Custom-Machined Miniplates and Bone-Supported Guides for Orthognathic Surgery: A New Surgical Procedure.

PURPOSE: Several surgical strategies exist to improve accuracy in orthognathic surgery, but ideal planning and treatment have yet to be described. The purpose of this study was to present and assess the accuracy of a virtual orthognathic positioning system (OPS), based on the use of bone-supported guides for placement of custom, highly rigid, machined titanium miniplates produced using computer-aided design and computer-aided manufacturing technology. MATERIALS AND METHODS: An institutional review board-approved prospective observational study was designed to evaluate our early experience with the OPS. The inclusion criteria were as follows: adult patients who were classified as skeletal Class II or III patients and as candidates for orthognathic surgery or who were candidates for maxillomandibular advancement as a treatment for obstructive sleep apnea. Reverse planning with computed tomography and modeling software was performed. Our OPS was designed to avoid the use of intermaxillary fixation and occlusal splints. The minimum follow-up period was 1 year. RESULTS: Six patients were enrolled in the study. The custom OPS miniplates fit perfectly with the anterior buttress of the maxilla and the mandible body surface intraoperatively. To evaluate accuracy, the postoperative 3-dimensional reconstructed computed tomography image and the presurgical plan were compared. In the maxillary fragments that underwent less than 6 mm of advancement, the OPS enabled an SD of 0.14 mm (92% within 1 mm) at the upper maxilla and 0.34 mm (86% within 1 mm) at the mandible. In the case of great advancements of more than 10 mm, the SD was 1.33 mm (66% within 1 mm) at the upper maxilla and 0.67 mm (73% within 1 mm) at the mandibular level. CONCLUSIONS: Our novel OPS was safe and well tolerated, providing positional control with considerable surgical accuracy. The OPS simplified surgery by being independent of support from the opposite maxilla and obviating the need for classic intermaxillary occlusal splints.

Survey of Spanish dentists on the prescription of antibiotics and antiseptics in surgery for impacted lower third molars.

BACKGROUND: This study explored the attitude of registered dentists in Biscay towards prescribing antibiotics and/or antiseptics to prevent potential infections after surgical extraction of completely bone-impacted third molars in otherwise healthy individuals, with no history of infection. MATERIAL AND METHOD: We sent letters to 931 registered dentists in Biscay, with an explanation of the study objectives, description of a case of lower third molar impaction, including a panoramic radiograph, and a questionnaire. The questionnaire asked whether they would prescribe antibiotics and/or antiseptics, in the hypothetical case of lower third molar extraction surgery presented, and if so, when, what type, at what dose and how long for. RESULTS: The questionnaire was completed by 261 dentists (28%), with a mean age of 44.3 years old (SD 11.05) and mean of 18.7 years working as a dentist (SD 9). A total of 216 dentists (82.7%) considered it necessary to prescribe antibiotics. Of these, 126 (58.3%) would prescribe amoxicillin and 74 (34.5%) amoxicillin/clavulanic acid, while 129 dentists (59%) would prescribe antibiotics both before and after surgery and 10 (4.6%) only after surgery. The most common doses were amoxicillin 500 mg or 750 mg every 8 hours, and amoxicillin/clavulanic acid 875/125 mg every 8 hours, in both cases for a mean of 7 days. Further, 74 dentists (28%) said they would use immediate post-extraction socket irrigation with chlorhexidine, while 211 (81%) would prescribe antiseptics in the postoperative period, of whom 97% recommended chlorhexidine. We did not find significant differences in the use of antibiotics or antiseptics by dentist age (ANOVA p=0.22 and p=0.53, respectively), or professional experience (ANOVA p=0.45 and p=0.62). CONCLUSIONS: In our sample, the prophylactic prescription of antibiotics and/or chlorhexidine is widespread in clinical practice, in most cases amoxicillin and amoxicillin/clavulanic acid for a week, starting the treatment before surgery.

Plasma variations in stress markers: clinical trial of two anesthetics used in regional block in the extraction of impacted inferior third molars.

OBJECTIVES: Was to evaluate the effect of different regional anesthetics (articaine with epinephrine versus prilocaine with felypressin) on stress in the extraction of impacted lower third molars in healthy subjects. STUDY DESIGN: [corrected] A prospective single-blind, split-mouth cross-over randomized study was designed, with a control group. The experimental group consisted of 24 otherwise healthy male volunteers, with two impacted lower third molars which were surgically extracted after inferior alveolar nerve block (regional anesthesia), with a fortnight's interval: the right using 4% articaine with 1:100.000 epinephrine, and the left 3% prilocaine with 1:1.850.000 felypressin. Patients were randomized for the first surgical procedure. To analyze the variation in four stress markers, homovanillic acid, 3-methoxy-4-hydroxyphenylglycol, prolactin and cortisol, 10-mL blood samples were obtained at t = 0, 5, 60, and 120 minutes. The control group consisted of 12 healthy volunteers, who did not undergo either extractions or anesthetic procedures but from whom blood samples were collected and analyzed in the same way. RESULTS: Plasma cortisol increased in the experimental group (multiple range test, P<0.05), the levels being significantly higher in the group receiving 3% prilocaine with 1:1.850,000 felypressin (signed rank test, p<0.0007). There was a significant reduction in homovanillic acid over time in both groups (multiple range test, P<0.05). No significant differences were observed in homovanillic acid, 3-methoxy-4-hydroxyphenylglycol or prolactin concentrations between the experimental and control groups. CONCLUSIONS: The effect of regional anesthesia on stress is lower when 4% articaine with 1:100,000 epinephrine is used in this surgical procedure.

Efficacy of amoxicillin treatment in preventing postoperative complications in patients undergoing third molar surgery: a prospective, randomized, double-blind controlled study.

PURPOSE: The aim of the present study was to evaluate and compare the occurrence of postoperative complications in patients receiving either pre- or postoperative amoxicillin versus placebo after third molar surgery. PATIENTS AND METHODS: A randomized, double-blind, placebo-controlled clinical trial was performed in 123 patients undergoing third molar surgery. The patients were randomized to 3 groups, according to the treatment regimen: preoperative amoxicillin, postoperative amoxicillin, and placebo. Both surgeon and patients were unaware of the treatment assignment. The clinical outcomes, including pain, wound infection, trismus, temperature, intra- and extraoral swelling, dysphagia, side effects, and postoperative complications, were assessed. RESULTS: Statistically significant differences were found in the incidence of pain, wound infection, temperature, trismus, and dysphagia between the groups receiving amoxicillin versus placebo. Suture dehiscence and infection of 5 sockets were only found in the placebo group. No cases of alveolitis were observed in the 3 groups studied. No significant differences in swelling were found among the different groups. No statistically significant differences in side effects were found between the groups. The efficacy was greatest in the group receiving postoperative amoxicillin compared with the group receiving a prophylactic preoperative dose. CONCLUSION: Amoxicillin administered pre- or postoperatively demonstrated greater efficacy than placebo in preventing postoperative complications in patients undergoing third molar surgery. The best results were obtained using the postoperative protocol.

Sentinel node biopsy in head and neck squamous cell cancer: 5-year follow-up of a European multicenter trial.

BACKGROUND: Sentinel node biopsy (SNB) may represent an alternative to elective neck dissection for the staging of patients with early head and neck squamous cell carcinoma (HNSCC). To date, the technique has been successfully described in a number of small single-institution studies. This report describes the long-term follow-up of a large European multicenter trial evaluating the accuracy of the technique. METHODS: A total of 227 SNB procedures were carried out across 6 centers, of which 134 were performed in clinically T1/2 N0 patients. All patients underwent SNB with preoperative lymphoscintigraphy, intraoperative blue dye, and handheld gamma probe. Sentinel nodes were evaluated with hematoxylin and eosin (H&E) staining, step-serial sectioning (SSS), and immunohistochemistry (IHC). There were 79 patients who underwent SNB as the sole staging tool, while 55 patients underwent SNB-assisted elective neck dissection. RESULTS: Sentinel nodes were successfully identified in 125 of 134 patients (93%), with a lower success rate observed for floor-of-mouth tumors (FoM; 88% vs. 96%, P = 0.138). Also, 42 patients were upstaged (34%); of these, 10 patients harbored only micrometastatic disease. At a minimum follow-up of 5 years, the overall sensitivity of SNB was 91%. The sensitivity and negative predictive values (NPV) were lower for patients with FoM tumors compared with other sites (80% vs. 97% and 88% vs. 98%, respectively, P = 0.034). CONCLUSIONS: Sentinel node biopsy is a reliable and reproducible means of staging the clinically N0 neck for patients with cT1/T2 HNSCC. It can be used as the sole staging tool for the majority of these patients, but cannot currently be recommended for patients with tumors in the floor of the mouth.

Does tumor depth affect nodal upstaging in squamous cell carcinoma of the head and neck?

PURPOSE: The aim of this study was to determine whether tumor depth affects upstaging of the clinically node-negative neck, as determined by sentinel lymph node biopsy with full pathologic evaluation of harvested nodes including step-serial sectioning (SSS) and immunohistochemistry (IHC). PATIENTS AND METHODS: One hundred seventy-two patients with cT1/2 N0 squamous cell carcinoma (SCC) of the oral cavity/oropharynx undergoing primary resection and either sentinel node biopsy (SNB) or SNB-assisted neck dissection as a staging tool for the cN0 neck. Harvested nodes were examined with hematoxylin-eosin staining, SSS, and IHC. Patients upstaged by SSS/IHC were denoted pN1mi. RESULTS: One hundred one of 172 patients were staged pN0, with 71 (41%) patients upstaged. Increasing tumor depth was associated with higher likelihood of upstaging (P < .001). Tumor depth showed a positive correlation with nodal stage according to TNM classification (P < .001). Tumor depth greater than 4 mm appears to be the most appropriate cutoff for risk stratification, although tumors in the oropharynx may require a lower value. CONCLUSION: Tumor depth is an important prognostic factor for patients with SCC of the oral cavity or oropharynx. Tumors greater than 4 mm are associated with greater risk of upstaging; however, this optimum cutoff value may vary between primary tumor sites.

Do systemic antibiotics prevent dry socket and infection after third molar extraction? A systematic review and meta-analysis.

OBJECTIVES: The use of antibiotics to prevent dry socket and infection is a controversial but widespread practice. The aim of the study is to assess the efficacy of systemic antibiotics in reducing the frequencies of these complications after extraction. STUDY DESIGN: A systematic review and meta-analysis, according to the PRISMA statement, based on randomized double-blind placebo-controlled trials evaluating systemic antibiotics to prevent dry socket and infection after third molar surgery. Databases were searched up to June 2015. Relative risks (RRs) were calculated with inverse variance-weighted, fixed-effect, or random-effect models. RESULTS: We included 22 papers in the qualitative and 21 in the quantitative review (3304 extractions). Overall-RR was 0.43 (95% confidence interval [CI] 0.33-0.56; P < .0001); number needed to treat, 14 (95% CI 11-19). Penicillins-RR: 0.40 (95% CI 0.27-0.59). Nitroimidazoles-RR: 0.56 (95% CI 0.38-0.82). No serious adverse events were reported. CONCLUSIONS: Systemic antibiotics significantly reduce the risk of dry socket and infection in third molar extraction.

OK432 (picibanil) efficacy in an adult with cystic cervical lymphangioma. A case report.

Cervical cystic lymphangioma (CCL) is a rare and benign tumour involving congenital and cystic abnormalities derived from lymphatic vessels. The most accepted treatment continues to be surgical excision. However, when this infiltrates vital neurovascular neck structures, complete excision is difficult and if only partial, the recurrence rate is very high. The most frequently used alternative treatment is to inject sclerosants into the lesion. The use of these techniques has reported good results in children; however, there are few references thereof with regard to adults. We are reporting on a cervical cystic lymphangioma in a male aged 22, treated with an intra-lesion injection of 20 cc with 0.01 mg/cc dilution of OK-432 (picibanil) in physiological serum. Sole complications were fever and local reaction where the solution was injected. One month after treatment the lymphangioma had totally remitted and sixteen months later continues in remittance.

Amoxicillin/clavulanic acid 2000/125 mg to prevent complications due to infection following completely bone-impacted lower third molar removal: a clinical trial.

OBJECTIVE: The purpose of this study was to determine the effect of amoxicillin/clavulanic acid to prevent infection following completely bone-impacted lower third molar removal. STUDY DESIGN: A random, double-blind placebo-controlled clinical trial including 118 adults randomly allocated to placebo (60 patients) or antibiotic treatment (58 patients): 2 g amoxicillin/125 mg clavulanic acid 2 hours before the surgery and post-operatively twice a day for 4 days. Infection was clinically assessed until 8 weeks after surgery. Adverse events, as well as clinical and surgical variables, were recorded. Analysis was by intention to treat. RESULTS: Infections developed in five patients in the placebo group, all in the first postoperative week, and in two in the antibiotic group, both after the first week, the difference not being statistically significant (P = .278, number needed to treat 19 [8-∞]). There were no relationships between any variables studied and infection. No serious adverse events were reported. CONCLUSION: There is insufficient evidence to recommend routine use of this antibiotic treatment.

Efficacy of amoxicillin/clavulanic acid in preventing infectious and inflammatory complications following impacted mandibular third molar extraction.

OBJECTIVE: To find out whether the frequency of postoperative infectious and inflammatory complications (IC) in subjects treated with placebo (Pl) is greater than those treated with antibiotic (Ab) after extraction of an impacted mandibular third molar (M3). Our hypothesis is there are more IC in Pl than in Ab, with a maximum ratio difference of 0.067. STUDY DESIGN: A double-blind placebo-controlled randomized clinical trial. The sample was derived from the population of subjects attending Cruces Hospital for evaluation and extraction of 1 M3 under local anesthesia. Patients were treated with postoperative placebo or amoxicillin/clavulanic acid 500/125 mg 3 times a day during 4 days. The outcome variable was infectious and inflammatory complications. Sex, age, smoking, molar depth, angulation, need for sectioning, ostectomy, and operation time were recorded. Analysis was by intention to treat, risk measures, and logistic regression. RESULTS: In 490 subjects (259 Ab and 231 Pl), the frequency of IC was 1.9% in the Ab and 12.9% in the Pl group (OR 7.6, 95%CI 2.9-19.9; P < .001). The number needed to treat was 10 (7-16). Unadjusted relative risk was 0.15 (0.06-0.38) (P < .001). Absolute reduction risk was 0.11(0.066-0.155)]. Therefore, the hypothesis cannot be rejected. Multivariate analysis shows treatment with antibiotic (OR = 8.66 (3.17-23.67); P < .001) and age (OR = 1.08 (1.00-1.16); P = .029) are the only variables to be included in the logistic regression model. CONCLUSION: Amoxicillin/clavulanic acid is efficacious in reducing the incidence of IC following third molar extraction but should not be prescribed in all cases.

Clinical Comparison of Dexketoprofen Trometamol and Dipyrone in Postoperative Dental Pain.

A total of 125 outpatients with moderate to severe pain after surgical removal of one impacted third molar were randomly assigned to receive dexketoprofen trometamol 12.5 or 25 mg or dipyrone 575 mg. For first-dose assessments, patients rated their pain intensity and its relief at regular intervals. From 60 min post dose to the end of the 6-h observation period, both doses of dexketoprofen trometamol had higher pain relief scores than dipyrone: Between 3 and 6 h the differences were statistically significant. In addition, peak measures (PIDmax and PARmax ) were statistically superior after both doses of dexketoprofen trometamol compared to dipyrone. The overall efficacy assessed at the end of the first-dose phase was rated as good or excellent by 90%, 83.3%, and 70% of patients receiving dexketoprofen trometamol 25 mg, dexketoprofen trometamol 12.5 mg, and dipyrone, respectively. The number of patients who required remedication during the 6-h period was significantly lower in both dexketoprofen groups. Repeated-dose data were also obtained. No significant differences were found in the efficacy after repeated doses, the number of doses taken, or the mean time elapsed between doses. The overall efficacy at the end of the repeated-dose phase was rated as good or excellent by 84.2%, 66.7%, and 70% of patients receiving dexketoprofen trometamol 25 mg, dexketoprofen trometamol 12.5 mg, and dipyrone, respectively. The frequency of adverse events was similar for all treatments and no serious adverse events were reported during the study.

Regeneración ósea tras la extirpación de quistes radiculares con y sin regeneración guiada / Bone regeneration after extirpation of radicular cysts with and without guided regeneration

Con el propósito de determinar el grado de regeneración ósea en quistes odontogenicos usando tecnicas de Regeneración Osea Guiada (ROG), hemos realizado un estudio clínico randomizado, controlado y prospectivo. Treinta pacientes con quistes radiculares fueron divididos en tres grupos. El grupo 1 o grupo control (n=10 pacientes) fue tratado con quistectomía de Parstch II y cierre primario. Los otros dos grupos fueron tratados con quistectomía de Parstch II y ROG, usando una membrana reabsorbible (n=10) y membrana no-reabsorbible (n=10). Las membranas se fijaron mediante tornillos no reabsorbibles Memfix System. El volumen residual y la densidad de los tejidos neoformados se evaluaron mediante Tomografia Axial Computarizada (TAC) y mediante analisis de Imagen Digitalizada y Asistida por Computadora (CADIA) antes de la enucleacion y a los 3 y 6 meses de la intervencion. Al realizar el analisis estadistico intergrupos, no se encontro diferencia estadisticamente significativa a los 6 meses respecto al volumen y densidad residual. Estos resultados sugieren que la ROG usando membranas no contribuye a incrementar la regeneración ósea.