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PREVENTING POCKET FORMATION AFTER IMPACTED THIRD MOLAR SURGERY Assessing the "Buccal Window" technique in removal of Bone-impacted mandibular third molars
Mohammad Hosein Kalantar Motamedi Behnam Bohluli Farshid Kavandi
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Table of Contents $EVWUDFW««««««««.««««««««««.««.«««««« CHAPTER 1. Introduction .................................................................................................. 5 Research hypothesis .................................................................................. 5 Implications of the study ........................................................................... 7 Background................................................................................................ 7 Aim .......................................................................................................... 10 CHAPTER 2 Method and Materials................................................................................ 11 Sampling.................................................................................................. 11 Variables, Types and Measurement ....................................................... 12 Surgical technique .................................................................................. 13 CHAPTER 3. Results.......................................................................................................... 17 CHAPTER 4. Discussion .................................................................................................... 19 CHAPTER 5. Conclusion ................................................................................................... 40 References ................................................................................................... 42
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PREVENTING POCKET FORMATION AFTER IMPACTED THIRD MOLAR SURGERY Assessing the "Buccal Window" technique in removal of Bone-impacted mandibular third molars Mohammad Hosein Kalantar Motamedi, DDS 1 Behnam Bohluli, DMD 2 Farshid Kavandi, DDS 3
1- Professor of Oral and Maxillofacial Surgery, Trauma Research Center,
Baqiyatallah Medical Sciences
[email protected]
University,
Tehran,
Iran.
Email:
2- Associate Professor of Oral and Maxillofacial Surgery, Bouali Hospital,
Azad Medical Sciences
[email protected]
University,
Tehran,
Iran.
Email:
3-Resident Oral and Maxillofacial Surgeon, Bouali Hospital, Azad Medical Sciences University, Tehran ,Iran Email:
[email protected]
ϯ
Abstract Background & Aim: The development of a deep pocket distal to the mandibular second molar following conventional techniques to extract impacted wisdom teeth is a common finding in crown-to-URRW LPSDFWLRQV 7KH ³%XFFDO :LQGRZ´WHFKQLTXHKDVEHHQVWDWHGWRREYLDWHWKHSRVVLELOLW\RISRFNHW formation. The present study compares the buccal window technique with the conventional method with regard to this complication. Methods and Materials: In this study 20 patients with bone-impacted crown-to-root third molars extracted via the conventional technique were matched and compared with
the study group of
20 patients whose impactions were
operated using the buccal window procedure. The pocket depths were evaluated pre-op, and a week, a month and 6 months after operation. The data was analyzed using the T- test and final comparison via the ANOVA test. Results: The mean pocket depth after surgery in the control group was (7251.25) and in the case group was (2.50.66). Also, after one week, one month and six months, the case groups mean pocket depth was significantly less than the controls.
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Conclusion: The buccal window concept significantly reduced the depth of second molar distal pocket formation following mandibular third molar extraction.
Keywords: Periodontal pocket formation, Impacted third molar surgery , Buccal window
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CHAPTER 1. Introduction
Surgery for removal of impacted third molar surgeries may be associated
with
several
postoperative
complications;
these
complications are more common in the mandible than in the maxilla; they may include bleeding, dry socket, nerve injury, delayed healing, periodontal pocketing, and infection. Many are preventable1.
All third molars need not be removed independent of disease findings and patients need not unnecessarily have to accept adverse consequences associated with the surgery risks and discomforts in the absence of pain, radiographic findings of pathology, and or marked clinical evidence of disease. However, when surgery is indicated several new concepts and techniques can prevent and or manage some of the common postoperative sequels of impacted third molar surgery1,2.
Herein we evaluate pocket formation distal to the mandibular second molar following surgical extraction of impacted third molars.3
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Research hypothesis: The formation of a deep pocket in distal surface of the second molar is a common complication of surgical extraction of impacted third molar3. The prevalence is higher in the lower jaw4. When a part of the crown of an impacted tooth is exposed to the oral cavity, the patient is vulnerable to periodontal pocket formation as well as pericoronitis5. In complete bone impacted mandibular 3rd molars without pockets, the result of extraction of this tooth can lead to an extensive bone defect at the distal of second molar, with possible extension to base of the tooth socket when there is no septal bone between the 2nd and 3rd molars5,7. When this occurs treatment of this periodontal pocket or regeneration of bone in the defect area may require a second surgery (second molar distal root amputation or grafts etc.)8. We sought to see if this complication is preventable in crown-to-root bone impacted mandibular 3rd molars.
Implications of the study: This study assesses the advantages of using the buccal window (BW) concept in preventing
deep pocket formation distal to the 2nd
mandibular molar following removal of fully bone-impacted 3rd molar.
Background: Motamedi2 coined the BW concept in 1999 as a method preventing deep pocket formation distal to the 2nd mandibular molar following removal of bone impacted crown-to-root 3rd molars. ϳ
Cetinkaya and others8 compared the effects of sutures on the periodontal health of
adjacent second molars after impacted
mandibular third molar extraction (there was no significant difference between two techniques in pocket formation).
Samartino and colleagues9 showed that PRP is effective in inducing and accelerating bone regeneration for the treatment of periodontal defects distal to the mandibular second molar after surgical extraction of a mesioangular, deeply impacted mandibular third molar.
Kuang-Yao Peng10 et al evaluated the long-term effects of third molar extraction on the periodontal health of the mandibular second molar. They compared periodontal status of 2 groups of mandibular second molars, with and without third molar extraction. Their experimental study examined 312 sites in 57 adult periodontitis patients. Periodontal parameters including pocket depth, attachment loss, gingival recession and radiographic intrabony level were measured. Significant effects of surgery on probing depth, attachment loss and bone loss were observed distal to the 2nd molar. Despite the notable number of cases an appropriate solution was not stated. Blondeau and Daniel3 evaluated extraction of impacted mandibular third molar complications and their risk factors in a prospective study. The purpose of the study was to evaluate the incidence of various complications.Data were collected for a total of 500 patients who ϴ
underwent extraction of an impacted third molar over a 12-month period. A variety of data including age, sex, medical status at the time of the procedure and type of procedure were collected. Patients were contacted at 2 days and 4 weeks after surgery and were followed for at least 24 months. They stated the risk of complications was higher in females, in Pell and Gregory IC or IIC classification of impactions, and age greater than 24 years.
In 2008 Diago11 used vestibular bone window for 4 mandibular impacted third molar extractions. They described a technical approach which reduces
possible periodontal defects distal to the second
mandibular molar. To facilitate the extraction, a small osteoctomy in the form of a window was made in the vestibular cortical bone, approaching the extraction through the bone. Using this technique, they prevented soft tissue collapse and helpsed avoid periodontal pockets on the second molar distally. Also, this technique minimized postoperative pain, swelling and trismus.
Chang and others12 compared the periodontal healing distal to the mandibular second molar after the removal of impacted mandibular third molars using distolingual alveolectomy and tooth division techniques. A total of 120 patients with bilaterally impacted mandibular third molars were included in the study. The third molar on one side was removed by distolingual alveolectomy, whereas the contralateral tooth was removed by the tooth division technique using burs. Attachment levels, periodontal pocket depth distal to the ϵ
mandibular second molars were assessed at 7 days, 3 months and 6 months after surgery. The results showed better periodontal healing and bone healing when distolingual alveolectomy was employed. However, this seems dangerous because of
the
proximity of the
lingual nerve.
Aim of current study: Assessment
of pocket formation distal to the mandibular second
molar following extraction of third molars via BW technique compared with conventional method.
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CHAPTER 2. Method and Materials In this study, 40 patients required mandibular third molar extraction based on impacted tooth, Pell & Gregory category ; primary pocket depths were randomly divided into two matched case and control groups, and then both underwent surgical extraction. All patients were assessed for pocket depth measured immediately, one week, one month and six months after Surgery, regardless which technique was used. Pocket depth changes in both groups were statistical analyzed by ANOVA and T-test. Inclusion criteria were good general health, no history
of smoking or disease, and no anti-microbial or anti-fungal
medications and crown-to-root impacted mandibular 3rd molars warranting removal. Patient consent forms were taken in order to participate in the study.
Sampling (Population, Size and Method): A- Population: Patients referring to the maxillofacial department of our university requiring bone-impacted mandibular third molar extraction. B- Size: A total 40 patients divided in two equal groups. The case group underwent the BW third molar extraction and controls were operated with the comventional technique. C- Method: Consecutive target-oriented sampling among patients within the inclusion criteria.
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Variables, Types and Measurement A- Study variables: 1. Tooth distal pocket 2. Pain and swelling 3. Dehiscence
B- Variable role: - Dependent variable: Surgical extraction technique (Conventional or B.W.) - Independent variable: Second molars distal pocket depth.
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Table of Variables Name
Role
Type
Definition
Scale
Surgical
Dependant
Qualitative -
The
Conventional or
Nominal
extraction
technique
tooth
B.W
technique Quantitative
The
In
molars
-
distance
using
distal
Continuous
between
periodontal
pocket
the gingival
probe
depth
margin and
Second
Independent
Millimeter
the base of the pocket Impacted
The
Clinical
tooth
Independent
Qualitative
position of
Radiographic
position
tooth
investigation
in
and
relation to
(Pell & Gregory
alveolar
classification)
crest
and
ramus Oral
Dependant
Qualitative
hygiene
Tooth,
Patient
History
gingival
and
clinical
and lingual
examination
condition
Surgical Technique After-full thickness mucoperiosteal flap reflection and bone exposure, bone removal is started in the lateral cortex 2 to 3 mm below the bony crest using an electric surgical handpiece and a round surgical bur. An RYDO³ZLQGRZ´RIEXFFDOERQHLVUHPRYHGRYer the lateral aspect of the ϭϯ
crown of the impacted wisdom tooth. The anterior part of the buccal window should be no closer than 1 to 2 mm from the distal root of the second molar (to prevent iatrogenic root damage). After the crown and cervical part of the impacted tooth and the upper third of its roots have been exposed, the tooth is sectioned vertically at the cementoenamel junction using a rose or fissure bur; the gap created in this way should be sufficient to accommodate movement of the sectioned crown. However, to prevent damage to the lingual or the alveolar nerve, the tooth is not sectioned completely. A straight elevator is placed in the groove to separate the crown from its roots. The crown is then sectioned horizontally and delivered buccally through the window (in pieces) using a hemostat. Next, the roots are sectioned at the bifurcation and removed (Fig. 1). After removal of the dental follicle, the flap is sutured in place. This technique ensures that no postoperative pocket is formed.
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Fig. 1. A. Crown-to-root impaction. $Q RYDO ³ZLQGRZ´ RI EXFFDO bone is removed over the lateral aspect of the crown of the impacted wisdom tooth . The anterior part of the buccal window should be no closer than 1 to 2 mm from the distal root of the second molar (to prevent iatrogenic root damage). B. A buccal window has been created lateral to the crown of the impaction.
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C. After the crown and cervical part of the impacted tooth and the upper third of its roots have been exposed, the tooth is sectioned vertically at the cementoenamel junction using a rose or fissure bur; the gap created in this way should be sufficient to accommodate movement of the sectioned crown. D. The tooth has been removed laterally through the window and the crestal bone is thus preserved.
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CHAPTER 3.
Results Both groups were similar with regard to the impacted tooth, lack of systemic disease, lack of medication usage, genral health and oral hygiene.
Table 2. shows pocket depths in each follow up appointment. It shows pockets depth were similar before the operation (p
