some of the results of sodium hypochlorite extrusion beyond the root canal apex into periapical tissues. Three of the cases required hospital admission and one of them had to be taken to theatres for debridement under general anaesthesia. All of them had transient or prolonged nerve injuries and two of them had persistent neuropathic pain. One complained of impaired hearing and visual disturbances. Conclusion: The result of accidental sodium hypochlorite spillage or extravasation is unpredictable with no set level in terms of concentration and volume that determine the severity of patient symptoms. Therefore, any incident should be treated with appropriate care and attention. A protocol for the management of these patients will be discussed.
Posters / British Journal of Oral and Maxillofacial Surgery 48 (2010) S25–S55
P35 The physics forceps – a breakthrough in dental extraction technology N.J. Perkins1 , H.M. Perez2 , C.E. Misch3 , R. Golden4 . 1 St. Helen’s Dental Practice, Cockermouth, Cumbria, UK; 2 OMFS, University of Detroit Mercy Dental School; 3 Oral Implantology, Temple University; 4 GDP, Detroit, Michigan, USA In recent years there has been an increased emphasis on the atraumatic removal of teeth, especially with regard to immediate placement of dental implants. The Physics Forceps are the latest innovation in dental extraction technology, and they provide an efficient means for atraumatic dental extractions. They were invented by Dr. Richard Golden in 2004, and have subsequently evolved to their current patented ‘beak and bumper’ design. Physics Forceps utilize the biomechanical principles of a first class lever, creep and favourable stress distribution. The application of the Physics Forceps involves 6 stages: (1) separation of the gingival attachment from the tooth (e.g. using a periotome); (2) placement of the ‘beak’ onto a secure palatal/lingual application point (root surface); (3) placement of the ‘bumper’ (with single-use plastic sleeve attached) onto the buccal aspect of the alveolus at the level of the mucogingival junction (this acts as a fulcrum; braces and protects the buccal plate); (4) application of a steady slow rotational force (facilitates creep in the periodontium) using only wrist movement for 30–40 seconds; (5) occlusal elevation of the tooth a few millimetres from its socket; (6) delivery of the tooth using a haemostat/rongeurs/conventional forceps. Lower molars (dependent on root morphology) may need sectioning to allow for a more predictable extraction. As with any new technique there is a learning curve for operators in making the transition from conventional forceps to Physics Forceps, especially the effective use of wrist movement. Physics Forceps represent an important addition to the armamentarium for atraumatic exodontia. P36 Risk factors associated with injury to the inferior alveolar and lingual nerves following third molar surgery W. Jerjes, T. Upile, P. Shah, F. Nhembe, D. Gudka, P. Kafas, E. McCarthy, S. Abbas, S. Patel, Z. Hamdoon, J. Abiola, M. Vourvachis, M. Kalkani, M. Al-Khawalde, R. Leeson, B. Banu, J. Rob, M. El-Maaytah, C. Hopper. UCLH Head and Neck Centre, UK Objective: Earlier reports, including a preliminary study within the same unit, have shown that the surgeon’s experience is one of the most influential factors in determining the likelihood of both permanent inferior alveolar nerve (IAN) and lingual nerve (LN) paraesthesia, following third molar surgery. The effect of this and other factors influencing such prevalence are being assessed in this study. Study design: This prospective study involved 3236 patients who underwent surgical removal of impacted third molars. Patients’ demographics and radiological parameters were recorded along with the grade of the treating surgeon. The prevalence of IAN and LN paraesthesia at 1 month, 6 months and 18–24 months postoperatively were also traced. Results: At one month postoperatively, the incidence of IAN paraesthesia was 1.5% and the LN was 1.8%. These figures decreased over time and 18–24 months postoperatively, the incidence of permanent dysfunction of the IAN was 0.6% and LN was 1.1%. With regards to the inferior alveolar nerve paraesthesia, risk factors included the patient’s age (26–30 years),
horizontally impacted teeth, close radiographic proximity to the inferior alveolar canal (IAC) and treatment by trainee surgeons. With regards to the lingual nerve, risk factors included male patients, distoangular impactions, close radiographic proximity to the IAC and treatment by trainee surgeons. Conclusion: One of the main risk factors of developing permanent sensory dysfunction is related to the surgical skills/experience of the operator. Other factors are associated with the type of impaction and the radiographic proximity of the tooth to the inferior alveolar nerve. P37 Odontogenic infection complicated by cervical pan-fascial space gas forming infection P. Naredla, G. Gillan, H. Djani, S. Rice, P. Hardee. Whipps Cross University Hospital NHS Trust, UK Introduction: Tissue space infections in the head and neck owing to odontogenic cause are well documented. Material: We present an unusual case of a 42 years old male patient who attended with a fluctuant swelling in left face and neck which was preceded by pain in lower left second molar. There was subtle crepitus on the left side of the neck on palpation. The primary focus was an abscess of the lower left second molar. CT scans of the head and neck revealed collection of pus and pockets of gas in the soft tissues consistent with gas forming sepsis. Results: Following incision and drainage foul smelling pus yielded a growth of mixed aerobes and anaerobes. Conclusion: This type of abscess with putrefaction of tissues and gas formation can be a characteristic feature of mixed anaerobic infections. P38 Before you reach for the bleach . . . H. Chaudhury, T. Wildan, S. Popat, R. Anand, D. Dhariwal. The John Radcliffe Hospital, UK Introduction: Endodontic treatment forms an essential part of routine general dental practice. Sodium hypochlorite is the most commonly used irrigant in endodontics due to its ability to dissolve organic soft tissue in the root canal system and its action as a powerful antimicrobial agent. However, if the sodium hypochlorite comes into contact with vital tissues it can cause severe inflammation and tissue necrosis. Even though these complications are supposedly very rare, four affected patients were seen in our unit in a four month time period. Case report: These cases are outlined in this paper and they highlight some of the results of sodium hypochlorite extrusion beyond the root canal apex into periapical tissues. Three of the cases required hospital admission and one of them had to be taken to theatres for debridement under general anaesthesia. All of them had transient or prolonged nerve injuries and two of them had persistent neuropathic pain. One complained of impaired hearing and visual disturbances. Conclusion: The result of accidental sodium hypochlorite spillage or extravasation is unpredictable with no set level in terms of concentration and volume that determine the severity of patient symptoms. Therefore, any incident should be treated with appropriate care and attention. A protocol for the management of these patients will be discussed.