- Email: [email protected]
The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery
G Model
JORMAS-586; No. of Pages 6 J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original Article
The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery Z. Gu¨mru¨kc¸u¨ Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Recep Tayyip Erdog˘an University, Rize, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 July 2018 Accepted 28 October 2018
Background: A retrospective clinical study was performed to compare the post-operative effects of the conventional surgery, piezo surgery technique and submucosal dexamethasone injection in lower third molars extractions. Methods: Data from 62 patients, subjected to surgical extraction of lower third molars, were pooled and divided into three groups such as: Conventional Group (22 patients), Piezo Group (20 patients) and Dex Group (conventional surgery + 4 mg/1 mL dexamethasone) (20 patients). Pain, swelling, trismus, analgesic consumption and operation time were comparatively evaluated. Results: Pain values were found lower in Dex Group in comparison to Conventional Group at 7th day (P = 0.007). Edema found to be higher in Conventional Group than Dex Group at 2nd day (P = 0.025). Minimally trismus values were found in Dex Group and the difference between the Dex and Conventional Group found to be statistically significant both in 2nd (P = 0.048) and 7th days (P = 0.010). The analgesic consumption in the Conventional Group was found to be higher than Piezo Group at 2nd day (P = 0.002). Conclusion: The better post-operative values were obtained in the Dex Group. Although longer operative time is considered to be a disadvantage for the piezo technique, piezotome may be preferred for surgical procedures due to its positive results in comparison to the conventional technique.
C 2018 Elsevier Masson SAS. All rights reserved.
Keywords: Third molar surgery Dexamethasone Piezosurgery Post-operative discomfort Pain
1. Introduction Removal of impacted third molars is the most common outpatient procedure carried out in maxillofacial surgery practices. This procedure often necessitates incision, flap reflection, and bone removal that can cause trauma to the tissues, which involves extensive amounts of connective tissue and blood vessels in the third molar region. Surgery-associated trauma initiates an inflammatory cascade, which results in triggering tissues’ biological responses such as pain, edema, and trismus [1,2]. These postoperative sequelae result in patient discomfort after surgery, thereby decrease a patient’s quality of life [3]. To prevent or minimize post-operative sequelae related to third molar surgery, different treatment protocols have been proposed. Among them, corticosteroids are considered a documented and widely accepted pharmacological adjunct therapy protocol in preventing post-operative complications after third molar surgery.
E-mail address: [email protected]
Their mechanism of action is based on the inhibition of inflammation and reduction of the post-operative pain, edema and trismus [1,4]. The most commonly used corticosteroid type in oral surgery is dexamethasone (dex), which is a synthetic analog of prednisolone and has potent anti-inflammatory effects that are 20–30-fold greater than natural corticosteroids [5,6]. In third molar surgery, dex administration using different methods has been investigated in various literature studies, and encouraging results have been reported. However, there still is a lack of consensus in terms of the timing, routes, and dex dosages that provide optimal clinical outcomes [3,7,8]. As the surgery necessitates bone removal, high-speed surgical hand pieces are routinely used in the third molar surgical procedures. However, these instruments inevitably generate temperatures and create irregular bone surfaces that cause an increase in post-operative discomfort [9]. To overcome these shortcomings, ultrasonic devices have emerged as an alternative to the conventional surgical instruments [10]. Piezosurgery devices that generate micro vibrations provide a less traumatic and more precise way of bone cutting and cause little damage to the bone
https://doi.org/10.1016/j.jormas.2018.10.012 C 2018 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
G Model
JORMAS-586; No. of Pages 6 Z. Gu¨mru¨kc¸u¨ / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
2
and adjacent tissues with minimal hemorrhaging. Thus, the occurrence of complications would be reduced considerably if this technique was the choice of surgical option [9,11]. The aim of the present retrospective clinical study was to investigate the effects of sub-mucosal dex injections on postoperative discomfort among patients who had undergone mandibular third molar surgery and also to compare the efficiency of conventional surgical instruments versus piezo surgery devices in terms of post-operative discomfort.
2. Materials and methods In this retrospective study, records from 62 patients, who had undergone third molar extraction with a conventional rotary device (22 patients), piezo surgery device (20 patients), and conventional rotary device in combination with 4 mg/1 mL submucosal dex injections (20 patients) were evaluated. Fortysix patients were female, and 16 were male. They ranged in age from 17 to 43 years. Data were obtained from the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Technical University archived records from January 2015 to April 2016. This study was conducted in accordance with the principles stated in the Declaration of Helsinki and was approved by the Scientific Research Ethics Committee of the Faculty of Medicine, Karadeniz Technical University (Grant: 2017/49). Among the available patients’ records, the following inclusion criteria were initially desired: American Society of Anesthesiology classification of a healthy patient with no systemic disease and not on continuous medication; mandibular third molars with Class II B position impaction; similar root formation characteristics, position, and degree of impaction for both mandibular third molars; absence of pericoronitis during the last 30 days; no signs of inflammation; non-smoking.
patients had received routine post-operative medications, including five days of antibiotics (amoxicillin, 2 g/d) and analgesics (1 g paracetamol every 4–6 h as prescribed but did not exceed 4 g per day), and mouthwash (0.12% chlorhexidine, twice a day); the sutures were removed seven days after surgery. A total of 62 patients met the inclusion criteria and were included in this study. Patient records were separated into three groups: control (conventional); piezo; and; dex group (dex). The control group consisted of 22 patients who underwent surgery with a conventional rotary device. The piezo group consisted of 20 patients who underwent surgery with the piezo device, and the dex group consisted of 20 patients, who underwent surgery with the conventional rotary device in combination with submucosal dex injections. A patient’s demographic information, systemic disease, allergy and inflammation history, and tooth number were obtained from the forms. Edema was evaluated by the same surgeon with the aid of a tape measure, as described by Antunes et al. [12]. The measurement data were obtained from the records of the patients who underwent three measurements using five reference points (lateral corner of the eye, angle of the mandible, tragus, lateral corner of the mouth, soft tissue pogonion). Three different measurement; the distance between the lateral corner of the eye and angle of the mandible (length A), the distance between tragus and lateral corner of the mouth (length B), and the distance between the tragus to soft tissue pogonion (length C) were evaluated (Fig. 1). Pre- and post-operative (second and seventh days) measurements of the length A, length B length C were obtained from the archival records. Comparisons were made
Exclusion criterion included the following parameters: patients who refused to participate in the study after reading the informed consent form; patients who were allergic to any drugs or were pregnant; patients with any systemic disease that would prevent tissue healing. Patient’s records were selected from the same clinician’s control visit records, which were obtained at the pre-, second and seventh post-operative day visits for third molar extractions. A second sorting was done among all patient’s records in order to standardize the patients in terms of surgery, medication, and postoperative follow-up sessions. The surgery and medication period for selected patient’s records was based on several guidelines: inferior alveolar and buccal nerve blocks was provided by administration of 4 % articaine hydrochloride in a 1:100,000 ratio with epinephrine; a triangular full thickness flap was applied with relaxing incisions on the mesio-buccal aspect of the second molars; osteotomies were done only around the impacted third molar crown until the enamel-cement demarcation line was reached; wound closure was done with a 4–0 silk suture; submucosal dex injections were performed in the surgical field with half of 8 mg/2 mL dex (Dekort, Deva Holding, Istanbul) ampoule for one patient;
Fig. 1. Measurement of distance A, B and C.
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
G Model
JORMAS-586; No. of Pages 6 Z. Gu¨mru¨kc¸u¨ / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
among groups by taking the total distance as a unit (sum of the three measured distances A, B, and C), and percentage change evaluated at the second and seventh post-operative days. The inter-incisal distance between upper and lower incisors was obtained from the forms and comparatively evaluated among groups. Pain levels were recorded on the second and seventh postoperative days by using a visual analogue scale calibrated between 0 and 10 and then comparatively evaluated. The number of analgesic use, in each patient per day, were obtained from the archival records of patients who were asked to take analgesic when they have pain, to stop analgesic intake when the symptoms abated and to record the number of analgesic they needed to receive [13]. Surgical time was taken as the time between the initial incision and closing of the patient’s mouth. An existing software program was used for statistical analysis (SPSS Inc., version 19.0, Chicago, IL, USA). The data were evaluated using the Shapiro–Wilk test to detect the data distribution. Comparisons between groups according to normality test results were made using the Kruskal–Wallis H-test or the one-way analysis of variance test. The Kruskal–Wallis H-test was used when there was a statistically significant difference between the groups, and Mann–Whitney Y-test with Bonferroni correction was used to identify the differences between groups. Numerical variable comparisons were also made with independent group-t-test (independent t-samples t-test). P < 0.05 was considered statistically significant.
A total of 62 patients was included in the study consisting of 46 women (74.2%) and 16 men (25.8%). Study patients’ age range varied between 17 and 43 years, and the mean age was 24.02 5.7 (N = 20). There were no statistical differences between the groups in terms of age distributions (P = 0.685) (Table 1). There were significant differences among each group with respect to surgery times. The longest surgery time was seen in the piezo group, and the shortest surgery time was seen in the control group (P < 0.05) (Table 2). The order of analgesic use values was found to be control > dex > piezo groups on the second post-operative day. In the control group, the number of analgesics used by the patients on the second post-operative day was found to be higher than the piezo group, and this difference found to be statistically significant (P = 0.02) (Table 3). Although the order of analgesic use was found as to be control > piezzo > dex groups on the seventh postoperative day, the differences among the groups were not found to be statistically significant (P > 0.05) (Table 3). The pain sequence on the second day was found to be control > dex > piezo groups. However, the differences among the groups were found to be statistically insignificant. (P > 0.05) On the seventh day, the pain sequence was found to be control > piezo > dex groups, and only the difference between the conventional and dex groups was found to be statistically significant (P = 0.07) (Table 4). Edema values were found to follow the sequence of control > piezo > dex groups on the second day of evaluation, Table 1 The average age in the groups. Mean Std deviation
Median (minimum–maximum)
24.7 6.1
23.5 (17–38)
P
0.685 Piezotome Dex Total
Table 2 Difference between the groups in terms of the duration of treatment. Operation time
Mean Std deviation
Median (minimum–maximum)
P
Control Piezotome Dex
8.2 1.3 15.1 2.5 10.1 1.2
8 (6–11)a 15 (10–21)a 10 (8–12)a
< 0.05 < 0.05 < 0.05
a There is a statistical difference for operation time between each group (P < 0.05).
Table 3 The difference in the number of analgesics intake between three groups in 2nd and 7th post-operative days.
2nd day
7th day
Groups
Mean Std deviation
Median (minimum–maximum)
Control Piezotome Dex Control Piezotome Dex
2.5 1.6 1.9 0.4 0.2 0.1
2 2 2 0 0 0
1 1.1 0.7 0.7 0.5 0.2
(0–5)a (0–5)a (0–3) (0–2) (0–2) (0–1)
a The median value of the analgesic intake number between Control and Piezotome group was found statistically different at post-operative 2nd day (P = 0.02).
Table 4 Comparison of pain levels in each groups at post-operative 2nd and 7th days.
3. Results
Control
3
24 5.9 23.3 5.2 24 5.7
22.5 (17–43) 22.5 (17–38) 23 (17–43)
Pain
Groups
Mean Std deviation
Median (minimum–maximum)
2nd day
Control Piezotome Dex Control Piezotome Dex
4.1 2.5 2.8 2.5 2.9 3.2 0.5 0.7 0.4 0.7 00
4 (0–10) 2 (0–7) 2.5 (0–8) 0 (0–3)a 0 (0–2) 0 (0–0)a
7th day
There was no statistical difference between all groups at 2nd day (P > 0.05). a At post-operative 7th days, pain level difference between Control Group and Dex Group found to statistically significant (P = 0.007).
and only the edema values in the control group were found to be statistically higher than the dex group (P = 0.002) (Table 5). Edema values were recorded in the sequence of control > piezo > dex groups on the seventh post-operative day evaluation but these differences among each group were not found to be statistically significant (P > 0.05). Percentage changes are summarized in Table 6. The mouth opening distance change sequence was found to be control > piezo > dex groups, and a significant difference between control and dex groups was seen on the second postTable 5 Comparison of edema values between three groups at 2nd post-operative day. The sum value of measurement A, B and C (in 2nd post-operative day)
Difference between groups (2nd day) (percentage) Mean Std deviation
Median (minimum–maximum)
Control Piezotome Dex
4.6 2.6 3.9 2.2 2.6 1.9
3.8 (0.3–9.5)a 3.6 (1.5–8.4) 2.3 (0–6.1)a
Measurement A; the distance between the lateral corner of the eye and angle of the mandible, Measurement B; the distance between tragus and lateral corner of the mouth, Measurement C; and the distance between the tragus to soft tissue pogonion. a At post-operative 2nd days, edema changes values found to be statistically higher in Conventional Group according to Dex Group (P = 0.002).
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
G Model
JORMAS-586; No. of Pages 6 Z. Gu¨mru¨kc¸u¨ / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
4
Table 6 Comparison of edema value between three groups at the 7th post-operative day. The sum value of measurement A, B and C (in 7th post-operative day
Difference between groups (7th day) (percentage) Mean Std deviation
Median (minimum–maximum)
Control Piezotome Dex
1.8 2.1 1 1.1 0.7 0.8
0.9 (0–6.6) 0.6 (0–3.5) 0.6 (0–2.9)
Measurement A; the distance between the lateral corner of the eye and angle of the mandible, Measurement B; the distance between tragus and lateral corner of the mouth, Measurement C; and the distance between the tragus to soft tissue pogonion. There is not significant edema difference in Conventional Group, Piezo Group and Dex Group (P > 0.05).
operative day (P = 0.048) (Table 7). Similarly, the mouth opening restriction sequence was found to be control > piezo > dex groups, and a significant difference between control and dex groups was found on the seventh post-operative day (P = 0.010) (Table 8).
4. Discussion Facial pain, swelling, and restriction in mouth opening are distressing situations that are often seen after impacted third molar surgery [8]. Therefore, nowadays, clinicians are trying to reduce post-operative complications via different strategies such as antiseptic mouthwashes, use of drains, flap design, antibiotics, muscle relaxants, physiotherapy, use of corticosteroids, and use of piezoelectric ultrasound osteotomy devices [14,15]. The use of anti-inflammatory drugs is the most common procedure for reducing post-operative complications as a result of their suppressive action on transudation [16]. Dex is known to be more potent because of its longer duration of action than methylprednisolone; therefore, dex is one of the most widely used corticosteroids owing to its strong anti-inflammatory effects [17]. Although the mechanism of action is not fully understood, it has been reported that anti-inflammatory effects are associated with the reduction of prostaglandins and leukotrienes that act as blockers in the phospholipase pathway in addition to inhibition of Table 7 Comparison of restriction in mouth opening between three groups at 2nd postoperative day. Difference in mouth opening
Difference Between Groups (2nd day) (Percentage) Mean Std deviation
Median (minimum–maximum)
Control Piezotome Dex
45.8 14 35.6 15.8 34.3 15.2
48.2 (18.5–67.5)a 35.3 (0–64.6) 37.7 (0–52.6)a
a There significant difference in mouth opening in conventional and dex group at 2nd post-operative day (P = 0.048).
Table 8 Comparison of restriction in mouth opening between three groups at 7th postoperative day. Restriction in mouth opening
Difference Between Groups (7nd day) (Percentage) Mean Std deviation
Median (minimum–maximum)
Control Piezotome Dex
20.9 13.9 14.6 12.2 9.6 12
17,9 (1.9–44.4)a 12,8 (0–45.8) 5,3 (0–46.2)a
a There significant difference in mouth opening in conventional and dex group at 7th post-operative day (P = 0.010).
exudate formation, edema, trismus, and pain [18,19]. Dex administered via intramuscular, oral, endo-alveolar, and/or submucosal pathways has been shown to produce very similar results. However, submucosal injections are considered the simplest and the most effective way by oral surgeons because of their significant half-life and potency [20–23]. Although local factors such as impacted teeth position and bone density play major role in the success of the third molar surgery, additional factors such as pre-operative planning, rigorous surgical technique, and the surgeon’s experience are also important to the success of the surgery [24]. The most critical stage of tooth extraction is bone removal because of the uncontrolled heat that lead to bone necrosis and healing/regeneration problems in the adjacent tissues [25,26]. On the other hand, a piezotome is a device that ensures precise selective cuts in bone and prevents trauma to the soft tissues, especially during third molar surgery. The device has a pulsating and serum-irrigating tip, provides active irrigation, ensures a cleaner surgical area, and provides more efficient cooling in the third molar surgical field due to its irrigator tips compared to the conventional technique [27–29]. Although there are a number of studies evaluating the efficacy of the piezotome or dex separately in third molar surgery, there are no comparative studies about the efficacy of combined use of the piezotome and dex [3,4,14,16,27,30,31]. This study was a pilot study because it is the first study to evaluate the concurrent use of piezo surgical instruments and dex on post-operative third molar surgery effects. Various studies that have evaluated the efficacy of steroid use in third molar surgery highlight that the use of steroids significantly reduced swelling [3,16,31,32]. In our retrospective study, the lowest edema values were found in the dex group and the highest edema values were found in the control group on the second postoperative day. However, only the differences between the conventional and dex groups were found to be statistically significant on the second post-operative day; this finding is consistent with the report of Warraich et al [16]. This significant difference in the dex group on the second post-operative day can be attributed to dex’s anti-inflammatory effects. Statistical differences were not found with respect to edema on the seventh post-operative day, and this result can be explained by the occurrence of peak swelling on the second post-operative day, which gradually decreased to a minimum over the course of a week. Although the edema values in the piezo group were found to be numerically higher than the control group and lower than the dex group, there were no significant differences in the piezo group in comparison to the dex and control groups with respect to edema on both the second and seventh post-operative days; these findings contradict the study of Goyal et al. [27] Goyal et al. [27] evaluated the differences in the tragus-corner of the mouth and tragus-pogonion distances separately, and they found a significant difference only in the distance of tragus-corner of the mouth. In our study, unlike the study of Goyal et al. [27], the distance of the lateral corner of the eye-angulus mandible was taken into consideration as a third length parameter. The distance changes in three measurements were added together, and group comparisons were made over a single numeric data. The contradiction in the results can be attributed to this methodolgical difference. Significant differences were observed among the three groups with respect to surgical duration, and in our study, the highest surgical duration was found in the piezo group. The median value of the surgical duration in the piezo group was statistically higher than in the control group, which confirmed other reports in the literature [11,27]. Jiang et al. [33] reported insignificant difference in pain levels between the conventional and piezo groups in their meta-analysis study. However, they reported less pain levels in the piezo group
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
G Model
JORMAS-586; No. of Pages 6 Z. Gu¨mru¨kc¸u¨ / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
compared to the conventional group after a few post-operative days, but this result was not found to be significant, which is similar with our study results. Goyal et al. [27] and Arakji et al. [34] reported significantly less pain as reported by the patients after third molar extraction using the piezotome. In our study, the pain values in the piezo group were found to be numerically lower than the dex and conventional groups on the second post-operative day, but this difference was not found to be statistically significant. On the seventh post-operative day, the pain values in the piezo group were found to be found to be numerically lower than pain values in the control group and higher than the dex group and only the difference between the control and dex groups were found to be statistically significant. This statistically insignificant result in the piezo group may have been caused by the lack of adequate sample numbers in the study. In our study, the patients in the dex and control groups showed the lowest and highest pain values, respectively, on the seventh post-operative day, and this difference was found to be statistically significant. Morachini et al. [3] reported a significant reduction in pain in the submucosal dex injection group in comparison to the control group as based on a meta-analysis study. This report is consistent with our seventh post-operative day results with respect to pain. Although steroids have been shown to reduce pain in other studies, the route of pain relief has not been fully elucidated. This positive result is thought to be due to the reduction of the swelling resulting from steroid use, and thus the pain relief due to the tension was caused by a reduction in the tension [31]. This decrease in pain is thought to be the result of the increase in the patient’s pain reaction caused by tissue bradykinin reduction and endorphin level increase resulting from steroidal actions [8]. The reduction of pain in our study after steroid use can be attributed to the above mentioned rationale. Although pain values were found to be significantly highest in the control group and significantly lowest in the dex group on the seventh post-operative day. In terms of analgesic consumption, the highest values were found in the control group and lowest values in the piezo group on second post-operative day, and these values were found to be statistically significant. Patients are usually concerned about swelling and pain in the first couple of postoperative days. Even in the absence of pain, patients may have consumed more painkillers because of pain-associated anxiety. The results concerning analgesic drug consumption, which was found to be significantly higher in the first days and was not parallel to the pain levels in the groups, can be explained by the exaggerated medication intake or the small sample size in our study. Majid and Mahmood [35] reported mouth opening distance differences in the dex group compared to the control group, but they did not report significant differences between these two groups as a result of their study. In contrast, in the present study, post-operative mouth opening presented significant differences in the control and dex groups on both the second and seventh postoperative days. While the highest differences in values were obtained from the control group, the lowest mouth opening distance difference values were found in the dex group. This result is consistent with the literature reports [16,32]. Ehsan et al. [36] reported a significant reduction in trismus on the second postoperative day after submucosal injections of dex (4 mg) in comparison with the control group; this finding is consistent with our study results. This result can be attributed to the role of steroids in inflammation inhibition/suppression and prevention of fibrosis formation since fibrosis plays an important role in early stages of the surgery [37]. Chang et al. [38] reported no significant differences in the mouth opening score between the control and piezo groups in their study. However, patients in the piezo group had numerically lower
5
mouth opening restriction values than patients in the control group on the second post-operative day, but this difference was not statistically significant between the control and piezo groups. This result is in agreement with our study results. Consistent with our study results, Al-Moraissi et al. [11] and Arakji et al. [34] reported significant mouth opening distance differences between the piezo and control groups. The lowest change in mouth opening was found in the dex group on both the second and seventh postoperative days, and the difference between the control and dex groups were found to be statistically significant on both the second and seventh post-operative days. Even if the change in the piezo group was found not to be significant in our study results, it demonstrated that the piezo device is a better choice in terms of mouth opening by the second and seventh post-operative days compared to the conventional method. In conclusion, perioperative submucosal injection of dexamethasone was effective in reducing swelling, pain, mouth opening restriction. Although significant results could not be detected in the piezo group, it was seen that the device has positive effects on pain, swelling, trismus, and number of used analgesics compared to the control group. However, there is a need to increase the range of specimens for a clearer distinction among groups; therefore, extensive new clinical studies are required. Disclosure of interest The authors have not supplied their declaration of competing interest.
Acknowledgements I would like to thank to my dear colleagues Dr. Sevda Kurt and Dr. Damla Torul owing to their valuable contributions in this study. References [1] Saravanan K, Kannan R, John RR, Nath Kumar C. A single pre operative dose of submucosal dexamethasone is effective in improving post-operative quality of life in the surgical management of impacted third molars: a comparative randomised prospective study. J Maxillofac Oral Surg 2016;15:67–71. [2] Schmelzeisen R, Frolich JC. Prevention of post-operative swelling and pain by dexamethasone after operative removal of impacted third molar teeth. Eur J Clin Pharmacol 1993;44:275–7. [3] Moraschini V, Hidalgo R, Porto Barbazo E. Effect of submucosal injection of dexamethasone after third molar surgery: a meta-analysis of randomized controlled trials. Int J Oral Maxillofac Surg 2016;45:232–40. [4] Nandini GD. Eventuality of dexamethasone injected intra-massetrically on post-operative sequel following the surgical extraction of impacted mandibular third molars: a prospective study. J Maxillofac Oral Surg 2016;15:456–60. [5] Bortoluzzi MC, Capella DL, Barbieri T, Pagliarini M, Cavalieri T, Manfro R. A single dose of amoxicillin and dexamethasone for prevention of post-operative complications in third molar surgery: a randomized, double-blind, placebo controlled clinical trial. J Clin Med Res 2013;5:26–33. [6] Boonsiriseth K, Klongnoi B, Sirintawat N, Saengsirinavin C, Wongsirichat N. Comparative study of the effect of dexamethasone injection and consumption in lower third molar surgery. Int J Oral Maxillofac Surg 2012;41:244–7. [7] Deo SP. Single-dose of submucosal injection of dexamethasone affects the post-operative quality of life after third molar surgery. J Maxillofac Oral Surg 2016;15:367–75. [8] Graziani F, D’Aiuto F, Arduino PG, Tonelli M, Gabriela M. Perioperative dexamethasone reduces post-surgical sequelae of wisdom tooth removal. A splitmouth randomized double-masked clinical trial. Int J Oral Maxillofac Surg 2006;35:241–6. [9] Basheer SA, Govind RJ, Daniel A, Sam G, Adarsh VJ, Rao A. comparative study of piezoelectric and rotary osteotomy technique for third molar impaction. J Contemp Dent Pract 2017;18:60–4. [10] Horton JE, Tarpley TM, Jacoway JR. Clinical applications of ultrasonic instrumentation in the surgical removal of bone. Oral Surg Oral Med Oral Pathol 1981;51:236–42. [11] Al-Moraissi EA, Elmansi YA, Al-Sharaee YA, Alrmali AE, Alkhutari AS. Does the piezoelectric surgical technique produce fewer post-operative sequelae after lower third molar surgery than conventional rotary instruments? A systematic review and meta analysis. Int J Oral Maxillofac Surg 2016;45:383–91. [12] Antunes AA, Avelar Rl, Martins Neto EC, Frota R, Dias E. Effect of two routes of administration of dexamethasone on pain, edema, and trismus in impacted lower third molar surgery. Oral Maxillofac Surg 2011;15:217–23.
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
G Model
JORMAS-586; No. of Pages 6 6
Z. Gu¨mru¨kc¸u¨ / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
[13] Lima CAA, Favarini VT, Torres AM, da Silva RA, Sato FRL. Oral dexamethasone decreases post-operative pain, swelling, and trismus more than diclofenac following third molar removal: a randomized controlled clinical trial. Oral Maxillofac Surg 2017;21:321–6. [14] Rullo R, Addabbo F, Papaccio G, D’Aquino R, Festa VM. Piezoelectric device vs. conventional rotative instruments in impacted third molar surgery: relationships between surgical difficulty and post-operative pain with histological evaluations. J Craniomaxillofac Surg 2013;41:33–8. [15] Kirmeier R, Truschnegg A, Payer M, Acham S, Schulz K, Jakse N. Evaluation of a muscle relaxant on sequelae of third molar surgery: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:8–14. [16] Warraich R, Faisal M, Rana M, Shaheen A, Gellrich NC, Rana M. Evaluation of post-operative discomfort following third molar surgery using submucosal dexamethasone – a randomized observer blind prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:16–22. [17] Montgomery MT, Hogg JP, Roberts DL, Redding SW. The use of glucocorticosteroids to lessen the inflammatory sequelae following third molar surgery. J Oral Maxillofac Surg 1990;48:179–87. [18] Alexander RE, Throndson RR. A review of perioperative corticosteroid use in dentoalveolar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:406–15. [19] Kim K, Brar P, Jakubowski J, Kaltman S, Lopez E. The use of corticosteroids and nonsteroidal antiinflammatory medication for the management of pain and inflammation after third molar surgery: a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:630–40. [20] Chen Q, Chen J, Hu B, Feng G, Song J. Submucosal injection of dexamethasone reduces post-operative discomfort after third-molar extraction: a systematic review and meta-analysis. J Am Dent Assoc 2017;148:81–91. [21] Simone JL, Jorge WA, Horliana AC, Canaval TG, Tortamano IP. Comparative analysis of preemptive analgesic effect of dexamethasone and diclofenac following third molar surgery. Braz Oral Res 2013;27:266–71. [22] Deo SP. Effect of submucosal injection of dexamethasone on post-operative sequelae of third molar surgery. JNMA J Nepal Med Assoc 2011;51:72–8. [23] Alcantara CE, Falci SG, Oliveira-Ferreira F, Santos CR, Pinheiro ML. Pre-emptive effect of dexamethasone and methylprednisolone on pain, swelling, and trismus after third molar surgery: a split-mouth randomized triple-blind clinical trial. Int J Oral Maxillofac Surg 2014;43:93–8. [24] Santamaria J, Arteagoitia I. Radiologic variables of clinical significance in the extraction of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:469–73. [25] Praveen G, Rajesh P, Neelakandan RS, Nandagopal CM. Comparison of morbidity following the removal of mandibular third molar by lingual split, surgical bur and simplified split bone technique. Indian J Dent Res 2007;18 [15-8.26].
[26] Kerawala CJ, Martin IC, Allan W, Williams ED. The effects of operator technique and bur design on temperature during osseous preparation for osteosynthesis self-tapping screws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:145–50. [27] Goyal M, Marya K, Jhamb A, Chawla S, Sonoo PR, Singh V, Aggarwal A. Comparative evaluation of surgical outcome after removal of impacted mandibular third molars using a Piezotome or a conventional handpiece: a prospective study. Br J Oral Maxillofac Surg 2012;50:556–61. [28] Leclercq P, Zenati C, Amr S, Dohan DM. Ultrasonic bone cut part 1: state-of-theart technologies and common applications. J Oral Maxillofac Surg 2008;66:177–82. [29] Robiony M, Polini F, Costa F, Vercellotti T, Politi M. Piezoelectric bone cutting in multipiece maxillary osteotomies. J Oral Maxillofac Surg 2004;62:759–61. [30] Bilginaylar K, Uyanik LO. Evaluation of the effects of platelet-rich fibrin and piezosurgery on outcomes after removal of impacted mandibular third molars. Br J Oral Maxillofac Surg 2016;54:629–33. [31] Klongnoi B, Kaewpradub P, Boonsiriseth K, Wongsirichat N. Effect of single dose pre-operative intramuscular dexamethasone injection on lower impacted third molar surgery. Int J Oral Maxillofac Surg 2012;41:376–9. [32] Mojsa IM, Pokrowiecki R, Lipczynski K, Czerwonka D, Szczeklik K, Zaleska M. Effect of submucosal dexamethasone injection on post-operative pain, oedema, and trismus following mandibular third molar surgery: a prospective, randomized, double-blind clinical trial. Int J Oral Maxillofac Surg 2017;46:524–30. [33] Jiang Q, Qiu Y, Yang C, Yang J, Chen M, Zhang Z. Piezoelectric versus conventional rotary techniques for impacted third molar extraction: a meta-analysis of randomized controlled trials. Medicine (Baltimore) 2015;94:1685. [34] Arakji H, Shokry M, Aboelsaad N. Comparison of Piezosurgery and conventional rotary instruments for removal of impacted mandibular third molars: a randomized controlled clinical and radiographic trial. Int J Dent 2016;2016:8169356. [35] Majid OW, Mahmood WK. Mahmood, effect of submucosal and intramuscular dexamethasone on post-operative sequelae after third molar surgery: comparative study. Br J Oral Maxillofac Surg 2011;49:647–52. [36] Ehsan A, Ali Bukhari SG A, Manzoor A, Junaid M. Effects of pre-operative submucosal dexamethasone injection on the post-operative swelling and trismus following surgical extraction of mandibular third molar. J Coll Physicians Surg Pak 2014;24:489–92. [37] Kakar PK, Puri RK, Venkatachalam VP. Oral submucous fibrosis–treatment with hyalase. J Laryngol Otol 1985;99:57–9. [38] Chang HH, Lee MS, Hsu YC, Tsai SJ, Lin CP. Comparison of clinical parameters and environmental noise levels between regular surgery and piezosurgery for extraction of impacted third molars. J Formos Med Assoc 2015;114:929–35.
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
JORMAS-586; No. of Pages 6 J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original Article
The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery Z. Gu¨mru¨kc¸u¨ Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Recep Tayyip Erdog˘an University, Rize, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 July 2018 Accepted 28 October 2018
Background: A retrospective clinical study was performed to compare the post-operative effects of the conventional surgery, piezo surgery technique and submucosal dexamethasone injection in lower third molars extractions. Methods: Data from 62 patients, subjected to surgical extraction of lower third molars, were pooled and divided into three groups such as: Conventional Group (22 patients), Piezo Group (20 patients) and Dex Group (conventional surgery + 4 mg/1 mL dexamethasone) (20 patients). Pain, swelling, trismus, analgesic consumption and operation time were comparatively evaluated. Results: Pain values were found lower in Dex Group in comparison to Conventional Group at 7th day (P = 0.007). Edema found to be higher in Conventional Group than Dex Group at 2nd day (P = 0.025). Minimally trismus values were found in Dex Group and the difference between the Dex and Conventional Group found to be statistically significant both in 2nd (P = 0.048) and 7th days (P = 0.010). The analgesic consumption in the Conventional Group was found to be higher than Piezo Group at 2nd day (P = 0.002). Conclusion: The better post-operative values were obtained in the Dex Group. Although longer operative time is considered to be a disadvantage for the piezo technique, piezotome may be preferred for surgical procedures due to its positive results in comparison to the conventional technique.
C 2018 Elsevier Masson SAS. All rights reserved.
Keywords: Third molar surgery Dexamethasone Piezosurgery Post-operative discomfort Pain
1. Introduction Removal of impacted third molars is the most common outpatient procedure carried out in maxillofacial surgery practices. This procedure often necessitates incision, flap reflection, and bone removal that can cause trauma to the tissues, which involves extensive amounts of connective tissue and blood vessels in the third molar region. Surgery-associated trauma initiates an inflammatory cascade, which results in triggering tissues’ biological responses such as pain, edema, and trismus [1,2]. These postoperative sequelae result in patient discomfort after surgery, thereby decrease a patient’s quality of life [3]. To prevent or minimize post-operative sequelae related to third molar surgery, different treatment protocols have been proposed. Among them, corticosteroids are considered a documented and widely accepted pharmacological adjunct therapy protocol in preventing post-operative complications after third molar surgery.
E-mail address: [email protected]
Their mechanism of action is based on the inhibition of inflammation and reduction of the post-operative pain, edema and trismus [1,4]. The most commonly used corticosteroid type in oral surgery is dexamethasone (dex), which is a synthetic analog of prednisolone and has potent anti-inflammatory effects that are 20–30-fold greater than natural corticosteroids [5,6]. In third molar surgery, dex administration using different methods has been investigated in various literature studies, and encouraging results have been reported. However, there still is a lack of consensus in terms of the timing, routes, and dex dosages that provide optimal clinical outcomes [3,7,8]. As the surgery necessitates bone removal, high-speed surgical hand pieces are routinely used in the third molar surgical procedures. However, these instruments inevitably generate temperatures and create irregular bone surfaces that cause an increase in post-operative discomfort [9]. To overcome these shortcomings, ultrasonic devices have emerged as an alternative to the conventional surgical instruments [10]. Piezosurgery devices that generate micro vibrations provide a less traumatic and more precise way of bone cutting and cause little damage to the bone
https://doi.org/10.1016/j.jormas.2018.10.012 C 2018 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
G Model
JORMAS-586; No. of Pages 6 Z. Gu¨mru¨kc¸u¨ / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
2
and adjacent tissues with minimal hemorrhaging. Thus, the occurrence of complications would be reduced considerably if this technique was the choice of surgical option [9,11]. The aim of the present retrospective clinical study was to investigate the effects of sub-mucosal dex injections on postoperative discomfort among patients who had undergone mandibular third molar surgery and also to compare the efficiency of conventional surgical instruments versus piezo surgery devices in terms of post-operative discomfort.
2. Materials and methods In this retrospective study, records from 62 patients, who had undergone third molar extraction with a conventional rotary device (22 patients), piezo surgery device (20 patients), and conventional rotary device in combination with 4 mg/1 mL submucosal dex injections (20 patients) were evaluated. Fortysix patients were female, and 16 were male. They ranged in age from 17 to 43 years. Data were obtained from the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Technical University archived records from January 2015 to April 2016. This study was conducted in accordance with the principles stated in the Declaration of Helsinki and was approved by the Scientific Research Ethics Committee of the Faculty of Medicine, Karadeniz Technical University (Grant: 2017/49). Among the available patients’ records, the following inclusion criteria were initially desired: American Society of Anesthesiology classification of a healthy patient with no systemic disease and not on continuous medication; mandibular third molars with Class II B position impaction; similar root formation characteristics, position, and degree of impaction for both mandibular third molars; absence of pericoronitis during the last 30 days; no signs of inflammation; non-smoking.
patients had received routine post-operative medications, including five days of antibiotics (amoxicillin, 2 g/d) and analgesics (1 g paracetamol every 4–6 h as prescribed but did not exceed 4 g per day), and mouthwash (0.12% chlorhexidine, twice a day); the sutures were removed seven days after surgery. A total of 62 patients met the inclusion criteria and were included in this study. Patient records were separated into three groups: control (conventional); piezo; and; dex group (dex). The control group consisted of 22 patients who underwent surgery with a conventional rotary device. The piezo group consisted of 20 patients who underwent surgery with the piezo device, and the dex group consisted of 20 patients, who underwent surgery with the conventional rotary device in combination with submucosal dex injections. A patient’s demographic information, systemic disease, allergy and inflammation history, and tooth number were obtained from the forms. Edema was evaluated by the same surgeon with the aid of a tape measure, as described by Antunes et al. [12]. The measurement data were obtained from the records of the patients who underwent three measurements using five reference points (lateral corner of the eye, angle of the mandible, tragus, lateral corner of the mouth, soft tissue pogonion). Three different measurement; the distance between the lateral corner of the eye and angle of the mandible (length A), the distance between tragus and lateral corner of the mouth (length B), and the distance between the tragus to soft tissue pogonion (length C) were evaluated (Fig. 1). Pre- and post-operative (second and seventh days) measurements of the length A, length B length C were obtained from the archival records. Comparisons were made
Exclusion criterion included the following parameters: patients who refused to participate in the study after reading the informed consent form; patients who were allergic to any drugs or were pregnant; patients with any systemic disease that would prevent tissue healing. Patient’s records were selected from the same clinician’s control visit records, which were obtained at the pre-, second and seventh post-operative day visits for third molar extractions. A second sorting was done among all patient’s records in order to standardize the patients in terms of surgery, medication, and postoperative follow-up sessions. The surgery and medication period for selected patient’s records was based on several guidelines: inferior alveolar and buccal nerve blocks was provided by administration of 4 % articaine hydrochloride in a 1:100,000 ratio with epinephrine; a triangular full thickness flap was applied with relaxing incisions on the mesio-buccal aspect of the second molars; osteotomies were done only around the impacted third molar crown until the enamel-cement demarcation line was reached; wound closure was done with a 4–0 silk suture; submucosal dex injections were performed in the surgical field with half of 8 mg/2 mL dex (Dekort, Deva Holding, Istanbul) ampoule for one patient;
Fig. 1. Measurement of distance A, B and C.
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
G Model
JORMAS-586; No. of Pages 6 Z. Gu¨mru¨kc¸u¨ / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
among groups by taking the total distance as a unit (sum of the three measured distances A, B, and C), and percentage change evaluated at the second and seventh post-operative days. The inter-incisal distance between upper and lower incisors was obtained from the forms and comparatively evaluated among groups. Pain levels were recorded on the second and seventh postoperative days by using a visual analogue scale calibrated between 0 and 10 and then comparatively evaluated. The number of analgesic use, in each patient per day, were obtained from the archival records of patients who were asked to take analgesic when they have pain, to stop analgesic intake when the symptoms abated and to record the number of analgesic they needed to receive [13]. Surgical time was taken as the time between the initial incision and closing of the patient’s mouth. An existing software program was used for statistical analysis (SPSS Inc., version 19.0, Chicago, IL, USA). The data were evaluated using the Shapiro–Wilk test to detect the data distribution. Comparisons between groups according to normality test results were made using the Kruskal–Wallis H-test or the one-way analysis of variance test. The Kruskal–Wallis H-test was used when there was a statistically significant difference between the groups, and Mann–Whitney Y-test with Bonferroni correction was used to identify the differences between groups. Numerical variable comparisons were also made with independent group-t-test (independent t-samples t-test). P < 0.05 was considered statistically significant.
A total of 62 patients was included in the study consisting of 46 women (74.2%) and 16 men (25.8%). Study patients’ age range varied between 17 and 43 years, and the mean age was 24.02 5.7 (N = 20). There were no statistical differences between the groups in terms of age distributions (P = 0.685) (Table 1). There were significant differences among each group with respect to surgery times. The longest surgery time was seen in the piezo group, and the shortest surgery time was seen in the control group (P < 0.05) (Table 2). The order of analgesic use values was found to be control > dex > piezo groups on the second post-operative day. In the control group, the number of analgesics used by the patients on the second post-operative day was found to be higher than the piezo group, and this difference found to be statistically significant (P = 0.02) (Table 3). Although the order of analgesic use was found as to be control > piezzo > dex groups on the seventh postoperative day, the differences among the groups were not found to be statistically significant (P > 0.05) (Table 3). The pain sequence on the second day was found to be control > dex > piezo groups. However, the differences among the groups were found to be statistically insignificant. (P > 0.05) On the seventh day, the pain sequence was found to be control > piezo > dex groups, and only the difference between the conventional and dex groups was found to be statistically significant (P = 0.07) (Table 4). Edema values were found to follow the sequence of control > piezo > dex groups on the second day of evaluation, Table 1 The average age in the groups. Mean Std deviation
Median (minimum–maximum)
24.7 6.1
23.5 (17–38)
P
0.685 Piezotome Dex Total
Table 2 Difference between the groups in terms of the duration of treatment. Operation time
Mean Std deviation
Median (minimum–maximum)
P
Control Piezotome Dex
8.2 1.3 15.1 2.5 10.1 1.2
8 (6–11)a 15 (10–21)a 10 (8–12)a
< 0.05 < 0.05 < 0.05
a There is a statistical difference for operation time between each group (P < 0.05).
Table 3 The difference in the number of analgesics intake between three groups in 2nd and 7th post-operative days.
2nd day
7th day
Groups
Mean Std deviation
Median (minimum–maximum)
Control Piezotome Dex Control Piezotome Dex
2.5 1.6 1.9 0.4 0.2 0.1
2 2 2 0 0 0
1 1.1 0.7 0.7 0.5 0.2
(0–5)a (0–5)a (0–3) (0–2) (0–2) (0–1)
a The median value of the analgesic intake number between Control and Piezotome group was found statistically different at post-operative 2nd day (P = 0.02).
Table 4 Comparison of pain levels in each groups at post-operative 2nd and 7th days.
3. Results
Control
3
24 5.9 23.3 5.2 24 5.7
22.5 (17–43) 22.5 (17–38) 23 (17–43)
Pain
Groups
Mean Std deviation
Median (minimum–maximum)
2nd day
Control Piezotome Dex Control Piezotome Dex
4.1 2.5 2.8 2.5 2.9 3.2 0.5 0.7 0.4 0.7 00
4 (0–10) 2 (0–7) 2.5 (0–8) 0 (0–3)a 0 (0–2) 0 (0–0)a
7th day
There was no statistical difference between all groups at 2nd day (P > 0.05). a At post-operative 7th days, pain level difference between Control Group and Dex Group found to statistically significant (P = 0.007).
and only the edema values in the control group were found to be statistically higher than the dex group (P = 0.002) (Table 5). Edema values were recorded in the sequence of control > piezo > dex groups on the seventh post-operative day evaluation but these differences among each group were not found to be statistically significant (P > 0.05). Percentage changes are summarized in Table 6. The mouth opening distance change sequence was found to be control > piezo > dex groups, and a significant difference between control and dex groups was seen on the second postTable 5 Comparison of edema values between three groups at 2nd post-operative day. The sum value of measurement A, B and C (in 2nd post-operative day)
Difference between groups (2nd day) (percentage) Mean Std deviation
Median (minimum–maximum)
Control Piezotome Dex
4.6 2.6 3.9 2.2 2.6 1.9
3.8 (0.3–9.5)a 3.6 (1.5–8.4) 2.3 (0–6.1)a
Measurement A; the distance between the lateral corner of the eye and angle of the mandible, Measurement B; the distance between tragus and lateral corner of the mouth, Measurement C; and the distance between the tragus to soft tissue pogonion. a At post-operative 2nd days, edema changes values found to be statistically higher in Conventional Group according to Dex Group (P = 0.002).
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
G Model
JORMAS-586; No. of Pages 6 Z. Gu¨mru¨kc¸u¨ / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
4
Table 6 Comparison of edema value between three groups at the 7th post-operative day. The sum value of measurement A, B and C (in 7th post-operative day
Difference between groups (7th day) (percentage) Mean Std deviation
Median (minimum–maximum)
Control Piezotome Dex
1.8 2.1 1 1.1 0.7 0.8
0.9 (0–6.6) 0.6 (0–3.5) 0.6 (0–2.9)
Measurement A; the distance between the lateral corner of the eye and angle of the mandible, Measurement B; the distance between tragus and lateral corner of the mouth, Measurement C; and the distance between the tragus to soft tissue pogonion. There is not significant edema difference in Conventional Group, Piezo Group and Dex Group (P > 0.05).
operative day (P = 0.048) (Table 7). Similarly, the mouth opening restriction sequence was found to be control > piezo > dex groups, and a significant difference between control and dex groups was found on the seventh post-operative day (P = 0.010) (Table 8).
4. Discussion Facial pain, swelling, and restriction in mouth opening are distressing situations that are often seen after impacted third molar surgery [8]. Therefore, nowadays, clinicians are trying to reduce post-operative complications via different strategies such as antiseptic mouthwashes, use of drains, flap design, antibiotics, muscle relaxants, physiotherapy, use of corticosteroids, and use of piezoelectric ultrasound osteotomy devices [14,15]. The use of anti-inflammatory drugs is the most common procedure for reducing post-operative complications as a result of their suppressive action on transudation [16]. Dex is known to be more potent because of its longer duration of action than methylprednisolone; therefore, dex is one of the most widely used corticosteroids owing to its strong anti-inflammatory effects [17]. Although the mechanism of action is not fully understood, it has been reported that anti-inflammatory effects are associated with the reduction of prostaglandins and leukotrienes that act as blockers in the phospholipase pathway in addition to inhibition of Table 7 Comparison of restriction in mouth opening between three groups at 2nd postoperative day. Difference in mouth opening
Difference Between Groups (2nd day) (Percentage) Mean Std deviation
Median (minimum–maximum)
Control Piezotome Dex
45.8 14 35.6 15.8 34.3 15.2
48.2 (18.5–67.5)a 35.3 (0–64.6) 37.7 (0–52.6)a
a There significant difference in mouth opening in conventional and dex group at 2nd post-operative day (P = 0.048).
Table 8 Comparison of restriction in mouth opening between three groups at 7th postoperative day. Restriction in mouth opening
Difference Between Groups (7nd day) (Percentage) Mean Std deviation
Median (minimum–maximum)
Control Piezotome Dex
20.9 13.9 14.6 12.2 9.6 12
17,9 (1.9–44.4)a 12,8 (0–45.8) 5,3 (0–46.2)a
a There significant difference in mouth opening in conventional and dex group at 7th post-operative day (P = 0.010).
exudate formation, edema, trismus, and pain [18,19]. Dex administered via intramuscular, oral, endo-alveolar, and/or submucosal pathways has been shown to produce very similar results. However, submucosal injections are considered the simplest and the most effective way by oral surgeons because of their significant half-life and potency [20–23]. Although local factors such as impacted teeth position and bone density play major role in the success of the third molar surgery, additional factors such as pre-operative planning, rigorous surgical technique, and the surgeon’s experience are also important to the success of the surgery [24]. The most critical stage of tooth extraction is bone removal because of the uncontrolled heat that lead to bone necrosis and healing/regeneration problems in the adjacent tissues [25,26]. On the other hand, a piezotome is a device that ensures precise selective cuts in bone and prevents trauma to the soft tissues, especially during third molar surgery. The device has a pulsating and serum-irrigating tip, provides active irrigation, ensures a cleaner surgical area, and provides more efficient cooling in the third molar surgical field due to its irrigator tips compared to the conventional technique [27–29]. Although there are a number of studies evaluating the efficacy of the piezotome or dex separately in third molar surgery, there are no comparative studies about the efficacy of combined use of the piezotome and dex [3,4,14,16,27,30,31]. This study was a pilot study because it is the first study to evaluate the concurrent use of piezo surgical instruments and dex on post-operative third molar surgery effects. Various studies that have evaluated the efficacy of steroid use in third molar surgery highlight that the use of steroids significantly reduced swelling [3,16,31,32]. In our retrospective study, the lowest edema values were found in the dex group and the highest edema values were found in the control group on the second postoperative day. However, only the differences between the conventional and dex groups were found to be statistically significant on the second post-operative day; this finding is consistent with the report of Warraich et al [16]. This significant difference in the dex group on the second post-operative day can be attributed to dex’s anti-inflammatory effects. Statistical differences were not found with respect to edema on the seventh post-operative day, and this result can be explained by the occurrence of peak swelling on the second post-operative day, which gradually decreased to a minimum over the course of a week. Although the edema values in the piezo group were found to be numerically higher than the control group and lower than the dex group, there were no significant differences in the piezo group in comparison to the dex and control groups with respect to edema on both the second and seventh post-operative days; these findings contradict the study of Goyal et al. [27] Goyal et al. [27] evaluated the differences in the tragus-corner of the mouth and tragus-pogonion distances separately, and they found a significant difference only in the distance of tragus-corner of the mouth. In our study, unlike the study of Goyal et al. [27], the distance of the lateral corner of the eye-angulus mandible was taken into consideration as a third length parameter. The distance changes in three measurements were added together, and group comparisons were made over a single numeric data. The contradiction in the results can be attributed to this methodolgical difference. Significant differences were observed among the three groups with respect to surgical duration, and in our study, the highest surgical duration was found in the piezo group. The median value of the surgical duration in the piezo group was statistically higher than in the control group, which confirmed other reports in the literature [11,27]. Jiang et al. [33] reported insignificant difference in pain levels between the conventional and piezo groups in their meta-analysis study. However, they reported less pain levels in the piezo group
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
G Model
JORMAS-586; No. of Pages 6 Z. Gu¨mru¨kc¸u¨ / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
compared to the conventional group after a few post-operative days, but this result was not found to be significant, which is similar with our study results. Goyal et al. [27] and Arakji et al. [34] reported significantly less pain as reported by the patients after third molar extraction using the piezotome. In our study, the pain values in the piezo group were found to be numerically lower than the dex and conventional groups on the second post-operative day, but this difference was not found to be statistically significant. On the seventh post-operative day, the pain values in the piezo group were found to be found to be numerically lower than pain values in the control group and higher than the dex group and only the difference between the control and dex groups were found to be statistically significant. This statistically insignificant result in the piezo group may have been caused by the lack of adequate sample numbers in the study. In our study, the patients in the dex and control groups showed the lowest and highest pain values, respectively, on the seventh post-operative day, and this difference was found to be statistically significant. Morachini et al. [3] reported a significant reduction in pain in the submucosal dex injection group in comparison to the control group as based on a meta-analysis study. This report is consistent with our seventh post-operative day results with respect to pain. Although steroids have been shown to reduce pain in other studies, the route of pain relief has not been fully elucidated. This positive result is thought to be due to the reduction of the swelling resulting from steroid use, and thus the pain relief due to the tension was caused by a reduction in the tension [31]. This decrease in pain is thought to be the result of the increase in the patient’s pain reaction caused by tissue bradykinin reduction and endorphin level increase resulting from steroidal actions [8]. The reduction of pain in our study after steroid use can be attributed to the above mentioned rationale. Although pain values were found to be significantly highest in the control group and significantly lowest in the dex group on the seventh post-operative day. In terms of analgesic consumption, the highest values were found in the control group and lowest values in the piezo group on second post-operative day, and these values were found to be statistically significant. Patients are usually concerned about swelling and pain in the first couple of postoperative days. Even in the absence of pain, patients may have consumed more painkillers because of pain-associated anxiety. The results concerning analgesic drug consumption, which was found to be significantly higher in the first days and was not parallel to the pain levels in the groups, can be explained by the exaggerated medication intake or the small sample size in our study. Majid and Mahmood [35] reported mouth opening distance differences in the dex group compared to the control group, but they did not report significant differences between these two groups as a result of their study. In contrast, in the present study, post-operative mouth opening presented significant differences in the control and dex groups on both the second and seventh postoperative days. While the highest differences in values were obtained from the control group, the lowest mouth opening distance difference values were found in the dex group. This result is consistent with the literature reports [16,32]. Ehsan et al. [36] reported a significant reduction in trismus on the second postoperative day after submucosal injections of dex (4 mg) in comparison with the control group; this finding is consistent with our study results. This result can be attributed to the role of steroids in inflammation inhibition/suppression and prevention of fibrosis formation since fibrosis plays an important role in early stages of the surgery [37]. Chang et al. [38] reported no significant differences in the mouth opening score between the control and piezo groups in their study. However, patients in the piezo group had numerically lower
5
mouth opening restriction values than patients in the control group on the second post-operative day, but this difference was not statistically significant between the control and piezo groups. This result is in agreement with our study results. Consistent with our study results, Al-Moraissi et al. [11] and Arakji et al. [34] reported significant mouth opening distance differences between the piezo and control groups. The lowest change in mouth opening was found in the dex group on both the second and seventh postoperative days, and the difference between the control and dex groups were found to be statistically significant on both the second and seventh post-operative days. Even if the change in the piezo group was found not to be significant in our study results, it demonstrated that the piezo device is a better choice in terms of mouth opening by the second and seventh post-operative days compared to the conventional method. In conclusion, perioperative submucosal injection of dexamethasone was effective in reducing swelling, pain, mouth opening restriction. Although significant results could not be detected in the piezo group, it was seen that the device has positive effects on pain, swelling, trismus, and number of used analgesics compared to the control group. However, there is a need to increase the range of specimens for a clearer distinction among groups; therefore, extensive new clinical studies are required. Disclosure of interest The authors have not supplied their declaration of competing interest.
Acknowledgements I would like to thank to my dear colleagues Dr. Sevda Kurt and Dr. Damla Torul owing to their valuable contributions in this study. References [1] Saravanan K, Kannan R, John RR, Nath Kumar C. A single pre operative dose of submucosal dexamethasone is effective in improving post-operative quality of life in the surgical management of impacted third molars: a comparative randomised prospective study. J Maxillofac Oral Surg 2016;15:67–71. [2] Schmelzeisen R, Frolich JC. Prevention of post-operative swelling and pain by dexamethasone after operative removal of impacted third molar teeth. Eur J Clin Pharmacol 1993;44:275–7. [3] Moraschini V, Hidalgo R, Porto Barbazo E. Effect of submucosal injection of dexamethasone after third molar surgery: a meta-analysis of randomized controlled trials. Int J Oral Maxillofac Surg 2016;45:232–40. [4] Nandini GD. Eventuality of dexamethasone injected intra-massetrically on post-operative sequel following the surgical extraction of impacted mandibular third molars: a prospective study. J Maxillofac Oral Surg 2016;15:456–60. [5] Bortoluzzi MC, Capella DL, Barbieri T, Pagliarini M, Cavalieri T, Manfro R. A single dose of amoxicillin and dexamethasone for prevention of post-operative complications in third molar surgery: a randomized, double-blind, placebo controlled clinical trial. J Clin Med Res 2013;5:26–33. [6] Boonsiriseth K, Klongnoi B, Sirintawat N, Saengsirinavin C, Wongsirichat N. Comparative study of the effect of dexamethasone injection and consumption in lower third molar surgery. Int J Oral Maxillofac Surg 2012;41:244–7. [7] Deo SP. Single-dose of submucosal injection of dexamethasone affects the post-operative quality of life after third molar surgery. J Maxillofac Oral Surg 2016;15:367–75. [8] Graziani F, D’Aiuto F, Arduino PG, Tonelli M, Gabriela M. Perioperative dexamethasone reduces post-surgical sequelae of wisdom tooth removal. A splitmouth randomized double-masked clinical trial. Int J Oral Maxillofac Surg 2006;35:241–6. [9] Basheer SA, Govind RJ, Daniel A, Sam G, Adarsh VJ, Rao A. comparative study of piezoelectric and rotary osteotomy technique for third molar impaction. J Contemp Dent Pract 2017;18:60–4. [10] Horton JE, Tarpley TM, Jacoway JR. Clinical applications of ultrasonic instrumentation in the surgical removal of bone. Oral Surg Oral Med Oral Pathol 1981;51:236–42. [11] Al-Moraissi EA, Elmansi YA, Al-Sharaee YA, Alrmali AE, Alkhutari AS. Does the piezoelectric surgical technique produce fewer post-operative sequelae after lower third molar surgery than conventional rotary instruments? A systematic review and meta analysis. Int J Oral Maxillofac Surg 2016;45:383–91. [12] Antunes AA, Avelar Rl, Martins Neto EC, Frota R, Dias E. Effect of two routes of administration of dexamethasone on pain, edema, and trismus in impacted lower third molar surgery. Oral Maxillofac Surg 2011;15:217–23.
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012
G Model
JORMAS-586; No. of Pages 6 6
Z. Gu¨mru¨kc¸u¨ / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
[13] Lima CAA, Favarini VT, Torres AM, da Silva RA, Sato FRL. Oral dexamethasone decreases post-operative pain, swelling, and trismus more than diclofenac following third molar removal: a randomized controlled clinical trial. Oral Maxillofac Surg 2017;21:321–6. [14] Rullo R, Addabbo F, Papaccio G, D’Aquino R, Festa VM. Piezoelectric device vs. conventional rotative instruments in impacted third molar surgery: relationships between surgical difficulty and post-operative pain with histological evaluations. J Craniomaxillofac Surg 2013;41:33–8. [15] Kirmeier R, Truschnegg A, Payer M, Acham S, Schulz K, Jakse N. Evaluation of a muscle relaxant on sequelae of third molar surgery: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:8–14. [16] Warraich R, Faisal M, Rana M, Shaheen A, Gellrich NC, Rana M. Evaluation of post-operative discomfort following third molar surgery using submucosal dexamethasone – a randomized observer blind prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:16–22. [17] Montgomery MT, Hogg JP, Roberts DL, Redding SW. The use of glucocorticosteroids to lessen the inflammatory sequelae following third molar surgery. J Oral Maxillofac Surg 1990;48:179–87. [18] Alexander RE, Throndson RR. A review of perioperative corticosteroid use in dentoalveolar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:406–15. [19] Kim K, Brar P, Jakubowski J, Kaltman S, Lopez E. The use of corticosteroids and nonsteroidal antiinflammatory medication for the management of pain and inflammation after third molar surgery: a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:630–40. [20] Chen Q, Chen J, Hu B, Feng G, Song J. Submucosal injection of dexamethasone reduces post-operative discomfort after third-molar extraction: a systematic review and meta-analysis. J Am Dent Assoc 2017;148:81–91. [21] Simone JL, Jorge WA, Horliana AC, Canaval TG, Tortamano IP. Comparative analysis of preemptive analgesic effect of dexamethasone and diclofenac following third molar surgery. Braz Oral Res 2013;27:266–71. [22] Deo SP. Effect of submucosal injection of dexamethasone on post-operative sequelae of third molar surgery. JNMA J Nepal Med Assoc 2011;51:72–8. [23] Alcantara CE, Falci SG, Oliveira-Ferreira F, Santos CR, Pinheiro ML. Pre-emptive effect of dexamethasone and methylprednisolone on pain, swelling, and trismus after third molar surgery: a split-mouth randomized triple-blind clinical trial. Int J Oral Maxillofac Surg 2014;43:93–8. [24] Santamaria J, Arteagoitia I. Radiologic variables of clinical significance in the extraction of impacted mandibular third molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:469–73. [25] Praveen G, Rajesh P, Neelakandan RS, Nandagopal CM. Comparison of morbidity following the removal of mandibular third molar by lingual split, surgical bur and simplified split bone technique. Indian J Dent Res 2007;18 [15-8.26].
[26] Kerawala CJ, Martin IC, Allan W, Williams ED. The effects of operator technique and bur design on temperature during osseous preparation for osteosynthesis self-tapping screws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:145–50. [27] Goyal M, Marya K, Jhamb A, Chawla S, Sonoo PR, Singh V, Aggarwal A. Comparative evaluation of surgical outcome after removal of impacted mandibular third molars using a Piezotome or a conventional handpiece: a prospective study. Br J Oral Maxillofac Surg 2012;50:556–61. [28] Leclercq P, Zenati C, Amr S, Dohan DM. Ultrasonic bone cut part 1: state-of-theart technologies and common applications. J Oral Maxillofac Surg 2008;66:177–82. [29] Robiony M, Polini F, Costa F, Vercellotti T, Politi M. Piezoelectric bone cutting in multipiece maxillary osteotomies. J Oral Maxillofac Surg 2004;62:759–61. [30] Bilginaylar K, Uyanik LO. Evaluation of the effects of platelet-rich fibrin and piezosurgery on outcomes after removal of impacted mandibular third molars. Br J Oral Maxillofac Surg 2016;54:629–33. [31] Klongnoi B, Kaewpradub P, Boonsiriseth K, Wongsirichat N. Effect of single dose pre-operative intramuscular dexamethasone injection on lower impacted third molar surgery. Int J Oral Maxillofac Surg 2012;41:376–9. [32] Mojsa IM, Pokrowiecki R, Lipczynski K, Czerwonka D, Szczeklik K, Zaleska M. Effect of submucosal dexamethasone injection on post-operative pain, oedema, and trismus following mandibular third molar surgery: a prospective, randomized, double-blind clinical trial. Int J Oral Maxillofac Surg 2017;46:524–30. [33] Jiang Q, Qiu Y, Yang C, Yang J, Chen M, Zhang Z. Piezoelectric versus conventional rotary techniques for impacted third molar extraction: a meta-analysis of randomized controlled trials. Medicine (Baltimore) 2015;94:1685. [34] Arakji H, Shokry M, Aboelsaad N. Comparison of Piezosurgery and conventional rotary instruments for removal of impacted mandibular third molars: a randomized controlled clinical and radiographic trial. Int J Dent 2016;2016:8169356. [35] Majid OW, Mahmood WK. Mahmood, effect of submucosal and intramuscular dexamethasone on post-operative sequelae after third molar surgery: comparative study. Br J Oral Maxillofac Surg 2011;49:647–52. [36] Ehsan A, Ali Bukhari SG A, Manzoor A, Junaid M. Effects of pre-operative submucosal dexamethasone injection on the post-operative swelling and trismus following surgical extraction of mandibular third molar. J Coll Physicians Surg Pak 2014;24:489–92. [37] Kakar PK, Puri RK, Venkatachalam VP. Oral submucous fibrosis–treatment with hyalase. J Laryngol Otol 1985;99:57–9. [38] Chang HH, Lee MS, Hsu YC, Tsai SJ, Lin CP. Comparison of clinical parameters and environmental noise levels between regular surgery and piezosurgery for extraction of impacted third molars. J Formos Med Assoc 2015;114:929–35.
Please cite this article in press as: Gu¨mru¨kc¸u¨ Z. The effects of piezosurgery and submucosal dexamethasone injection on post-operative complications after third molar surgery. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.10.012