(1) Odontóloga. Alumna del Máster de Cirugía e Implantología Bucal. Facultad de Odontología de la Universidad de Barcelona
(2) Odontóloga. Profesora Asociada de Cirugía Bucal. Profesora del Máster de Cirugía e Implantología Bucal. 
Facultad de Odontología de la Universidad de Barcelona
(3) Profesor Titular de Patología Quirúrgica Bucal y Maxilofacial. Profesor del Máster de Cirugía e Implantología Bucal. 
Facultad de Odontología de la Universidad de Barcelona
(4) Catedrático de Patología Quirúrgica Bucal y Maxilofacial. Director del Máster de Cirugía e Implantología Bucal. 
Facultad de Odontología de la Universidad de Barcelona. Cirujano Maxilofacial del Centro Médico Teknon. Barcelona. España

Adress:
Dr. Cosme Gay Escoda.
Centro Médico Teknon.
C/ Vilana 12.
08022 Barcelona (España).
http//www.gayescoda.com
E-mail: cgay@bell.ub.es

Receveid: 22-06-2003 Accepted: 1-02-2004

Day case or ambulatory surgery is understood to comprise those therapeutic and/or diagnostic procedures of medium complexity which allow the patient to return home on the same day of surgery, after a period of observation and monitorization (1).

Although day case interventions in children date back to the year 1909, it was only with the introduction of certain technical innovations (particularly improvements in anesthesiology and pain control, changes in clinical practice, etc.) that ambulatory surgery of some complexity became possible in such patients. On the other hand, the need to control costs and increase efficacy in this sector, together with the long waiting lists for certain types of interventions have increased interest in day surgery (1).

The basic premise for ambulatory surgery is the existence of certain operations which can be completed without the need for patient hospitalization while maintaining adequate health care quality with a lesser economical cost per pathological process (1).

According to Espinàs et al. (1), the potential advantages of day surgery are:

a) Patient benefits: reduced waiting time; shortened hospital stay, which implies a lesser risk of nosocomial infections; less interference with daily life activities; and the possibility of choosing from among various treatment alternatives.
Pineault et al. (2) showed the satisfaction of patients programmed for day case interventions to be less than in patients subjected to the same operation but with admission to hospital. Despite this observation, however, it seems clear that the lesser the social identification between pathology, surgery and hospitalization, the greater the acceptance to be expected of day surgery (3).

b) Lesser economical costs: Day case surgery is more cost-effective than surgery with patient hospitalization. Savings in services are obtained, though the actual surgical costs are very similar in both modalities.

c) Improved quality patient care: Day case surgery should be carried out with the same or even greater health care quality than surgery involving patient hospitalization (1).
On the other hand, patients subjected to ambulatory surgery should have a very low risk of serious complications, since they are selected according to their general condition (i.e., with the absence of serious systemic diseases)(1). The studies conducted to date seem to indicate that day surgery offers significantly better results than surgery with hospitalization, with fewer and less serious postoperative complications and a lower readmission rate (4).

d) Shortened waiting lists: The existence of waiting lists is a complex phenomenon which cannot always be solved by increasing the available health care resources. If the reason is a shortage of hospital beds, ambulatory surgery will be an effective solution (1).

To summarize, a series of factors contribute to the growing popularity of day surgery (5): (a) surgery with patient admission to hospital is expensive; (b) recent technological advances have made it possible to perform many operations on an ambulatory basis; (c) the new drugs used in anesthesia allow sedation or general anesthesia with rapid recovery and no side effects; and (d) day surgery interferes less with patient daily life activities.

Different medical and dental specialties can benefit from this ambulatory approach to treatment (1,6). Accordingly, in oral surgery, the accepted day case interventions comprise tooth extractions (erupted or impacted), the removal of root fragments, tooth fenestration for orthodontic treatment, small maxillary cyst enucleations, hard and soft tissue biopsies, frenectomy, extraction of osteosynthesis plaques and wires from the jaws, minor soft tissue surgery, peripheral nerve cryoanesthesia, and laser and cryosurgery (4,5).

The aim of the present study is to show that most pediatric oral surgical interventions can be performed on a day case surgery or ambulatory basis by odontologists or stomatologists with adequate training in oral surgery, and to describe the activity of the Master of Oral Surgery and Implantology (Barcelona University Dental School, Spain) in this population group during the year 2000.

PATIENTS AND METHODS

The present study comprises part of the activity of the Master of Oral Surgery and Implantology (Barcelona University Dental School, Spain), with six treatment units (oral surgery, laser surgery, orofacial implantology, periodontal pathology and surgery, temporomandibular joint pathology and orofacial pain, and ambulatory major oral surgery), corresponding to the period between January 1 and December 31, 2000. The surgical activity in pediatric patients corresponding to two of these units is described for the mentioned period: oral surgery and laser surgery.

A series of protocols for pediatric patients were developed, adapted to the type of surgery involved: extraction of non-impacted teeth, upper and lower molar germinal resection, other impacted teeth, supernumerary teeth, impacted canines, oral frenulum or soft tissue lesions. In each case the most relevant data were recorded, including: indication of the operation, the surgical technique used, Nolla stage and the degree of impaction in the case of lower third molars according to the classifications of Pell and Gregory and Winter, postoperative complications, etc. (6-8).

Most patients were referred from primary care centers in the southern area of metropolitan Barcelona, and the same systematic approach was adopted in all cases:

a) A first visit with anamnesis, oral, regional and general exploration, and conduction of the required complementary tests (orthopantomography being mandatory). Posteriorly, the patient and relatives were informed of the diagnosis, treatment plan and possible complications of the specified surgical technique.

b) In the event surgical treatment was required, the patient and relatives were informed of the type of surgery indicated, with the provision of a series of preoperative instructions. Informed consent to day surgery was also obtained from the relatives or tutor. The patient was then programmed for the operation under local anesthesia (truncal anesthesia of the inferior alveolar nerve, supraperiosteal paraapical infiltration anesthesia, etc.), with prior preparation of a sterile surgical field.

c) After the operation, the patient and relatives received postoperative drug prescriptions and instructions, with an appointment for suture removal and follow-up after 7 days. If the postoperative control visit proved satisfactory, the patient was discharged. In the case of complications, the patient was visited again to assess the clinical course.

In the course of the year 2000, a total of 3187 oral surgical interventions were carried out in the units of oral surgery and laser surgery, of which 487 corresponded to patients under 18 years of age (Table 1). The most common interventions were tooth extractions (89.2%) – particularly lower third molar germinal resections (55.6%).

The most common postoperative complications were associated with third molar extraction surgery (Table 2) – the lower molars presenting a larger number of complications versus the upper molars at the first postoperative control after 7 days (13.3% for the lower molars versus 2.6% for the upper).

Following the application of local warmth, physiotherapy and/or the administration of antibiotics and/or analgesia-antiinflammatory medication as required, these complication disappeared within 15 days. In one case lingual nerve paresthesia was documented, with recovery in one month, while in another case of inferior alveolar nerve paresthesia the problem was resolved within two months.

In the case of the lower molars, impaction grade C (Pell and Gregory classification) led to more complications after surgery (11.1%) than grades A or B (1.5% and 6.6%, respectively). Likewise, as regards available space, grade II (Winter classification) presented the highest percentage of complications (10.7% versus 5.5% in position III and 3% in position I). In relation to the Nolla stage of the extracted molar, most complications were associated with stage 7 (i.e., completion of one-third of the root)(5.5%).

Of the conventional extractions carried out, most corresponded to permanent first molars which were removed due to caries (36%), or premolars removed for orthodontic reasons (32%).

Impacted canines were the indication for surgery in 4.7% of cases in children between 13-18 years of age. In 95% of cases canine impaction was palatal, while in the same proportion of cases the chosen treatment option was fenestration – extraction being indicated in only one case (4.4%).

Frenectomies in turn accounted for 4.1% of the interventions. The oral frenula treated corresponded to the tongue (age range 5-15 years) and upper lip (age range 8-18 years). There were no lower lip frenula. For the upper lip frenula, surgery was warranted by the presence of an interincisal diastema. The operation was carried out both with a cold scalpel and with the CO₂ laser (42.8% in both cases), while the Er:YAG laser was used in a single case (14.3%). In the case of tongue frenulum removal, surgery was indicated by the presence of ankyloglossia – using the CO₂ laser in 65.5% of the patients, and a cold scalpel in the rest.

As to the other impacted teeth (i.e., other than third molars and canines), the distribution comprised premolars in 66.6% of cases, and both molars and incisors in 16.7%. Extraction of the impacted tooth was the management of choice in 50% of cases, followed by fenestration (41.7%) and non-intervention / control of the impacted tooth (8.3%). These patients were operated upon between 10 and 18 years of age, depending on the impacted tooth and on the causes and possible consequences of impaction.

Supernumerary tooth extraction accounted for 2.5% of the operations in patients between 7-17 years of age. In 50% of cases these were supernumerary representatives of the molar teeth, while 41.7% were supernumerary incisors and 8.3% supernumerary representative of the premolars.

Of the three cases (0.6%) in which soft tissue resection was required, a CO₂ laser was used in two patients and a cold scalpel in one (33.3%). The tentative diagnosis in all three cases was mucocele, while the definitive diagnosis (following histopathological study) corresponded to two minor salivary gland mucoceles (in patients aged 15 and 17 years) and one dermoid cyst (in a 6-year-old child).

Finally, two lower molar relocations were carried out (0.4%), with no postoperative problems in either case.

DISCUSSION

The most frequent oral surgical procedure in the day care setting is third molar extraction (4,9-11). In a review of the literature on impacted teeth conducted by Ruiz-Mirete and Gay-Escoda (9), lower third molars were seen to be the most commonly impacted teeth. On the other hand, according to Pons et al. (11), prophylactic extraction of the third molars would be indicated for preventing future complications of a cystic or infectious nature which often accompany impacted teeth or eruption alterations. In our case, most of our clinical activity in patients under 18 years of age involves the extraction of impacted teeth. Accordingly, in the year 2000 a total of 390 germinal resections were performed, in coincidence with the results published in 1998 regarding the total surgical interventions carried out in our Service (5).

The surgical extraction of impacted teeth is the most common intervention for a number of reasons:

a) Reduction in the caries index implies fewer extractions of non-impacted teeth. This could partly account for the increased extraction of impacted teeth – including third molars (9,10); 

b) The increased demand for orthodontic treatment has in turn increased the number of interventions in application to impacted canines (extraction or fenestration) or the extraction of other permanent teeth such as the premolars (9,10).

c) The number of orthopantomographs made has increased over the past 25 years. This complementary exploratory technique allows the early detection of unerupted teeth (9,10), as well as control of eruption turnover or dental and/or maxillary pathology requiring surgery. In this context, we consider it essential to perform orthopantomography as a basic complementary measure for diagnosis and the planning of patient treatment.

The percentage of complications recorded after lower third molar extraction was 13.3%. This figure doubles that reported by Pons et al. (11)(6.4%) after 156 lower third molar germinal resections in 78 patients during 1996 and 1997. However, they are similar to the data published by Peñarrocha et al. (12) in the year 2000 (13.1%), and slightly inferior to the percentage reported by Satorres et al. (4) in 1998 (18.4%) – though it should be taken into account that these surveys do not distribute the study subjects into different age groups.

The complications identified at follow-up 7 days after surgery were practically all associated with lower third molar extractions. Such complications were predominantly observed in grade C impactions (13). Taking into account the available space, the position presenting the greatest number of complications corresponded to type II – though this result may be due to the fact that this is the position comprising a larger number of operated patients. In both cases a larger ostectomy is required to allow extraction of the impacted tooth. According to some studies, ostectomy and surgical timing prolong the duration of the intervention and increase the risk of postoperative complications (15,16). In the study by Peñarrocha et al. (12), swelling was the most common complication (8.9%) after the surgical removal of 190 mandibular third molars. In our series swelling was observed in 3.8% of cases and was likewise the most common complication, followed by pain (3.3%).

Sensory alterations of the inferior alveolar nerve after lower third molar extractions are less frequent than alterations of the lingual nerve (12).

One of the advantages of germinal resection is that the risk of inferior alveolar paresthesia is less, since the roots of the third molar are not fully formed and its relation to the nerve is either inexistent or much less evident than in the adult (11).

The percentage of nerve lesions varies among authors, though in the case of the inferior alveolar nerve the figure is around 5% (12,14,15). Accordingly, Peñarrocha et al. (12) reported an incidence of 1.1%, while Valmaseda et al. (15) observed 1.3%. In the study published by Carmichael and McGowan (16) involving 1339 surgically treated molars, inferior alveolar nerve damage was identified in 0.9% of cases one year after extraction.

Lingual nerve lesions are relatively common following lower third molar extraction, though the reported percentages again differ according to the authors and surgical technique employed. According to Valmaseda et al. (17), most series refer prevalences of 0-10%, while Peñarrocha et al. (12) reported figures of 0.06-1.5% (15). The percentages corresponding to lingual nerve paresthesia in this latter study varied from 0.5-2%, while Valmaseda et al. reported 2% (17).

In our series, nerve lesions were observed in 0.5% of cases (one inferior alveolar nerve lesion and one case of lingual nerve damage).

Most inferior alveolar and lingual nerve lesions associated with mandibular third molar extraction are completely reversible. In some cases conduction block is involved, which disappears within a few days or weeks. In the case of more serious lesions, regeneration may require weeks or months, though recovery can be complete. The minimum time for axonal recovery is 4-6 weeks (12). However, in the case of nerve fiber rupture and/or the presence of some obstacle preventing nerve regeneration (such as the formation of a neuroma or separation of the proximal and distal ends), complete spontaneous regeneration may not be possible (16-18).

Peñarrocha et al. (12) indicate that most cases are resolved within the first 6 months, with only few cases persisting for longer periods of time. On the other hand, if axonal regeneration does not occur within two years, the regenerating potential is lost and the damage becomes permanent (12).

The time to recovery in our series was one and two months for the case of lingual nerve and inferior alveolar nerve paresthesia, respectively.

As regards the rest of interventions, repeat surgery was only required in one case involving impacted 4.5 fenestration, due to closure of the mucosal window. We consider this case to be a complication, though not attributable to surgery as such but rather to the fact that the bracket was not positioned at the correct time – thereby precluding the start of orthodontic traction at the appropriate moment.

Ambulatory surgery has experienced an enormous growth in recent years (3-8). According to Junquera et al. (3), and regardless of political and economical criteria, the two main reasons for this are important patient satisfaction with such procedures, and a percentage of postoperative complications similar to that seen in surgery with admission to hospital.

On the other hand, Greenwood (19) reported that in the United Kingdom the expansion of day surgery is attributable to the fact that the care received by these patients is not inferior to that offered to hospitalized patients – this being one of the essential conditions for performing oral surgery on an ambulatory basis, as we have already pointed out above.

According to a questionnaire-based study conducted in 1990 by the Audit Commission of the National Health Service in the United Kingdom, 80% of patients subjected to day care oral surgery are satisfied with this type of care – the mean reason cited being minimum interference with daily life, and a shortening of the waiting list (19).

In conclusion, day surgery is perfectly adaptable to most oral surgical interventions, since the latter are characteristically short operations that can be programmed and performed under locoregional anesthesia (5). Moreover, these techniques are normally applied to young individuals without associated systemic pathology (5) - including the pediatric population. Our own experience shows that day care surgery can be carried out safely and effectively in non-hospital centers, provided the required sterility conditions and resources are available, and the health care professionals are adequately trained in these techniques (5). The benefits afforded include reduced social and economical costs, since improved medical care is provided, with only minimum interference with patient occupational and daily life activities (5).

BIBLIOGRAFÍA        [ Links ]

2. Pineault R, Contandriopoulos AP, Valois M. Randomized clinical trial of one-day surgery. Med Care 1985;23:171-82.         [ Links ]

3. Junquera LM, López JS, de Vicente JC. Cirugía ambulatoria maxilofacial. Rev Esp Cirug Oral y Maxilof 1994;16:173-8,         [ Links ]

4. Satorres Niet M, Delgado Molina E, Berini Aytés L . Cirugía bucal ambulatoria. Presentación de la actividad clínica del Máster de Cirugía e Implantología Bucal de la Universidad de Barcelona durante el año 1998. Arch Odontoestomatol 2000;16:83-90.         [ Links ]

5. Rodríguez Armijo AM, Romero MJ, Gallardo PA. Cirugía bucal ambulatoria. Arch Odontoestomatol 1998;14:224-8.         [ Links ]

6. Renton T, McGurk M. Direct referral day case oral surgery for dental practitioners: a pilot investigation. Br Dent J 1999;186:334-7.         [ Links ]

7. Sleeman D, Barry H, Ryan C. Day case oral surgery: a review of 25 experience at the Dublin Dental Hospital. Br Dent J 1995;179:221-4.         [ Links ]

8. Bryant CJ, Clean SJ, Hopper C. Maxillofacial surgery and the role of the extended case. Br Dent J 1997;182:134-8.         [ Links ]

9. Gay Escoda C, Berini Aytés L, eds. Cirugía bucal. Madrid: Ergon; 1999.         [ Links ]

10. Ruiz Mirete P, Gay Escoda C. ¿Qué hacer con los dientes incluidos? Ortod Esp 1982;26:129-36.         [ Links ]

11. Pons Salvadó S, Berini Aytés L, Gay Escoda C. Terceros molares inferiores incluidos. Revisión de 156 casos de germenectomías bilaterales. Arch Odontoestomatol 2000;16:41-50.         [ Links ]

12. Peñarrocha Diago M, Sáez Cuesta U, Sanchís Bielsa JM et al. Estudio de las complicaciones postoperatorias tras la extracción quirúrgica de 190 terceros molares mandibulares incluidos. Av Odontoestomatol 2000;16:435-41.         [ Links ]

13. Lombardía E, González M, Junquera LM et al. Estudio del dolor postoperatorio habido tras la extracción de terceros molares inferiores. Rev Esp Cirug Oral y Maxilofacial 1989;11:98-101.         [ Links ]

14. Goldberg MH, Albraith DA. Late onset of mandibular and lingual dysesthesia secondary to postextraction infection. Oral Surg Oral Med Oral Pathol 1984;58:269-71.         [ Links ]

15. Valmaseda Castellón E, Berini Aytés L, Gay-Escoda C. Inferior alveolar nerve damage after lower third molar surgical extraction: A prospective study of 1117 surgical extractions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:377-83.         [ Links ]

16. Carmichael F, McGowan D. Incidence of nerve damage following third molar removal: a west of Scotland oral surgery research group study. Br J Oral Maxillofac Surg 1992;30:78-82.         [ Links ]

17. Valmaseda Castellón E. Alteraciones nerviosas tras la extracción quirúrgica de terceros molares inferiores. Estudio prospectivo.Tesis Doctoral. Universidad de Barcelona; 1998.         [ Links ]

18. Valmaseda Castellón E, Berini Aytés L, Gay Escoda C. Lingual nerve damage after third lower molar surgical extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:567-73.         [ Links ] 19. Greenwood M. Patients’ views of oral day surgery. Br Dent J 1993;175:130-2.        [ Links ]