ARTÍCULO ESPECIAL

 

Literature review of oral surgery articles published in 2005

Revisión bibliográfica de los artículos publicados de cirugía bucal en el año 2005

 

 

C. Larrazábal Morón¹, S. Galán Gil¹, M. Peñarrocha Diago³

¹ Máster de Cirugía e Implantología Oral.
² Profesor Titular de Cirugía Bucal. Director del Máster de Cirugía e Implantología Oral.
Facultad de Medicina y Odontología. Universidad de Valencia. España

Correspondence

 

 

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ABSTRACT

Introduction. Oral surgery articles published in 2005 were reviewed.
Material and method. Three reviewers searched journals indexed in Medline and classified the articles by topic. The search criteria were: articles of special interest, published in national and international impact journals, that updated any of the topics selected.
Results. The most interesting articles on oral surgery published in 2005 were: 11 articles on cysts, 35 on jaw and soft tissues tumors, 4 jaw infections, 11 periapical surgery, 15 third molar pathology, 5 dental impaction, 11 dental transplantation and reimplantation, 5 drugs, and 3 articles on other topics.
Conclusion. The authors offer other researchers a quick overview of the most important articles in oral surgery published in 2005.

Key words: Oral surgery; Literature review.

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RESUMEN

Introducción. El objetivo de este trabajo es revisar los artículos de cirugía oral publicados en el año 2005.
Material y método. Tres revisores han realizado una búsqueda en las revistas indexadas en Medline, clasificando los artículos de acuerdo a diferentes temas. Los criterios de búsqueda fueron: artículos de especial interés publicados en revistas de impacto nacional e internacional, que actualizaran cualquiera de los temas señalados.
Resultados. Los artículos más interesantes sobre cirugía bucal publicados en el año 2005 son: 11 artículos sobre quistes, 35 de tumores de los maxilares y tejidos blandos, 4 de infecciones de los maxilares, 11 de cirugía periapical, 15 de patología del tercer molar, 5 de inclusiones dentarias, 11 de transplantes y reimplantes dentarios, 5 de fármacos y 3 artículos de otros temas.
Conclusión. Aportar a otros investigadores una rápida identificación de los artículos más importantes de cirugía bucal publicados en el año 2005.

Palabras clave: Cirugía bucal; Revisión bibliográfica.

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Introduction

We present a review of the most interesting articles on oral surgery published in 2005. We searched journals indexed in Medline, dividing topics by sections (cysts, jaw and soft tissue tumors, jaw infections, periapical surgery, third molar pathology, dental impaction, dental transplantation and reimplantation, drugs, and other topics) to facilitate reading and the search for information. The articles are briefly discussed for other investigators.

 

Material and method

A search was made of articles published in 2005 in journals indexed in Medline. Articles were classified by topic. The search criteria were: articles of special interest, published in national and international impact journals, that updated one of the topics selected.

 

Results

Cysts

BMP-4 protein intervenes in the cellular differentiation and proliferation of odontogenic epithelial cysts. Seong et al.¹ compared BMP-4 protein expression in histologic analysis of 34 keratocysts and 43 dentigerous cysts. The presence of BMP-4 protein was more intense in odontogenic keratocysts than in dentigerous cysts.

Basal cell nevus syndrome, also known as Gorlin-Goltz syndrome, is an autosomal dominant hereditary disorder characterized by the presence of multiple maxillary keratocysts and facial basal cell carcinomas. Díaz et al.² reviewed the literature and presented six cases of patients with basal cell nevus syndrome in which maxillary cysts were resected under general anesthesia.

Dentigerous cysts usually are associated with third-molar crowns. Smith et al.³ made a retrospective study from 1975 to 2004 of 327 radiographs of patients with head and neck infections to evaluate the presence of dentigerous cysts associated with infections. They found 7 cases (2.1%). The most frequent location was the mandibular ramus, surrounding an impacted third molar. The mean age of patients was 46 years. All of the patients were treated by cyst enucleation and only one patient had a recurrence.

Edamatsu et al.⁴ studied cellular apoptosis in dental follicles and dentigerous cyst associated with impacted third molars. They examined Fas, bcl-2, and ssDNA and compared the results with Ki67 immunoreactivity, a marker of cellular proliferation. The sample was formed by 80 dental follicles (DF) and 27 dentigerous cysts (DC) associated with mandibular impacted third molars. The results indicated less bcl-2 protein in dental follicles that in dentigerous cysts. However, ssDNA was slightly more abundant in dental follicles and Ki67 protein was predominant in odontogenic cysts. Inflammatory dental follicles were slightly more positive for ssDNA and Ki67 than dental follicles of non-inflammatory origin.

Glandular odontogenic cysts are infrequent. The differential diagnosis must be made with other radiolucent lesions. Kaplan et al.⁵ reviewed 56 cases of glandular odontogenic cyst, 49 published in the literature and 7 of their own cases, in 34 men and 22 women with a mean age of 48 years. Seventy- three percent (73.2%) appeared in the maxilla and 26.8% in the jaw; in most cases in the anterior part. Radiographically, 53.6% were unilocular and 46.4% were multilocular. The cortex remained intact in 53.6%, 39.3% presented perforation, and 14.3%, cortical erosion. In 29.2%, there was recurrence, at a mean of 2.9 years, which was associated with minor surgery like enucleation or curettage. None of the patients treated with peripheral ostectomy, surgical margin resection, or partial jaw resection presented recurrence.

Qin et al.⁶ published 14 cases of glandular odontogenic cyst collected in the last 50 years. They based the diagnosis on histopathologic findings and orthopantomography and computed tomography imaging. Nine were located in the maxilla and 3 in the mandible, anterior zone, and molars. None involved the mandibular ramus or maxillary sinus. The radiologic study showed 11 unilocular and 3 multilocular lesions. All lesions were treated surgically.

Kaplan et al.⁷ studied the presence of molecular markers like p53, PCNA and Ki67 in 35 patients who presented 10 glandular odontogenic cysts, 15 radicular cysts, and 9 mucoepidermoid carcinomas. The presence of p53 protein was greater in glandular odontogenic and mucoepidermoid carcinoma than in the radicular cysts, in contrast with Ki-67 protein, which had a greater presence in glandular odontogenic cysts and radicular cysts than in mucoepidermoid carcinomas. No statistically significant differences were found with PCNA protein. The p53 and Ki67 markers helped in the differential diagnosis of glandular odontogenic cyst.

With respect to developmental non-odontogenic epithelial cysts, Tanimoto et al.⁸ reported the case of a 39-year old woman with swelling that raised the junction of the external nare with the upper lip. No abnormality was observed in orthopantomography. After performing magnetic resonance imaging with contrast and visualizing the lesion, it was excised surgically. Histologic study established the diagnosis of nasoalveolar cyst.

Takeda et al.⁹ studied the incidence of ciliated and mucosal cells of the epithelial lining of inflammatory (205 radicular cysts) and developmental cysts (130 dentigerous cysts and 26 primordial cysts). They found mucosal cells in 20.8% of the cysts examined and ciliated cells in 11.4% of the total. No significant differences were appreciated in the relative proportion of these cells in the different cysts. They concluded that the ciliated and mucosal cells of the epithelium of intraosseous odontogenic cysts are of metaplastic origin, but the ultimate cause and biological meaning remain unclear.

Baykul et al.¹⁰ investigated cystic changes associated with mandibular impacted third molar and angling with respect to the adjacent tooth. In 94 patients aged 14-45 years, half exhibited radiologic changes at age 20-25 years. The relation between cystic changes and the angular position was statistically significant (p<.05). Vertically positioned impacted third molars showed a more intense radiologic lesion.

In the differential diagnosis of cysts, we must consider the Stafne defect. Belmonte et al.¹¹ reported a 68-year-old man with a left paramandibular radiolucent lesion diagnosed as radicular cyst, of 5-6 years of evolution, in which cystectomy was performed due to a change in size. The lesion was of soft consistency and reddish-brown color, with a vascular or salivary gland component. The definitive diagnosis of Stafne defect was established after histologic analysis.

Tumors

Odontogenic tumors

With regard to epithelial tumors without ectomesenchyme, Fernandes et al.¹² studied the frequency of odontogenic tumors in a Brazilian population. Of 19,123 biopsies of oral pathologies reviewed from 1954 to 2004, 340 were odontogenic tumors (1.78%). The most frequent tumor was ameloblastoma (45.2%), followed by odontoma (24.9%), and myxoma (9.1%).

In a Nigerian population, mean age 29.9 years, Ladipo et al.¹³ found a frequency of odontogenic tumors of 9.6% in 319 patients. Of the total, 96.6% were intraosseous and 3.4% were peripheral (7 peripheral odontogenic fibromas, 3 peripheral myxomas, and 1 peripheral ameloblastoma). Ninety-seven percent (96.6%) were benign and 3.4% were malignant. The most frequent odontogenic tumor was ameloblastoma (63%), followed by adenomatoid odontogenic tumor (7.5%), myxoma (6.5%), calcifying odontogenic epithelial cyst (5.3%), odontogenic fibroma (5.3%), odontoma (2.5%), and ameloblastic carcinoma (2.2%). There were no significant differences in age between the patients who had benign and malignant tumors.

Simon et al.¹⁴ studied the epidemiology and clinical and pathologic characteristics of odontogenic tumors in a Tanzanian population. Of 116 patients with odontogenic tumors reviewed in 4 years, ameloblastoma was the most frequent (80.1%), followed by odontogenic myxoma (7%). Two patients had a recurrence of ameloblastoma.

Taiwo et al.¹⁵ made a retrospective clinical-pathological study of 990 tumors of the jaw and perioral lesions in a Nigerian population and found that 318 (32%) cases were odontogenic tumors. Ninety-nine percent of the tumors were benign and 1% were malignant. Of the benign tumors, 73% were ameloblastomas, 12% odontogenic myxomas, 3% ameloblastic fibromas, and 2% adenomatoid odontogenic tumor. They followed up only 60 cases of ameloblastoma, of which 8 recurred.

Artés et al.¹⁶ reported the cytological characteristics of two cases of malar recurrence of ameloblastoma of the mandibular ramus, which exhibited a granular background, isolated macrophages, giant multinucleate cells, and squamous cells of metaplasia. The cytology of these tumors revealed the components of the lesion, which was sufficient to reach the diagnosis of ameloblastoma, especially in cases of recurrence.

Torres et al.¹⁷ reported six patients with ameloblastoma of the jaw. The zone most affected was the mandibular body (4 cases), followed by the symphysis (1 case), and angle (1 case). The tumor showed a predilection of 2:1 for women with respect to men. The mean age of patients was 42.3 years. The therapeutic management consisted of resection of the lesion, perilesional milling of the bone, or block resection, depending on the type of ameloblastoma. None of the patients had a recurrence.

Muvova et al.¹⁸ followed up 92 cases of recurrent ameloblastoma of the jaw. The patients, 66 black Africans and 26 Caucasians, underwent conservative surgery and the authors evaluated them using biostatistical and bioclinical criteria. The success rate was more than 80% for the two races, which made conservative treatment a viable alternative for recurrences in ameloblastomas.

Arotiba et al.¹⁹ reviewed the clinical manifestations and treatment of 79 cases of ameloblastoma in Nigerian children and adolescents. They observed that it was more frequent in men than in women (1.3:1), with an incidence at 15 years in men and at 17 years in women. All the tumors were intraosseous and the majority were located in the symphyseal region of the jaw (57.3%). The most common morphology was multicystic ameloblastoma (82.3%) with a multilocular radiologic presentation (66.2%). The surgical technique used in most cases (72.2%) was resection.

Patel et al.²⁰ reported a case of dentigerous cyst-like unicystic ameloblastoma in a 14-year-old male patient with Gardner syndrome. Radiologically, the patient exhibited a radiolucent lesion surrounding an impacted second premolar that extended from the first permanent molar to the canine. The treatment of choice was surgical resection and curettage of the lesion.

On the other hand, Cunha et al.²⁰ reported the case of a 49-year-old man referred for inflammation in the left posterior zone of the mandible. The radiologic study disclosed a well-defined radiolucent lesion, 3 cm in diameter, that affected the mandible from the second premolar to the second molar. After enucleation, histologic examination disclosed the diagnosis of unicystic ameloblastoma. Ten years earlier, a lesion with the same characteristics, measuring 1.5 cm in diameter, had been detected in the root of 3.6. A cystic lesion was diagnosed and enucleation was recommended, but only the first molar was extracted.

Desmoplastic ameloblastoma is a histologic variant of ameloblastoma. Hirota et al.²² reported the case of a 17- year-old woman with ameloblastoma located in the right mental region. A zone of mixed radiolucency and radiopacity was evident on radiography. Partial maxillectomy was performed during tumor resection under general anesthesia. After 7 years of follow-up, clinical and radiographic examination did not disclose any recurrence.

Calcifying odontogenic tumor is a rare developmental odontogenic lesion. Few studies in the literature have described its immunohistochemical characteristics and proliferative activity Seim et al.²³ studied the case of a 53-year-old man with a unilocular radiolucent lesion in the right posterior jaw. Computed tomography showed an impacted third molar. The third molar was removed and tumor enucleation and curettage was performed. Histopathologic study revealed a hybrid tumor formed by an ameloblastoma and calcifying epithelial odontogenic tumor.

In a study of epithelial tumors with ectomesenchyme, with or without dental hard tissue, Chen et al.²⁴ compared the clinical and pathologic characteristics of 13 ameloblastic fibromas and 7 ameloblastic fibro-odontomas. In most of the patients with ameloblastic fibroma (69.2%), the tumor occurred at 22 years of age and was located in the posterior part of the mandible (76.9%). Ameloblastic fibromas recurred in 4 of 11 patients; 2 of them exhibited malignant transformation. In contrast, ameloblastic fibro-odontoma occurred at an earlier age (9 years) and 2 of the 5 patients followed up exhibited recurrence with limited growth and complex odontomas.

Handschel et al.²⁵ and Motamedia et al.²⁶ reported adenomatoid odontogenic tumors associated with an impacted canine. The tumor and tooth were excised in the Handschel case and the canine was repositioned in the dental arcade by orthodontics in the Motamedia case. There were no recurrences.

Barboza et al.²⁷ analyzed the presence of proliferating cell nuclear antigen and p53 protein in 16 cases of ameloblastoma and 8 cases of adenomatoid odontogenic tumor. The ameloblastoma cases were classified by histology as: 7 follicular, 4 plexiform, 3 follicular and acanthomatic, and 2 basal cell. The cases of follicular ameloblastoma showed more positive proliferating cell nuclear antigen expression, whereas p53 protein expression was stronger in plexiform type ameloblastomas. The results also indicated that ameloblastomas had more proliferative potential than adenomatoid odontogenic tumors.

Odontoma sometimes can disturb tooth eruption. Nelson et al.²⁷ reported the case of a 20-month-old boy who had suffered 5.1 avulsion after trauma, that also caused morphologic changes in the permanent successor tooth. One year after the injury, fan odontoma-like mass had formed. Six years after the accident, the odontoma was surgically resected and orthodontic alignment was performed on the incisor, resulting in acceptable tooth alignment in the dental arcade.

Tomizawa et al.²⁹ presented a series of 39 odontomas in 38 children, (23 boys and 15 girls), age 1.2 to 14 years. Eighty-seven percent of cases were associated to delayed eruption. The region most affected was the anterior jaw. Surgical exeresis was performed in every case and the histopathologic study showed 30 cases of compound odontoma, 7 complex odontomas, and 2 mixed odontomas. One recurrence was found at six years.

Gallana et al.³⁰ observed calcifying odontogenic cyst associated to odontoma in a 19-year-old patient with an impacted permanent upper canine. Radiographically, there was a well-defined radiolucent, unilocular lesion containing a radiopaque mass and impacted 13. Surgical resection was performed under local anesthesia.

Casap et al.³¹ described the use of a computer system for dental implant planning and treatment in a patient two years after a left mandibular odontogenic myxoma was excised. Three implants were made and rehabilitation with a fixed prosthesis was implemented. One year after implantation, the patient was asymptomatic.

Non-odontogenic tumors

Carranza et al.³² described the principles of the diagnosis and follow-up of oncologic head and neck pathology using positron emission tomography (PET) and developing other techniques like high resolution computed tomography (HRCT), and magnetic resonance tomography (MRT).

In a retrospective study by Aregbesola et al.³³ of orofacial tumors in 512 children, treated from 1991 to 2001 at the Nigeria University Hospital, 146 tumors (28% of patients) were found. Boys were affected more often than girls (1: 1.4) and most of the tumors occurred in the first decade of life. Of 146 tumors, 74 were malignant (51%) and 72 were benign (49%). Of the benign tumors, 31 were soft-tissue tumors and 41 were of the mandible (20 odontogenic and 21 non-odontogenic). The most frequent benign tumors of the soft tissues and jaw were gingival epulis and ameloblastoma, respectively. Of the malignant tumors, 67 were lymphomas, 5 sarcomas, and 2 carcinomas.

Alvares et al.³⁴ reported a case of osteoblastoma around an impacted permanent lower central incisor in an 8-yearold boy. The lesion was excised surgically and orthodontic therapy was given. They discussed the radiologic and microbiologic aspects, the differential diagnosis, and therapy, in addition to reviewing the literature.

Nakayama et al.³⁵ determined the relation between the computed tomography (CT) radiologic findings and the histologic characteristics of 10 mandibular osteosarcomas. The points analyzed in CT were patterns of osteogenesis and signs of bone destruction. Osteoblasts, chondroblasts, and fibroblasts were studied by histopathology. Eight cases were osteoblastic and 2 were chondroblastic. There was no statistically significant relation between the CT findings and the histopathologic characteristics of the osteosarcomas.

Chaparro et al.³⁶ observed five cases of peripheral giantcell granuloma in 3 men and 2 women aged 19 to 66 years, three of them in the upper jaw. Treatment consisted of exeresis-biopsy, in two cases by CO₂ laser and in three cases by cryocautery. They did not observe any recurrence in the postoperative follow-up (range 10 months to 4 years). Early and exact diagnosis of this lesion allowed conservative therapy without risk to neighboring teeth or adjacent bone.

Other tumors

Given the different therapeutic methods for lip cancer, Finestres et al.³⁷ assessed the results obtained in 28 patients (17 women and 11 men) with carcinoma of the lip (27 basalcell carcinomas and 1 squamous-cell carcinoma) treated using brachytherapy high-dose rate surface molds. In every case, complete remission was achieved with good therapeutic tolerance and no complications or recurrences.

García et al.³⁸ assessed the overexpression of c-erb-B2, p53, bcl-2, Ki67, and CD44varV6 proteins and established its prognostic value in squamous-cell carcinoma of the lip. They made an immunohistochemical study of the proteins in 79 squamous-cell carcinomas of the lip over a period of 20 years. Immunostaining was positive for c-erb-B2 protein in 75% of cases, for p53 in 70.6%, bcl-2 in 3.8%, and CD44varV6 in 89.9%. The protein expression of ki67 ranged from 0% to 6.29%. Only the patients who expressed CD44varV6 molecule showed a significant association with longer survival.

Saiz et al.³⁹ studied 81 oral squamous-cell carcinomas in search of possible prognostic factors; flow cytometry was performed in 67, but the remaining 14 were excluded due to the lack of sufficient histologic material. None of the cytometric variables studied (cellular proliferation, mitotic index) showed a relation with local or regional recurrence, distant metastasis, or survival. They concluded that these variables had no value as prognostic factors in squamous-cell carcinoma of the oral cavity.

The purpose of the study by Villarroel et al.⁴⁰ was to determine, using flow cytometry, the expression of major histocompatibility complex class II molecules and the co-stimulant molecules CD40, CD80, and CD86 in keratinocytes from healthy oral mucosa and from squamous-cell carcinomas. It was confirmed that keratinocytes expressed human major histocompatibility complex class II molecules after IFN stimulation in vitro. All the cell lines expressed CD40, but CD80 and CD86 were negative. The absence of CD80 and CD86 could explain why the oral carcinomas escaped immunologic monitoring and could grow, invade, and metastasize despite the immune system.

Ito et al.⁴¹ made a retrospective study of 496 tumors of the salivary glands from 1972 to 2001 in the Brazilian population. Women were involved more often (58.5%) than men (52.2%) and the majority occurred in the adult age (40-50 years). One hundred sixty-one of all cases were malignant and 335 were benign. Most of the cases occurred in the parotid gland (67.7%), followed by the minor salivary glands (22.8%) and submandibular glands (9.5%). Pleomorphic adenoma was the most frequent tumor (54.2%), followed by mucoepidermoid carcinoma (13.5%), Warthin’s tumor (8.5%), and adenoid cystic carcinoma (7.9%).

Toida et al.⁴² also made a retrospective study of 82 tumors of the intraoral minor salivary glands: 55 benign and 27 malignant. Men were affected more often than women (1:1.9). The tumors affected the palate (n=64), vestibular region (n=10), upper lip (n=6), mouth floor (n=1), and retromolar region (n=1). Histologically, the tumors were classified as pleomorphic adenoma (n=54), adenoid cystic carcinoma (n=10), mucoepidermoid carcinoma (n=8), acinarcell carcinoma (n=3), adenocarcinoma (n=2), basal-cell adenocarcinoma (n=1), pleomorphic adenocarcinoma (n=2), and cystoadenocarcinoma (n=1).

Prieto et al.⁴³ described the cytopathologic characteristics of acinar carcinoma in 4 patients who were diagnosed of tumors of the parotid and laterocervical territory by fineneedle puncture biopsy. Cytological smears revealed abundant tumoral cellularity, bare nuclei on the background of the smears, and absence of ductal fat and epithelium.

González et al.⁴⁴ and Sánchez et al.⁴⁵ reported two patients diagnosed of adenocarcinoma of abdominal and esophageal origin with metastasis in the maxillary bone. The intraoral lesions were asymptomatic and rapidly growing. In view of the poor prognosis of the lesions, they decided on symptomatic treatment, which allowed an acceptable quality of life.

González et al.⁴⁶ presented an unusual case of stage IV low-grade polymorphic adenocarcinoma located in the nasal cavity with pterygoid extension. The primary tumor was treated by resection through a Lefort I type osteotomy of the maxilla. In the neck, same-side supraomohyoid cervical lymph node dissection was performed. The patient later received coadjuvant treatment with postoperative irradiation. In two years of follow-up, there has been no recurrence.

Jaw infections

Jaw infections are one of the most varied and complex conditions among infectious pathologies. Suei et al.⁴⁷ proposed a classification of mandibular osteomyelitis that differentiated: bacterial osteomyelitis and osteomyelitis associated with synovitis, acne, pustules, hyperostosis, and osteitis syndrome. The diagnostic criterion for bacterial osteomyelitis was suppuration and osteolytic changes; lesions were treated with antibiotics.

Ebihara et al.⁴⁸ reported the case of a 30-year-old man who suffered Garré’s osteomyelitis after root canal of the right mandibular second molar without previous infection. It was diagnosed by computed tomography and three-dimensional imaging. The root canal was repeated and there were no recurrences in the 10 months after treatment.

Ramirez et al.⁴⁹ presented a patient with HIV/AIDS who had been treated for nodular tuberculosis 4 years earlier. The patient had a lingual ulcer and the histopathologic study revealed chronic granulomatous inflammation and multinucleated giant cells suggestive of mycobacterial infection. Due to the possible recurrence of tuberculosis, rifampicin, pyrazinamide, ethambutol, and streptomycin were prescribed. The lingual lesion evolved favorably, with partial healing the first week and total remission at 45 days of starting treatment. At 7 months of follow-up, the patient was recurrencefree. The case had the particularity that the lingual ulcer was the only manifestation of tuberculosis-like mycobacterial infection in a patient with HIV/AIDS.

Torres et al.⁵⁰ reviewed the literature on alveolar osteitis, studying the forms of clinical occurrence, risk factors, and etiopathogenic theories. The guidelines currently used in the treatment of alveolar osteitis were examined and the drug options used were analyzed; the authors criticized the results obtained.

Periapical surgery

Von Arx⁵¹ reviewed the indications and limitations of periapical surgery. Case selection and the clinical and radiographic examination were the most important parameters for success. The author concluded that the use of microinstruments, illumination, and magnification simplified the systematics of work and made it possible to achieve high success rates with this technique. Regeneration techniques were considered a valid option as a complement to these interventions.

Tsesis et al.⁵² compared the postoperative symptoms in periapical surgery performed using the classic 45º beveled radicular resection technique with retrograde cavity preparation with conventional instruments and performed using a microscopic technique with a minimum bevel and retrograde cavity preparation with ultrasound. With respect to quality of life, the microscopic technique was accompanied by less pain, but more postoperative difficulties for opening the mouth, mastication, and speech.

Martí et al.,⁵³ in 71 teeth with 100 root ends treated by ultrasonographic periapical surgery and retrograde silveramalgam filling, conducted a 1-year follow-up, evaluating the evolution at 6 and 12 months. They studied the shortterm success in relation to the size of the lesion, apical resection, and the dimensions of the retrograde filling. The overall success rate (defined by Von Arx) at 12 months was 84.2%. No relation was found between success and the size of the periapical lesion, the amount of apex resected, or the retrograde filling volume.

Taschieri et al.,⁵⁴ in a prospective study of 50 teeth in 34 patients with one year of follow-up, evaluated the success of periapical preparation with ultrasound in relation to the type of tooth and its location, presence of radicular posts, and the type of ultrasound tip used. In the 46 teeth included in the study, they found 91.3% of teeth with complete healing, one tooth with dubious healing, and 3 failures. No statistically significant relation was found with the other study variables.

With regard to the filling materials used in periapical surgery, a study was made in dogs of the periapical tissue response and regeneration of the radicular cement. Three of the materials most used for retrograde filling were analyzed (amalgam, super-EBA and MTA). There was less inflammation of the periapical tissue in teeth filled with MTA and super-EBA MTA than in teeth filled with silver amalgam. Cement neoformation only occurred with MTA, which made it the best material of the three presented, followed by super- EBA, which produced better marginal sealing than amalgam.⁵⁵

A study was made⁵⁶ in humans to evaluate the marginal sealing capacity of 3 retrograde filling materials, super-EBA, IRM and Pro Root MTA. Three groups of 27 canine roots each were examined. No differences were found between super-EBA and IRM, but MTA had the lowest microfiltration rate.

In an intraoperative study, Von Arx⁵⁷ analyzed the presence of an isthmus at the level of the radicular resection in 124 roots of 56 lower first molars and 32 upper first molars in which periapical surgery was performed. The author examined root sections by endoscopy, finding that 76% of the mesiovestibular roots of the upper first molars had two canals and an isthmus, 10% had two canals but no isthmus, and 14% had only one canal. All the distovestibular and palatal roots had only one canal. In the mandibular first molars, 83% of the mesial roots had two canals with an isthmus, 11% had two canals and no isthmus, and 6% had a single canal; 64% of the distal roots had a single canal and 39% had two canals and an isthmus.

The introduction of microsurgery and ultrasound to form the retrograde filling space greatly reduces the trauma of the intervention. Therefore, Velvart et al.⁵⁸ proposed an exhaustive preoperative study of the tissue to be handled, the design and management of a minimally traumatic flap, and tension- free sutures with nonresorbible atraumatic thread, insisting that such advances make atraumatic management of soft tissues possible, and that this is essential for scar-free results.

Gagliani et al.⁵⁹ studied the surgical retreatment of teeth after periapical surgery. In a 5-year follow-up of 231 roots with periapical lesions, 162 roots had received conventional pulp canal treatment without success and 69 roots were treated previously with periapical surgery. At 5 years, 86% of the conventional pulp canal treatment group healed completely and exhibited radiographic evidence of success, whereas 7% did not heal completely and 6% failed. In the group or previous periapical surgery, 59% healed completely, 17% healed incompletely, and 23% failed. They concluded that surgical retreatment is a valid prior alternative to extraction, but it has a higher failure rate when the tooth has been intervened previously.

Mead et al.⁶⁰ reviewed the literature to evaluate studies that assessed success or failure in periapical surgery from 1970. They analyzed 70 clinical studies to which they assigned a score of 1 to 5 to the level of evidence for purposes of evaluation. They found that very few studies compared the success of surgical treatment with nonsurgical retreatment, but the results still demonstrated that periapical surgery was effective in saving natural teeth.

Lindeboom et al.⁶¹ evaluated the administration of clindamycin in the prophylaxis of infection after periapical surgery. They made a double-blind prospective study of 256 patients, comparing a group that took 600 mg of clindamycin one hour before the intervention to a control group that took placebo. Patients were controlled for a period of 4 weeks and no statistically significant differences were found in the occurrence of infections between groups.

Third molar pathology

Susarla et al.⁶² estimated the subjective and objective factors related to the difficulty of removing the third molar. They made a cohort study in which 14 surgeons participated and 450 third-molar extractions in 150 patients were included. They found that the location of molar in the dental arcade, molar anatomy, Winter classification, number of teeth removed in a single intervention, type of procedure, and the operator’s experience were the factors related to complexity.

Susarla et al.⁶³ presented another study made to estimate the relation between the operator’s surgical skill in extracting complicated third molars and possible errors as a result of the difficulty of the intervention. They found that estimation of the difficulty is susceptible to variables that can lead to errors. These variables can be demographic, like age, sex, and race; or anatomic, like cheek flexibility and mouth opening. The factors least related to errors in calculating the difficulty are radiographic variations and the operator’s surgical experience.

Mc Ardle et al.⁶⁴ evaluated 100 patients with 122 mandibular molars extracted that caused cervical decay in the second molar; 82% were angled 40º to 80º. When the molar was mesially angled, as age increased there was a greater tendency to second molar decay. They concluded that prophylactic removal of mesially angled third molars helps to protect the second molar from possible lesions.

Dodson⁶⁵ made a study in patients at risk of suffering a distal periodontal defect of the second molar after extraction of the third molar due to age (26 years old or older), third-molar position (mesially angled or horizontal), or a preexisting distal periodontal defect of the second molar. After extraction, bone regeneration with demineralized bone powder was performed in one group, guided tissue regeneration in another, and nothing in the last group. After 26 weeks of follow-up, the group with better results was the one treated by bone regeneration with demineralized bone powder when the third molar was extracted.

Sammartino et al.⁶⁶ analyzed, in 18 patients aged 21- 26 years, the effectiveness of platelet-rich plasma (PRP) in inducing bone regeneration in distal periodontal defects created in the lower second molar, after the extraction of mesially angled third molars. Patients were followed up for 12 months, observing in each control bone-tissue formation in the defects.

Gomes et al.⁶⁷ made a study to evaluate the frequency, type, and risk factors associated with lingual nerve injuries incurred during third-molar extraction when lingual retraction flaps were made . In 55 patients with bilateral impacted third molars, extractions were made with a lingual flap on one side and without a lingual flap on the other side. Lingual nerve injury occurred in 9.1% of the extractions with lingual flap retraction, but no case occurred in the absence of a lingual flap. The performance of lingual flap retraction during surgery of the lower third molar was a major risk factor for lingual nerve injury.

Robert et al.⁶⁸ emphasized the high rate of nerve injuries, both temporary and permanent, that occurred during the extraction of lower third molars. In 535 interventions referred by the members of the California Association of Oral and Maxillofacial Surgery, 94.5% of the operators had some case of inferior alveolar nerve injury in a 12-month period, of which 53% were in the lingual nerve; 78% of the operators reported cases of permanent nerve injuries, of which 46% were in the lingual nerve. They concluded that injuries to the inferior alveolar nerve were prevalent over lingual nerve injuries; the most frequent causes were the surgeon’s inexperience, poor technique, and diagnostic errors derived from false radiographic images.

A retrospective study was made ⁶⁹ to analyze the evolution of inferior alveolar nerve injuries after lower third molar extraction. In 4995 extractions, there were 55 (1.1%) inferior alveolar nerve injuries; in the case of injuries, the most frequent outcome was the recovery of sensitivity within three months; 50% showed complete recovery before six months, and, in some cases, complete recovery took at least one year. The investigation showed that age was a risk factor for total recovery of inferior alveolar nerve injuries that occurred during extraction of the lower third molar.

In randomly selected patients, Renton et al.⁷⁰ evaluated the risk of inferior alveolar nerve injury, including coronectomy in the surgical procedure. The use of this technique significantly reduced nerve iatrogenesis, but they emphasized that root mobilization after coronectomy for its removal could be responsible for complications. They advised of the importance of radiographic diagnosis in prevention, in view of the relation between the roots and dental canal continuity.

Injury of the inferior alveolar nerve after lower third molar surgery is the most frequent complication after alveolar osteitis and postoperative infection. Sedaghatfar et al.⁷¹ studied the extraction of 423 lower third molars, evaluating the risk of injury to the inferior alveolar nerve. There were 24 (5.7%) cases of alveolar nerve injury. Based on radiographic examination, four findings were associated clearly with inferior alveolar nerve injury: dental root darkening, dental root narrowing, interruption of the white lines of the canal, and divergence of the canal.

With respect to the complications of third-molar surgery, Short et al.⁷² made a retrospective study of 390 extractions of upper and lower third molars in 173 patients, who were divided into three age groups: 12-14, 15-16, and 17-18 years, to evaluate the incidence and type of complications. The most frequent reason for extraction was an orthodontic indication (40.5%); the 17-18 year old age group had the largest number of extractions (62.8%). The incidence of postextraction complications was 15.62%, which occurred most frequently in lower molars (12.82%). All the complications were mild and reversible and the age group most affected was the 15-16 year old group, with 19%.

Pasqualini et al.⁷³ studied the closure of the surgical wound to analyze which situation was more favorable during the postoperative period. They compared two groups of 100 patients of the same characteristics, in which the wound was closed by complete flap suture in one group and the wound was closed in a second attempt after removing 5-6 mm of mucosa in the other group. They evaluated pain and inflammation during one week, finding that in interventions of equivalent surgical difficulty, there was less pain and inflammation and a better postoperative period in the wounds closed in the second attempt.

Figuereido et al.⁷⁴ made a study of delayed-onset infections in 958 lower third molar extractions; after removing the suture, they observed 1.5% of surgical wound infections, which approaches the rate of other similar studies. The infections that occurred generally developed 3-5 weeks after surgery. Half of the cases presented radiolucency around the crown; most of the cases had odontosection (13/14) and osteotomy (11/14).

With respect to medication in third-molar extraction surgery, Esen et al.⁷⁵ found satisfactory results using remifentanil in combination with midazolam during the intervention, which eliminated pain and provided an acceptable level of sedation.

The effectiveness of robecoxib in the control of postoperative third molar pain was compared by preoperative administration of robecoxib 50 mg, ibuprofen 400 mg, and placebo. Robecoxib provided appreciable analgesia in the first six hours after tooth extraction; it reduced analgesic use in the first 12 hours compared with ibuprofen and placebo.⁷⁶

Dental impaction

García et al.⁷⁷ reported a case of successful surgical repositioning of an impacted lower second molar without extraction of the third molar germ. They studied the different therapeutic possibilities, depending on the type of retention and its cause.

Lewis et al.⁷⁸ presented two cases of canine transposition to replace impacted incisors. They removed the left central incisor surgically, realigned the canine, and placed a veneer crown to replicate the appearance of an upper central incisor.

Kofod et al.⁷⁹ treated a case of ankylosis of an upper central incisor that had been reimplanted after an injury. Taking advantage of the ankylosis, the incisor was used for anchorage and distalization of the maxillary teeth. Later, the apical portion of the ankylosed root was eliminated and moved to its final position.

Bayrak et al.⁸⁰ reported a case in which they discussed the need for computed tomography in the diagnosis of supernumerary teeth located palatally to the permanent central incisors to rule out a relation between the supernumeraries and the incisor roots. They concluded that computed tomography offered more complete information, but the patient’s radiation exposure was greater. CT use would be restricted to cases in which conventional radiography offered little information.

Shapira et al.⁸¹ reported a canine impacted in the palatal that migrated through the palatal suture to the other side of the maxillary bone. They concluded that the migration of impacted canines is a rare condition that can occur in either the maxilla or mandible and that examination by orthopantomography is essential before orthodontic treatment to discover possible canine migration. When the canine was horizontal and had migrated from its original position, the treatment of choice was extraction.

Dental transplantation and reimplantation

With respect to autologous dental transplantation, in an evaluation of 182 cases, Kim et al.⁸² found a failure rate of 4.5%. Primary stability, radicular resorption, and ankylosis were analyzed and it was found that transplants with good initial stability healed better. The mean extraoral time was 7.58 min; no relation was found between extraoral time and radicular resorption.

Maia et al.⁸³ reported an impacted upper central incisor with a radicular curvature that was resolved by autotransplantation. Tooth positioning was complex due the form of the root, so it was turned around, with the vestibular face toward the palate, to conserve the vestibular plate, which would have been compromised otherwise. They commented that although many techniques are used to rescue an impacted tooth, autotransplantation is a system that should be considered when discussing treatment possibilities with the patient.

Many techniques have been described for stabilizing transplanted teeth, such as orthodontic brackets, ligatures, sutures, and resin compounds. Akkocaoglu et al. (84) measured the success rate in autotransplanted teeth without stabilization. The results of their study demonstrated that autotransplantation on a socket of suitable mesiodistal dimensions, opened for the tooth to be transplanted, did not require primary fixation for stabilization. Consequently, it was a safe treatment for cases of impacted canines and third molars with closed apexes of favorable prognosis.

According to Gauss et al.,⁸⁵ prolonged rigid splinting during the autotransplantation of immature third molars had a negative influence on root development and final root length, especially when a dental germ was involved.

Chappuis and Von Arx⁸⁶ followed up the evolution of 45 reimplanted avulsed teeth for one year. The success rate was about 95.6%; 2 reimplantations failed. Ankylosis occurred in 28.9%; its incidence was assessed in relation to extraoral dry time. If root canal guidelines are followed, inflammatory root resorption diminishes to 6.7%.

Pohl et al.⁸⁷ studied the outcome of the reimplantation of avulsed permanent teeth and wrote three successive articles in which they analyzed separately three parameters: endodontic and periodontal considerations, and survival analysis.

With respect to the transport of the avulsed tooth, Pohl et al.⁸⁸ explained that conserving and transporting the tooth in a physiological solution helps to promote neoformation of the periodontal ligament. In the case of teeth conserved in dry or otherwise poor conditions, in which the physiologic repair potential could be altered, they indicated that the use of an enamel matrix derivative (Emdogain^®) with topical glucocorticoids and systemic doxycycline may favor periodontal regeneration. They recommended that all public and private places where children congregate be equipped with physiological systems for the transport of avulsed teeth because the exposure time and transport medium are of vital importance for the success of tooth reimplantation.

According to Pohl et al.,⁸⁹ the only factor significantly related to the loss of reimplanted teeth is the physiological capacity for regenerating the periodontal ligament. The complications of endodontic treatment were due to the maturity of the tooth; in this study, unlike other studies, this was not a predictive factor of successful reimplantation.

A case was reported in which an enamel matrix derivative (Emdogain^®) was applied to the root surface of an avulsed tooth, where just a few cells of the cement had survived after the injury and dry conservation conditions. The result was not good, from which it was inferred that the enamel matrix derivative did not yield good results unless a sufficient number of cells of the periodontal ligament and cement was present.⁹⁰

Barrett et al.⁹¹ applied enamel matrix derivative (Emdogain ^®) to the root surface of avulsed permanent incisors in children and followed up their evolution for 32 months. After analyzing the radiographic outcome and comparing it with other controlled studies, they found that the reimplanted incisors experienced radicular resorption and ankylosis, although none exhibited root infection or inflammatory resorption. They concluded that the enamel matrix derivative (Emdogain^®) per se did not prevent root resorption or promote regeneration of the periodontal ligament, although the results of healing were significantly better when compared with those of the control studies.

In a case reported by Çaglar et al.,⁹² the reimplantation of a central incisor and lateral incisor treated with an enamel matrix derivative (Emdogain^®) was evaluated. Two minutes before reimplantation, they bathed the root surface and socket with saline solution and then treated it with the enamel matrix derivative. The teeth were inserted with digital pressure and a semirigid plate was used for 10 days. At 2, 6, and 12 months of follow-up, there was no inflammatory lesion or root resorption.

Drugs

Intraligamentous anesthesia with articaine 4% and epinephrine 1:100,000 had an efficacy similar to an injection of lidocaine 2% and epinephrine 1:100,000 in studies by Berlin et al.⁹³

Brkovic et al.⁹⁴ compared clonidine and epinephrine with lidocaine in the blockade of the inferior alveolar nerve. Clonidine induced anesthesia more rapidly, but no differences between groups were found in the duration and perceived intensity of anesthesia. There was less postoperative pain in the clonidine group and the patients in the clonidine group took a significantly lower total number of analgesic medications.

Blood catecholamine concentration and hemodynamic response to the vasoconstrictor were analyzed in conventional injection compared to the Gow-Gates technique in mandibular anesthetic blockade. The plasma epinephrine concentration was higher with the conventional technique, but there were no significant differences between the two groups. The hemodynamic parameters showed no relation with the type of anesthetic injection.⁹⁵

Dogan et al.⁹⁶ reported a case of ophthalmologic disorder and Horner syndrome in a 19-year-old woman referred by a dentist. She presented diplopia, miosis, partial enophthalmos and lacrimation of the left eye after local intraoral anesthesia for extraction of the upper left third molar; the symptoms appeared a few seconds after the injection of prilocaine 5 mg. The symptoms disappeared completely without treatment, after 6 hours.

Horowitz et al.⁹⁷ reported three cases of ophthalmologic disorder due to dental anesthesia; two with sameside optic neuropathy and one with same-side diminished abduction and pupil dilation and diminished pupil activity after local anesthesia for treatment of the upper teeth. In one case, the pupil was not dilated, cerebral and orbital CT disclosed no radiologic findings and the patient recovered sight in two weeks; in the second case, the pupil was dilated, the CT findings were negative, and the patient did not recover sight; in the last case, the patient’s sight recovered in 24 hours.

Other

Pérez et al.⁹⁸ demonstrated that most surgical interventions of the oral cavity in pediatric patients can be performed in the outpatient setting. They tabulated the surgical activity of the oral surgery and laser surgery units in the pediatric population of the "Master of Oral Surgery and Implantology" course of the University of Barcelona. Of 3187 operations performed, 489 were in patients younger than 18 years. Surgical extraction of the lower third molars was the most frequent intervention (55.6%), followed by other dental extractions (33.6%), surgical or nonsurgical. The rest of the interventions (10.6%) included: fenestration of impacted canine or other teeth, frenulum or mucocele excision, and dental repositioning. Complications appeared after surgical extraction of third molars in 15.93% of cases, the most frequent being pain (4.35%) and swelling (4.35%), which are signs of postoperative inflammation.

Stübinger et al.⁹⁹ described a case in which a patient was seen for loss of right eyesight, painful swelling, and erythema of the orbital area days after undergoing extraction of a right upper molar. They found an odontogenic infection that had not been treated before extraction. Due to anatomical proximity with the maxillary sinus, it had produced this complication. They recommend treating infectious processes before extraction to avoid serious complications.

Bagán et al.¹⁰⁰ reported 10 patients with osteoradionecrosis lesions of the mandible; half of them also had maxillary lesions. All had received chemotherapy for the treatment of metastases, 6 of breast cancer and 4 of multiple myeloma. They analyzed metastasis location, the characteristics of the osteonecrosis, and treatment. After histopathologic study, all the lesions were diagnosed as chronic osteonecrosis without evidence of metastasis and all were treated with bisphosphonates. Jiménez-Soriano and Bagán,¹⁰¹ in another article, discussed the relation between the bisphosphonates and osteonecrosis. They reviewed the literature and some of the most interesting aspects of this topic.

 

Conclusion

The authors offer other researchers a quick overview of the most important articles in oral surgery published in 2005.

 

 

Correspondence:
Miguel Peñarrocha Diago
Facultad de Medicina y Odontología
Gascó Oliag, 1
46021 Valencia. España
Email: penarroc@uv.es

Recibido: 01.08.06
Aceptado: 21.07.08

 

 

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