Efficacy of adjunctive modalities during tooth extraction for the prevention of osteoradionecrosis: A systematic review and meta-analysis.

BACKGROUND: Jaw osteoradionecrosis (ORN) is a complication in patients with previous head and neck radiotherapy. Its incidence increases with dental extractions. Hence, this review aimed to evaluate the efficacy of adjunctive treatment modalities undertaken at the time of extraction in previous head and neck radiotherapy patients in preventing ORN. METHODS: A systematic review was conducted, where studies with data on ORN incidence after extraction with or without adjunctive interventions were included. Meta-analyses were conducted to estimate the pooled prevalence of ORN per intervention and the pooled odds ratio for incidence of ORN between interventions. RESULTS: In total, 1520 patients in 29 studies were included. Interventions identified were hyperbaric oxygen (HBO), pentoxifylline-tocopherol (PENTO), antibiotics (ABX), platelet-rich fibrin and photobiomodulation. The pooled prevalence of ORN for HBO (4.6%), PENTO (3.4%) and ABX (3.8%) was significantly lower than the Control (17.6%). For studies with direct comparisons between groups, HBO had lower but not significant odds of developing ORN than the Control (OR 0.27) and ABX (OR 0.57). CONCLUSIONS: HBO, PENTO and ABX may reduce the incidence of ORN compared to no intervention. Given that all three have similar incidences of ORN, ABX may be the most cost-effective and accessible adjunctive modality.

Maxillary Impaction Does Not Negatively Affect the Nasal Airway: A Systematic Review With Meta-Analysis.

PURPOSE: Le Fort I maxillary impaction is an orthognathic surgical procedure to reposition the maxillary complex superiorly. The objective of this study is to investigate if maxillary impaction negatively affects the nasal airway. METHODS: A systematic review with meta-analysis was performed to investigate the effects of maxillary impaction on the nasal cavity. PubMed, Embase, and Cochrane Library databases were accessed. Observational studies, nonrandomized, and randomized controlled trials were included if Le Fort 1 maxillary impaction and nasal airway outcomes assessments were performed. Studies were excluded if maxillary impaction or nasal airway outcome assessment was not performed or if the study included patients with cleft or craniofacial syndromes, previous nasal surgeries, or active respiratory tract. The demographic data, study methodology, magnitude of maxillary impaction, and outcomes related to the nasal airway were collected. These outcomes includes anatomical changes (evaluated by rhinoscopy, acoustic rhinometry, and computed tomography), changes to nasal airflow and resistance (evaluated by rhinomanometry) and changes to quality of life. RESULTS: The search yielded 7517 studies. Ten studies were included after the application of the selection criteria. A total of 126 patients underwent pure maxillary impaction, 97 underwent maxillary impaction and advancement, and 12 had impaction with setback. Despite that maxillary impactions decreased the nasal cavity volume by +21.7%, the cross-sectional area of the narrowest parts of the cavity was only reduced by -8.4%. Maxillary impactions generally increases the nasal airflow (+12.6%) while reducing nasal resistance (-20.2%). Rhinoscopies also showed a reduction in nasal obstruction. CONCLUSION: Maxillary impaction did not negatively affect the nasal airway. The surgeries did not lead to the reduction of the cross-sectional area at the strictures of the nasal cavities. The nasal airflow and resistance was not decreased and increased, respectively. The quality of life of the patients was also not shown to have worsened.

Influence of lip form on the perceived ideal incisal show at rest.

INTRODUCTION: A widely used guide of 2 mm incisal show at rest is used as an esthetic guide in treatment planning for many patients. However, this does not consider the lip form at rest. This study aimed to investigate the most esthetic incisal show at rest, at varying lip forms, perceived by dental professionals and laypeople. METHODS: Three volunteers of each gender and type of lip form (straight, moderate, and high) were recruited. For each volunteer, 6 images of their perioral region with a variable incisal display at rest were generated. A survey was conducted whereby respondents were asked to grade the attractiveness of each image using a numerical visual analog scale from 0-10. RESULTS: A survey sample of 107 respondents participated in the study (male-to-female ratio = 37 to 70; dental professionals-to-laypeople ratio = 50 to 57). Mann-Whitney U-test was used to analyze the differences in preferences between the various groups (P <0.05). Both dental professionals and laypeople responded that 2 mm incisal show at rest is only suitable for patients with straight lip form. However, for patients with moderate or high lip forms, an incisal show of 4-5 mm was preferred. There was also no significant difference between the perceived ideal incisal show of dental professionals and laypeople, except for the ideal incisal show of models with straight lip form. CONCLUSIONS: The guide of 2 mm incisal show at rest is appropriate only for patients with straight lip form. Patients with moderate or high lip form should have a greater incisal show. This finding was agreed on by both dental professionals and laypeople, regardless of their gender.

Accuracy of a digital workflow for bimaxillary orthognathic surgery: comparison of planned and actual outcomes.

AIM: The aim of the present prospective proof-of-concept study was to evaluate the accuracy of 3D orthognathic surgical planning and CAD/CAM splints by comparing planned with actual postoperative outcomes. MATERIALS AND METHODS: Ten patients scheduled for bimaxillary orthognathic surgery to correct a skeletal Class III dentofacial deformity were recruited. All subjects had CBCT scans taken not more than 2 months preoperatively and within the 1-week postoperative period. The distance between six dental landmarks (midpoint of the maxillary and mandibular incisors, mesiobuccal cusps of the maxillary and mandibular first molars) and three intersecting symmetry planes (Frankfort horizontal plane [FHP], midsagittal plane [MSP], and coronal plane [CP]) were measured, and the differences between the virtually simulated and actual postoperative models were computed. The threshold for accuracy was set at 2 mm. RESULTS: Differences between the planned and actual outcomes were analyzed via chi-square tests and two-tailed paired student t tests. The overall mean linear difference for all six landmarks was 0.98 mm. The overall mean linear differences for both maxillary and mandibular landmarks relative to the FHP, MSP, and CP were 1.3, 0.7, and 0.9 mm, respectively. Four cases showed all linear differences of the six landmarks to be < 2.0 mm, while the other six cases had at least one linear difference of > 2.0 mm, the majority of which were in the superior-inferior direction. There were statistically significantly greater inaccuracies in the FHP compared with the MSP and CP (P < 0.05). CONCLUSION: Most of the linear differences between the simulated and actual outcomes were clinically acceptable. However, greater linear differences were seen in the superior-inferior direction, indicating a greater surgical error in achieving the desired vertical position of the maxillomandibular complex. (Int J Comput Dent 2022;25(4):397-0; doi: 10.3290/j.ijcd.b2599749).

Use of an improvised clamp to manage bleeding tongue injuries.

We report a case of a 67-year-old Chinese man admitted to the emergency department for a persistent bleed on the tongue. Initial digital pressure and application of topical tranexamic acid did not stop the bleeding. An improvised clamp applied to the tongue was successful in achieving haemostasis. Using this method, there was no need for a clinical staff to be present for manual application of pressure. This frees up the staff for other clinical duties and matters.

Scoping review: Facilitators and barriers in the adoption of teledentistry among older adults.

OBJECTIVE/BACKGROUND: Access to oral health care among older adults is a key issue in society, which has been exacerbated by social distancing measures and lockdowns during the COVID-19 pandemic. Older adults would greatly benefit from teledentistry, yet little information exists on the enablers and challenges of adopting this technology for use with this group. The aim of this scoping review is to summarise the applications and key factors associated with the adoption of teledentistry among older adults. MATERIALS AND METHODS: This scoping review was developed in accordance with Arksey and O'Malley's five-stage framework and the Joanna Briggs Institute scoping review protocol guidelines. Publications on teledentistry involving direct clinical services for older adults aged 60 and above were included. Publications that focused solely on teleeducation were excluded. A systematic search was carried out on major electronic databases until 25 August 2020. Out of 1084 articles screened, 25 articles were included. Facilitators and barriers were categorised using the socio-ecological model. RESULTS/DISCUSSION: Teleconsultation and telediagnosis were the most reported applications of teledentistry among older adults. Reported policy-level factors were data privacy issues (n = 7) and regulations (n = 17). Community-level facilitators and barriers included the availability of resources (n = 15) and support (n = 3). Familiar care settings (n = 2) and effective administration (n = 20) were key organisational-level factors. Staff attitudes and education (n = 23) and individual patient knowledge, attitudes and practices (n = 10) can influence teledentistry adoption while complex medical conditions (n = 8) may pose a challenge. CONCLUSION: Key factors in the uptake of teledentistry among older adults span across policy, community, organisational, interpersonal and individual factors. Commonly reported barriers included technical issues, lack of funding, consent issues and cognitive impairments.

Kern's six-step approach allows for meaningful implementation of an orthognathic surgery training course.

OBJECTIVES: This study investigated the effectiveness of simulation training in improving the confidence and competency of oral and maxillofacial surgery (OMS) residents in performing orthognathic surgery (OGS). METHODS: Kern's six-step approach was applied when designing the simulation training for OMS residents. The difficulties encountered by the residents when learning OGS were considered when designing the training program. A training course consisting of didactic sessions, hands-on training on three-dimensional training models, and an assessment tool was implemented for OMS residents. Improvement in the confidence and competence of OMS residents in performing OGS, fidelity of the three-dimensional models, and satisfaction with the course was evaluated. RESULTS: All OMS residents (10/10) completed the course. The perceived difficulty in learning OGS was mainly related to the manipulation of the jawbones. While there were improvements in the median confidence and competence scores (3/5 to 4/5), only the differences in competence were found to be statistically significant (p < 0.01, Wilcoxon signed-rank test). Improvements in confidence and competence did not correlate. The mean fidelity scores of both the maxillary and mandibular models were adequate at 3.2 out of 5. Overall, satisfaction with the course was high (5/5). CONCLUSIONS: The six-step approach provides a guided process for educators to formulate a training course directed toward the perceived needs of students. Targeted training can significantly enhance the students' competence. Greater efforts should also be put in place to allow simultaneous developments in the students' confidence along with their competence.

Implant presence-triggered osteonecrosis: A scoping review.

Unlike medication-related osteonecrosis of the jaw (MRONJ), implant presence-triggered osteonecrosis of the jaw (IPTO) is not well appreciated. Recent reports have suggested a mechanical aetiology unique to osseointegrated dental implants that may be responsible for this phenomenon. A scoping review was performed to consolidate the available evidence. Two reviewers independently searched the PubMed, EMBASE, CINAHL, and Cochrane Library databases. The study was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) extension for scoping reviews. Studies that described or evaluated the development of IPTO in osseointegrated implants, which were placed prior to the commencement of anti-resorptive or anti-angiogenic agents, were included. Twenty-three (23) articles were included in this study. Patient characteristics, aetiopathogenesis, presentation, and treatment of the disease were evaluated. Most studies suggested a 6-month period between dental implant insertion and the commencement of anti-resorptive therapy as a criterion for IPTO. Both infective and mechanical processes were reported to be involved in the pathogenesis of IPTO. Most patients required surgical intervention to achieve resolution. While there are several knowledge gaps regarding IPTO, the evidence points towards a continuum in the pathogenesis of the disease, whereby there is a mechanical cause followed by secondary infection. Similar to typical MRONJ, the severity and treatment required also vary. Persistent peri­implantitis features around a dental implant should alert the clinician to the possibility of IPTO in patients taking anti-resorptive or anti-angiogenic agents. Prompt identification of the disease may play a role in timely management or appropriate referrals.

Cross sectional study on the competence and confidence of dental students and graduates in the management of medically compromised patients and acute medical emergencies.

A rapidly aging population means many people have multiple health issues leading to an increased risk of acute medical emergencies. The objective of this study was to evaluate how essential experiential learning is in developing dental graduates' ability to manage medically compromised patients. Three hundred and twenty-seven students and graduates were invited to participate in an online survey to rate their confidence in managing medically compromised patients and acute medical emergencies using a 5-point Likert scale. Competence of knowledge was evaluated using 30 multiple choice questions (MCQs) across six domains. The respondents were also asked whether a theory-only training adequately prepared them to manage medically compromised patients, or whether it must be supplemented with clinical training. Two-hundred and sixty-four responses were collected from 75 undergraduates (UG), 96 junior dental officers (JDO) and 93 senior dental officers (SDO). The UG reported that they infrequently managed medically compromised patients, whereas both the JDO and SDO reported having frequent encounters with these patients. The mean confidence scale in the management of medically compromised patients were 2.62, 3.50 and 3.69 (out of 5), respectively. In contrast, their confidence scale in the management of acute medical emergencies was 2.05, 2.33 and 2.50 (out of 5), respectively. The MCQ scores were 25.51, 26.44 and 26.86 out of 30, respectively. The outcomes of the JDO and SDO were significantly better than the UG (t-tests, p<0.05). All three groups responded that a theory-only training in dental school did not adequately prepare them to manage medically compromised patients. Both the JDO and SDO felt that their clinical work experience better prepared them to manage these patients. Experiential learning from "real-life" clinical experience is an essential component in developing graduates' confidence and competence in the management of medically compromised patients. A dental curriculum with theory-only training in this aspect is inadequate.

Validation of low-cost mobile phone applications and comparison with professional imaging systems for three-dimensional facial imaging: A pilot study.

PURPOSE: The objective of this study was to investigate the accuracies of three-dimensional (3D) facial scanning mobile phone applications as compared to professional 3D facial imaging systems. MATERIALS AND METHODS: A manikin head model was used as the subject for comparing six 3D facial imaging systems which comprised three professional 3D scanners (3dMDface, Artec Eva and Vectra H2) and three mobile phone applications (Bellus3D, ScandyPro and Hedges). For each system, five scans were taken to analyse (1) linear accuracy using 9 measurements (2) global and (3) regional 3D accuracy of the scanned surface by root mean square (RMS) and colour map analysis. Another set of five scans was repeated by a second operator to evaluate the inter-operator reproducibility for each system. RESULTS: All the facial imaging systems had absolute errors lesser than 1.0 mm for the linear measurements. The technical error of measurement (TEM) for inter-examiner and intra-examiner linear measurements were within acceptable limits. Artec Eva, Vectra H2 and Scandy Pro had poor global 3D trueness (RMS > 1.0 mm) but good 3D regional trueness (RMS < 1.0 mm). 3dMDface, Bellus3D Face App and Heges had good global and regional 3D trueness. All the facial imaging systems had good global and regional 3D precision and reproducibility (RMS < 1.0 mm). CONCLUSION: This study demonstrated that mobile phone 3D scanning applications had comparable trueness, precision and reproducibility to professional systems. Colour map analysis supplemented the use of the RMS value to demonstrate facial regions of significant deviation. Clinicians should also consider the specific area or region of inaccuracies for each system to determine whether the chosen system is appropriate for the clinical condition or procedure. CLINICAL SIGNIFICANCE: Mobile phone 3D facial imaging applications may be as accurate as 3D professional facial scanning systems for craniomaxillofacial purposes. However, the choice of the system may vary depending on the specific area of interest.

Orthognathic Surgery for Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) involves obstruction or reduction of an individual's airway during sleep and is associated with several comorbidities. Patient evaluation includes detailed history, clinical and radiographic examination, endoscopy, and polysomnography. Management may be nonsurgical or surgical, and Phase II of the Stanford Protocol of surgical management involves maxillomandibular advancement (MMA). Surgical considerations (eg, degree of movement, timing of surgery) and potential complications specific to MMA are discussed in this review. With adequate planning and communication with the patient, MMA is effective in treating OSA, as measured with objective and subjective measures.

Virtual surgical planning in orthognathic surgery: a dental hospital's 10-year experience.

PURPOSE: The primary objective of this study was to evaluate how the utilization of virtual surgical planning (VSP) and the epidemiological profile of patients undergoing orthognathic surgery (OGS) have changed in the past decade. METHODS: The records of patients who had undergone orthognathic surgery at a national dental hospital were reviewed. Trends in VSP, epidemiological data, presentation of dentofacial deformity, and management details were recorded. RESULTS: A total of 1184 patients were included in this study. The majority of the patients seeking treatment in this dental hospital were young Chinese adults with dentofacial deformities requiring bimaxillary surgeries. Most patients presented with a skeletal Class III pattern (79.0%), and asymmetry was diagnosed in 80.8% of all cases. CONCLUSION: There was an initial slow pick-up rate for VSP, but this rapidly increased to a high adoption rate of 98.7-100% between 2019 and 2021. Together with an increasing body of evidence suggesting greater accuracy in VSP, utilization in this technology can be enhanced with greater familiarity with the technology and improvements in the VSP services.

The effects of VY closure on lip morphology after Le Fort I maxillary advancement: A systematic review.

VY closure of the Le Fort 1 incision may commonly be indicated to mitigate the lip shortening effects of maxillary advancement. The objective of this systematic review was to investigate if VY closure prevents lip shortening when compared with conventional continuous closure (CS) methods, in patients who underwent le fort 1 maxillary advancement. PubMed, Embase, and Cochrane Library databases were accessed. Hand searching was also performed. Observational studies, non-randomised and randomized controlled trials were included if Le Fort 1 maxillary advancement was performed to correct a dentofacial deformity. Comparisons were made between VY and CS, and morphological changes to the upper lip were evaluated. The demographic data, study methodology, magnitude of maxillary movements and outcomes related to the lip morphology (length, vermillion exposure, thickness and angulation) were extracted. The search yielded 487 articles. Six studies were included after the application of the selection criteria. A total of 100 and 94 patients received CS and VY respectively. VY was not found to reliably prevent lip shortening. VY was more likely to mitigate lip shortening when there is a large maxillary advancement. It was consistent for a protrusive or "rolled-out" lip morphology to occur after a VY closure. This was demonstrated by the increase in lip vermillion exposure, thickness, and angulation. VY closure was a useful adjunctive technique in patients undergoing large maxillary advancements to mitigate the lip shortening effect from the procedure. Surgeons who employ this technique must also be aware of the consequence of a more protrusive lip with increased vermillion exposure and assess if this would be aesthetically desirable for the individual patient.

Dental Evaluation Prior to Cancer Therapy.

A comprehensive oral examination and dental care prior to the start of cancer therapy is the standard of care in many cancer centers. This is because good oral health will likely minimize the undesirable complications such as opportunistic infections during cancer therapy. As the considerations differ between anti-neoplastic regimens, this chapter discusses the indications and rationale when planning and executing a treatment plan for patients undergoing various cancer therapies.

Should we stop dual anti-platelet therapy for dental extractions? An umbrella review for this dental dilemma.

OBJECTIVES: Dual Anti-platelet Therapy (DAPT) are prescribed to patients who had or are at risk of cerebrovascular or cardiovascular ischemic events. This umbrella review appraises existing systematic reviews on the risk of bleeding related complications during and after dental extractions for patients on DAPT. STUDY DATA AND SOURCES: This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered to the PROSPERO (International prospective register of systematic reviews) database. A systematic electronic literature search was conducted according to the PRISMA guidelines, via PubMed, Ovid, Cochrane and Embase. STUDY SELECTION: Four systematic reviews met the inclusion criteria and were included the analysis. They show DAPT increases the risk of bleeding related complications after dental extractions, but the differences may not be clinically significant as local haemostatic measures were adequate in controlling bleeding. CONCLUSION: Despite the increased risk of bleeding after dental extractions in patients on DAPT, it may not be necessary to interrupt the anti-platelet therapy. Local haemostatic agents may be sufficient in controlling both the primary or secondary bleeding. On the other hand, the complications of discontinuing DAPT may be more severe and fatal.

Use of anterior ramus bone graft for mandibular reconstruction in elderly patients.

In this study, we investigated the feasibility of using a geometrically designed anterior ramus graft to reconstruct lateral mandibular defects. This was achieved by assessing the anatomical dimensions of the mandibular ramus on computed-tomographies. The design sequence and application of the graft was also demonstrated using one of our cases. The following dimensions were measured; a and b - horizontal length from mid-ramus to the posterior and anterior ramus border respectively, c - longest length of the graft, Mp - width at the centre of the ramus, h - vertical length of the angle at its cross-section, w - horizontal length of the angle at its cross-section, x - cross-sectional area along the mandible angle. A total of 80 mandibular rami were examined. The mean length of a, b, c were 17.3 ± 1.8 mm, 15.9 ± 1.2 mm, 54.6 ± 3.8 mm, respectively. The mean width of Mp was 9.8 ± 1.1 mm. The mean cross section area of Eo-Md (x) was 326.7 ± 67.8 mm2. The average length of h and w were 26.5 ± 3.2 and 15.6 ± 2.1 mm, respectively. The use of virtual surgical planning (VSP) to geometrically design the graft was also described. Together with VSP, the anterior ramus bone graft will allow for reconstruction of the mandible with greater surgical efficiency, reduced complexity and without the need for extra-oral bone harvest. This may be an useful alternative in situations where simpler reconstructive procedures are preferred.

Accuracy of 3-dimensional soft tissue prediction for orthognathic surgery in a Chinese population.

OBJECTIVES: This study aims to determine the validity of a 3D planning software in predicting the soft tissue outcome of Chinese patients undergoing orthognathic surgery for correction of Skeletal III dentofacial deformity. METHODS: Pre- and post-operative 3D facial stereophotogrammetric scans and cone beam computed tomography were taken for 10 Chinese patients who had underwent orthognathic surgery. The pre-operative 3D facial scan was integrated with the pre-operative CBCT using the ProPlan CMF software. The simulated soft tissue 3D face was then compared with the actual 3D facial scan obtained at least 6 months postoperatively. Two outcome measures were computed as follows (i) mean absolute difference between meshes (ii) percentage of points where the distance between the two meshes is 2mm or less. RESULTS: The mean absolute difference between the predicted and actual soft tissue surface meshes for the full face and the 6 anatomic regions ranged from 0.72mm to 1.42 mm. The mean absolute distance between the meshes for all the anatomic regions were within 2 mm (p<0.05). The percentage of mesh points with less than 2mm error ranged from 72.5% to 92.5%. The accuracy of soft tissue prediction, assessed using mean absolute distance for the full face, was significantly correlated to the amount of sagittal surgical movement (r=0.707, p=0.022). The lower lip was also found to be the least accurate. CONCLUSIONS: Using ProPlan CMF, the accuracy of 3D soft tissue predictions for bimaxillary orthognathic surgery in Chinese Skeletal III patients were clinically satisfactory.