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Surgeon experience and third molar surgical complications
(0.58%), buccal mucosa (0.58%; Fig 5), and lingual frenum (0.58%). Discussion.—The clinical identification of oral lesions is important to determine whether they are neoplastic or non-neoplastic, to make an accurate diagnosis, and to formulate an appropriate treatment plan. The current data indicate that mucoceles are most common in white female subjects aged 11 to 20 years. They occur most often on the lower lip. Clinical Significance.—Mucoceles are carefully excised along with any adjacent minor salivary glands showing evidence of
involvement. They can recur and require surgical intervention. For ranulas, the sublingual gland is removed surgically and/or marsupialized. Because of these different treatments, it is essential to understand the characteristics of the various lesions and make an accurate diagnosis.
Hayashida AM, Zerbinatti DCZ, Balducci I, et al: Mucus extravasation and retention phenomena: A 24-year study. BMC Oral Health 10:15, 2010 Reprints available from http://www.biomedcentral.com/1472-6831/ 10/15
Oral Surgery Surgeon experience and third molar surgical complications Background.—Third molar surgery is among the most common procedures done by oral and maxillofacial surgeons. Indications for such surgery include pain, recurrent swelling, and infection. These prompt a thorough clinical examination and study of a two-dimensional radiograph of the site. The decision to use local anesthesia, intravenous sedation, or general anesthesia is based on the difficulty anticipated, possible complications, patient preference, patient fear and/or anxiety, and the surgeon’s experience combined with the published guidelines for such cases. Some evidence has linked an increased incidence of postoperative complications to the surgeon’s experience (Table 1). The specific effect of the surgeon’s level of experience on the outcome of third molar surgery was evaluated. Methods.—The affected third molars were removed from 3236 patients aged 17 to 36 years. Data included information from the patient obtained at postoperative review appointments, demographic information, preoperative radiographic results, complexity of the surgery, occurrence of postoperative complications, and the surgeon’s level of experience. Seven specialists and 12 residents were responsible for the surgeries. Results.—Specialists treated a few more of the patients aged R30 years and those aged 17 to 20 years than residents did. Residents treated a higher proportion of women than the specialists. Just over 78% of the teeth
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Dental Abstracts
removed had roots that were radiographically found to be 2 mm or less from the inferior alveolar canal (IAC). Both surgeon groups removed approximately equal numbers of teeth close to the inferior alveolar nerve and equal numbers of fully erupted and partially erupted teeth. More fully affected teeth were removed by specialists than by residents. Residents removed more teeth that were horizontally affected, and specialists removed more that were mesioangularly affected.
Table 1.—Disadvantages of Non-Apprenticeship Training Models and Training Paradigms Disadvantages of non-apprenticeship training models
Increased time to train Costs of specialised audiovisual systems Cost and ethics of animal models Cost and availability of ‘mock’ or artificial models to operate upon Availability of consenting subjects Training paradigms
Animal models Cadaveric open dissection Plastinated staged prosections 3D virtual training models with haptic feedback 3D video of selected cases with commentary Direct clinical supervision with endoscopic monitoring of the operative site (Courtesy of Jerjes W, Upile T, Nhembe F, et al: Experience in third molar surgery: An update. Br Dent J 209:E1, 2010.)
Table 3.—Incidence of Each Type of Postoperative Complication in Relation to Seniority of the Surgeon Undertaking the Procedure Complications
Trismus Swelling Bleeding Sore throat Alveolar osteitis Delayed healing Infection Abscess Up 1 month Up 6 months Up 18-24 months Tongue 1 month Tongue 6 months Tongue 16-24 month
Residents-treated group
Specialists treated group
Overall
Pearson (2-sided)
Fisher’s (2-sided)
Likelihood ratio
260 208 43 29 364 43 176 23 39 36 19 44 42 31
177 194 97 12 129 24 80 23 9 9 1 13 10 6
437 402 140 41 493 67 256 46 48 45 20 57 52 37
<0.001 0.147 <0.001 0.004 <0.001 0.009 <0.001 0.823 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
<0.001 0.150 <0.001 0.004 <0.001 0.009 <0.001 0.882 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
25.159 2.098 18.779 8.530 155.730 6.922 47.125 0.050 22.545 19.419 21.095 20.241 23.684 20.386
Note: The numbers refer to the number of patients. ‘ Lip’’ refers to patients reporting numbness of the lip. ‘ Tongue’’ refers to patients reporting numbness of the tongue. (Courtesy of Jerjes W, Upile T, Nhembe F, et al: Experience in third molar surgery: An update. Br Dent J 209:E1, 2010.)
Significantly more of the patients treated by residents suffered postoperative complications, including trismus, sore throat, delayed healing, alveolar osteitis, and postoperative infection compared with patients treated by specialists (Table 3). Specialist-treated patients had a significantly higher incidence of postoperative bleeding than among resident-treated patients. Postoperative swelling and abscess occurred with equal frequency in the two groups. Patients treated by residents were over 20 times more likely to develop inferior alveolar and lingual nerve paraesthesia during the first month postoperatively than patients treated by specialists. The same group was more likely to develop this complication during the first 2 years postoperatively as well. Discussion.—Patients treated by residents in oral and maxillofacial surgery experienced a significantly higher rate of postoperative complications than those treated by specialists. Only postoperative bleeding was significantly more common among patients treated by specialists. No difference in the rates of abscess and postoperative swelling was noted between the two groups. The ethics of allowing residents to perform such surgery knowing that complications are much more likely to result must be questioned.
Clinical Significance.—All clinicians tend to develop skill with experience, but complications occur even among the most experienced practitioners. However, third molar surgery is a very common procedure, and skill performing it is an essential part of oral and maxillofacial surgical practice. The high rates of complications that accompany resident surgeons’ efforts in this task must raise questions about their training and skill. In the interest of informed consent, patients may have to be made aware that there is an increased risk of complications if they allow less experienced surgeons to perform their surgery. Teachers of surgery must take on the task of imparting not just knowledge of how to do the procedure, but also experience in avoiding complications.
Jerjes W, Upile T, Nhembe F, et al: Experience in third molar surgery: An update. Br Dent J 209:E1, 2010 Reprints available from W Jerjes; e-mail: [email protected]
Radiotherapy and osteoradionecrosis patients Background.—Osteoradionecrosis (ORN) of the jaws is a complication associated with radiotherapy used to treat
head and neck cancer. It occurs in as many as 20% of patients who have dental extractions just before or after
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2011
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involvement. They can recur and require surgical intervention. For ranulas, the sublingual gland is removed surgically and/or marsupialized. Because of these different treatments, it is essential to understand the characteristics of the various lesions and make an accurate diagnosis.
Hayashida AM, Zerbinatti DCZ, Balducci I, et al: Mucus extravasation and retention phenomena: A 24-year study. BMC Oral Health 10:15, 2010 Reprints available from http://www.biomedcentral.com/1472-6831/ 10/15
Oral Surgery Surgeon experience and third molar surgical complications Background.—Third molar surgery is among the most common procedures done by oral and maxillofacial surgeons. Indications for such surgery include pain, recurrent swelling, and infection. These prompt a thorough clinical examination and study of a two-dimensional radiograph of the site. The decision to use local anesthesia, intravenous sedation, or general anesthesia is based on the difficulty anticipated, possible complications, patient preference, patient fear and/or anxiety, and the surgeon’s experience combined with the published guidelines for such cases. Some evidence has linked an increased incidence of postoperative complications to the surgeon’s experience (Table 1). The specific effect of the surgeon’s level of experience on the outcome of third molar surgery was evaluated. Methods.—The affected third molars were removed from 3236 patients aged 17 to 36 years. Data included information from the patient obtained at postoperative review appointments, demographic information, preoperative radiographic results, complexity of the surgery, occurrence of postoperative complications, and the surgeon’s level of experience. Seven specialists and 12 residents were responsible for the surgeries. Results.—Specialists treated a few more of the patients aged R30 years and those aged 17 to 20 years than residents did. Residents treated a higher proportion of women than the specialists. Just over 78% of the teeth
152
Dental Abstracts
removed had roots that were radiographically found to be 2 mm or less from the inferior alveolar canal (IAC). Both surgeon groups removed approximately equal numbers of teeth close to the inferior alveolar nerve and equal numbers of fully erupted and partially erupted teeth. More fully affected teeth were removed by specialists than by residents. Residents removed more teeth that were horizontally affected, and specialists removed more that were mesioangularly affected.
Table 1.—Disadvantages of Non-Apprenticeship Training Models and Training Paradigms Disadvantages of non-apprenticeship training models
Increased time to train Costs of specialised audiovisual systems Cost and ethics of animal models Cost and availability of ‘mock’ or artificial models to operate upon Availability of consenting subjects Training paradigms
Animal models Cadaveric open dissection Plastinated staged prosections 3D virtual training models with haptic feedback 3D video of selected cases with commentary Direct clinical supervision with endoscopic monitoring of the operative site (Courtesy of Jerjes W, Upile T, Nhembe F, et al: Experience in third molar surgery: An update. Br Dent J 209:E1, 2010.)
Table 3.—Incidence of Each Type of Postoperative Complication in Relation to Seniority of the Surgeon Undertaking the Procedure Complications
Trismus Swelling Bleeding Sore throat Alveolar osteitis Delayed healing Infection Abscess Up 1 month Up 6 months Up 18-24 months Tongue 1 month Tongue 6 months Tongue 16-24 month
Residents-treated group
Specialists treated group
Overall
Pearson (2-sided)
Fisher’s (2-sided)
Likelihood ratio
260 208 43 29 364 43 176 23 39 36 19 44 42 31
177 194 97 12 129 24 80 23 9 9 1 13 10 6
437 402 140 41 493 67 256 46 48 45 20 57 52 37
<0.001 0.147 <0.001 0.004 <0.001 0.009 <0.001 0.823 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
<0.001 0.150 <0.001 0.004 <0.001 0.009 <0.001 0.882 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
25.159 2.098 18.779 8.530 155.730 6.922 47.125 0.050 22.545 19.419 21.095 20.241 23.684 20.386
Note: The numbers refer to the number of patients. ‘ Lip’’ refers to patients reporting numbness of the lip. ‘ Tongue’’ refers to patients reporting numbness of the tongue. (Courtesy of Jerjes W, Upile T, Nhembe F, et al: Experience in third molar surgery: An update. Br Dent J 209:E1, 2010.)
Significantly more of the patients treated by residents suffered postoperative complications, including trismus, sore throat, delayed healing, alveolar osteitis, and postoperative infection compared with patients treated by specialists (Table 3). Specialist-treated patients had a significantly higher incidence of postoperative bleeding than among resident-treated patients. Postoperative swelling and abscess occurred with equal frequency in the two groups. Patients treated by residents were over 20 times more likely to develop inferior alveolar and lingual nerve paraesthesia during the first month postoperatively than patients treated by specialists. The same group was more likely to develop this complication during the first 2 years postoperatively as well. Discussion.—Patients treated by residents in oral and maxillofacial surgery experienced a significantly higher rate of postoperative complications than those treated by specialists. Only postoperative bleeding was significantly more common among patients treated by specialists. No difference in the rates of abscess and postoperative swelling was noted between the two groups. The ethics of allowing residents to perform such surgery knowing that complications are much more likely to result must be questioned.
Clinical Significance.—All clinicians tend to develop skill with experience, but complications occur even among the most experienced practitioners. However, third molar surgery is a very common procedure, and skill performing it is an essential part of oral and maxillofacial surgical practice. The high rates of complications that accompany resident surgeons’ efforts in this task must raise questions about their training and skill. In the interest of informed consent, patients may have to be made aware that there is an increased risk of complications if they allow less experienced surgeons to perform their surgery. Teachers of surgery must take on the task of imparting not just knowledge of how to do the procedure, but also experience in avoiding complications.
Jerjes W, Upile T, Nhembe F, et al: Experience in third molar surgery: An update. Br Dent J 209:E1, 2010 Reprints available from W Jerjes; e-mail: [email protected]
Radiotherapy and osteoradionecrosis patients Background.—Osteoradionecrosis (ORN) of the jaws is a complication associated with radiotherapy used to treat
head and neck cancer. It occurs in as many as 20% of patients who have dental extractions just before or after
Volume 56
Issue 3
2011
153