Effect of Advanced Platelet-Rich Fibrin (A-PRF) on Postoperative Level of Pain and Swelling Following Third Molar Surgery.

BACKGROUND: Postoperative pain and swelling following third molar (M3) removal can be debilitating, and there is interest in using advanced platelet-rich fibrin (A-PRF) to reduce their severity. PURPOSE: This study compared postoperative pain and swelling between A-PRF and gelatin dressing in extraction sockets following mandibular M3 removal. METHODS, SETTING, SAMPLE: This split-mouth, single-blinded, randomized controlled trial was completed at the Oral Surgery clinic of University of Otago between November 2020 and July 2021. Patients aged between 16 and 40 years with bilaterally impacted mandibular M3 of similar Pederson index difficulty and deemed to be American Society of Anesthesiologists (ASA) I or II comprised the study sample. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: The exposure variable was M3 socket management. One socket received A-PRF and 1 gelatin dressing, while the other received 2 gelatin dressings. MAIN OUTCOME VARIABLE(S): The outcome variables were postoperative pain and swelling over 7 days. Pain was measured using the visual analog scale (VAS), and swelling using stereophotogrammetry. COVARIATES: Demographic characteristics (gender, ethnicity, and age), dental anxiety, smoking status, Pederson index, and intraoperative surgical time were the covariates. ANALYSES: The two sides were compared using cross-tabulations and the McNemar test for categorical and paired t-tests for continuous variables. Statistical analysis used IBM SPSS Statistics for Windows (version 28).The Alpha level was 0.05. RESULTS: 76 (87.3%) of 87 patients who met the eligibility criteria participated in the study, and 70 patients (65.7% female; age range 16-30 years) were included in the analysis. Mean visual analog scale scores showed no statistically significant difference between the A-PRF and control sides, being 29.6 (95% CI 23.9, 35.3) and 29.5 (95% CI 23.5, 35.5) on day 2, and falling to 12.6 (95% CI 8.7, 16.5) and 14.2 (95% CI 10.0, 18.4) by day 7. Likewise, mean peak facial swelling on day 2 was recorded as 6.3 cm3 (95% CI 4.9, 7.7) and 6.6 cm3 (95% CI 5.5, 7.7), and by day 7 they were 1.1 cm3 (95% CI 0.5, 1.7) and 1.0 cm3 (95% CI 0.3, 0.7) on the A-PRF and control sides, respectively. CONCLUSIONS: A-PRF placement in M3 sockets did not reduce postoperative pain and swelling over gelatin dressing alone.

Trends in maxillofacial fractures in Otago-Southland, New Zealand: 2009 to 2020.

AIMS: Fractures to the maxillofacial region can have a serious impact on quality of life. The over-representation of males in the occurrence of almost all types and mechanisms of these injuries has tended to divert attention away from maxillofacial fractures in females. This study aimed to describe trends in maxillofacial trauma in a New Zealand tertiary trauma centre over a 12 year period, with a particular focus on gender differences. METHOD: A retrospective audit was undertaken of records for maxillofacial fracture cases referred to Dunedin Hospital and Southland Hospital Maxillofacial Units during the period January 2009 to December 2020. Information on age, gender and ethnicity, aetiology, alcohol and/or drug involvement, fracture type, and management was obtained from the Southern District Health Board - Health Connect South Network. RESULTS: Over the observation period, 1,561 patients presented for a total of 2,480 fractures. There was an increase in the proportion of fractures arising from falls and involving the orbit, while those due to interpersonal violence (IPV) or involving the mandible fell. Additionally, the proportion of cases treated conservatively rose, while the use of surgical fixation fell. While overall just over one in five patients were female, that proportion increased from one in six in 2009-2011 to one in four in 2018-2020. Fractures among females were due mainly to falls (55.6%) and road traffic accidents (23.2%), and frequently involved the orbit (46.3%). The proportion of presentations involving people aged 50 or older also increased over time. CONCLUSIONS: A greater proportion of women are suffering from facial fractures in the past decade than they have previously. Public health interventions for those at risk and their families are necessary. Interventions should have a focus on preventing falls and domestic violence, with a particular focus on older people and Maori/Pasifika populations. Improved and continued monitoring of these changing patterns is important for addressing the issues they present to New Zealand.

Lyophilised Platelet-Rich Fibrin: Physical and Biological Characterisation.

BACKGROUND: Platelet-rich fibrin (PRF) has gained popularity in craniofacial surgery, as it provides an excellent reservoir of autologous growth factors (GFs) that are essential for bone regeneration. However, the low elastic modulus, short-term clinical application, poor storage potential and limitations in emergency therapy use restrict its more widespread clinical application. This study fabricates lyophilised PRF (Ly-PRF), evaluates its physical and biological properties, and explores its application for craniofacial tissue engineering purposes. MATERIAL AND METHODS: A lyophilisation method was applied, and the outcome was evaluated and compared with traditionally prepared PRF. We investigated how lyophilisation affected PRF's physical characteristics and biological properties by determining: (1) the physical and morphological architecture of Ly-PRF using SEM, and (2) the kinetic release of PDGF-AB using ELISA. RESULTS: Ly-PRF exhibited a dense and homogeneous interconnected 3D fibrin network. Moreover, clusters of morphologically consistent cells of platelets and leukocytes were apparent within Ly-PRF, along with evidence of PDGF-AB release in accordance with previously reports. CONCLUSIONS: The protocol established in this study for Ly-PRF preparation demonstrated versatility, and provides a biomaterial with growth factor release for potential use as a craniofacial bioscaffold.

Potential of Lyophilized Platelet Concentrates for Craniofacial Tissue Regenerative Therapies.

OBJECTIVE: The use of platelet concentrates (PCs) in oral and maxillofacial surgery, periodontology, and craniofacial surgery has been reported. While PCs provide a rich reservoir of autologous bioactive growth factors for tissue regeneration, their drawbacks include lack of utility for long-term application, low elastic modulus and strength, and limited storage capability. These issues restrict their broader application. This review focuses on the lyophilization of PCs (LPCs) and how this processing approach affects their biological and mechanical properties for application as a bioactive scaffold for craniofacial tissue regeneration. MATERIALS AND METHODS: A comprehensive search of five electronic databases, including Medline, PubMed, EMBASE, Web of Science, and Scopus, was conducted from 1946 until 2019 using a combination of search terms relating to this topic. RESULTS: Ten manuscripts were identified as being relevant. The use of LPCs was mostly studied in in vitro and in vivo craniofacial bone regeneration models. Notably, one clinical study reported the utility of LPCs for guided bone regeneration prior to dental implant placement. CONCLUSIONS: Lyophilization can enhance the inherent characteristics of PCs and extends shelf-life, enable their use in emergency surgery, and improve storage and transportation capabilities. In light of this, further preclinical studies and clinical trials are required, as LPCs offer a potential approach for clinical application in craniofacial tissue regeneration.

Mechanical properties of the human scalp in tension.

Mechanical properties of the human scalp have not been investigated to a great extent with limited information available. The purpose of this study was to provide new baseline material data for human scalp tissue of various ages, which can be applied to experimental and constitutive models, such as in the area of impact biomechanics. This study used specimens from the left and right temporal, fronto-parietal and occipital regions of the human scalp. It investigated the tensile behavior of scalp tissue using tissues harvested from unfixed, fresh cadavers. These samples were subjected to an osmotic stress analysis and upon testing, cyclic loading followed by stretching until failure in a universal testing machine. Strain evaluation was conducted using digital image correlation in a highly standardized approach. Elastic modulus, tensile strength, strain at maximum load and strain to failure were evaluated computationally. No significant differences were observed comparing the tensile strength between males and females. In contrast to that, a sex-dependent difference was found for the elastic modulus of the occipital scalp region and for the elongation properties. Additionally, regional differences within the male group, as well as an age dependent correlation for females were found in the elastic modulus and tensile strength. Scanning electron microscope analyses have shown the ultrastructural failure patterns, indicated by damaged keratin plates, as well as partially disrupted and retraced collagens at the failure site. The novel data obtained in this study could add valuable information to be used for modeling purposes, as well as provide baseline data for simulant materials and comparisons of tissue properties following head injury or forensic investigations.

Elastic behavior of brain simulants in comparison to porcine brain at different loading velocities.

Blunt force impacts to the head and the resulting internal force transmission to the brain and other cranial tissue are difficult to measure. To model blunt force impact scenarios, the compressive properties resembling tissue elasticity are of importance. Therefore, this study investigated and compared the elastic behavior of gelatin, alginate, agar/glycerol and agar/glycerol/water simulant materials to that of porcine brain in a fresh and unfixed condition. Specimens, 10 × 10 × 10mm3, were fabricated and tested at 22°C, apart from gelatin which was conditioned to 4°C prior to testing. For comparison, fresh porcine brains were sourced and prepared to the same dimensions as the simulants. Specimens underwent compression tests at crosshead displacement rates of 2.5, 10 and 16mms-1 (equivalent to strain rates of 0.25, 1 and 1.6s-1), obtaining apparent elastic moduli values at different strain rate intervals (0-0.2, 0.2-0.4 and 0.4-0.5). The results of this study indicate that overall all simulant materials had an apparent elastic moduli similar in magnitude across all strain ranges compared to brain, even though comparatively higher, especially the apparent elastic moduli values of alginate. In conclusion, while agar/glycerol/water and agar/glycerol had similar apparent elastic moduli in magnitude and the closest apparent elastic moduli in the initial strain range (E1), gelatin showed the most similar values to fresh porcine brain at the transitional (E2) and higher strain range (E3). The simulant materials and the fresh porcine brain exhibited strain rate dependent behavior, with increasing elastic moduli upon increasing loading velocities.

Efficacy of Codeine When Added to Paracetamol (Acetaminophen) and Ibuprofen for Relief of Postoperative Pain After Surgical Removal of Impacted Third Molars: A Double-Blinded Randomized Control Trial.

PURPOSE: The use of opioids in combination with nonopioids is common practice for acute pain management after third molar surgery. One such combination is paracetamol, ibuprofen, and codeine. The authors assessed the efficacy of codeine when added to a regimen of paracetamol and ibuprofen for pain relief after third molar surgery. MATERIALS AND METHODS: This study was a randomized, double-blinded, placebo-controlled trial conducted in patients undergoing the surgical removal of at least 1 impacted mandibular third molar requiring bone removal. Participants were randomly allocated to a control group (paracetamol 1,000 mg and ibuprofen 400 mg) or an intervention group (paracetamol 1,000 mg, ibuprofen 400 mg, and codeine 60 mg). All participants were treated under intravenous sedation and using identical surgical conditions and technique. Postoperative pain was assessed using the visual analog scale (VAS) every 3 hours (while awake) for the first 48 hours after surgery. Pain was globally assessed using a questionnaire on day 3 after surgery. RESULTS: There were 131 participants (36% men; control group, n = 67; intervention group, n = 64). Baseline characteristics were similar for the 2 groups. Data were analyzed using a modified intention-to-treat analysis and, for this, a linear mixed model was used. The model showed that the baseline VAS score was associated with subsequent VAS scores and that, with each 3-hour period, the VAS score increased by an average of 0.08. The treatment effect was not statistically meaningful, indicating there was no difference in recorded pain levels between the 2 groups during the first 48 hours after mandibular third molar surgery. Similarly, the 2 groups did not differ in their global ratings of postoperative pain. CONCLUSION: Codeine 60 mg added to a regimen of paracetamol 1,000 mg and ibuprofen 400 mg does not improve analgesia after third molar surgery.

Surgical management in dentistry: the interdisciplinary relationship between periodontology and oral and maxillofacial surgery.

Surgical procedures of the oral cavity can be performed by a number of dental specialists and clinicians. Because of the limited number of surgical procedures that can be performed inside the oral cavity, the boundaries between specialties may become indistinct and lead to confusion for general dentists in terms of patient referrals. In this article, what the two surgical specialties of dentistry (i.e. periodontology and oral and maxillofacial surgery) have to offer is highlighted, together with clinical examples to illustrate the interdisciplinary relationship between them.

Damage control surgery and combat-related maxillofacial and cervical injuries: a systematic review.

Damage control surgery involves rapid assessment, life-saving resuscitation, and abbreviated surgery for a patient with severe injuries. Traditionally the concept of damage control surgery has been restricted to penetrating abdominal injuries, but more recently it has been expanded to areas outside of the abdomen including the maxillofacial and neck regions. However, we know of little evidence that, when applied to injuries to the face and neck, it changes outcomes. We systematically reviewed published papers to identify those that discussed damage control in the context of combat-related trauma of the face and neck. We identified three papers that discussed the principles of managing combat-related maxillofacial injuries, all three of which were review articles that advocated the use of damage control principles in facial injuries either in isolation or as part of a multisystem approach. Anecdotal experience and opinion indicates that the concept of damage control is applicable when managing combat-related injuries of the face and neck, but no outcomes were confirmed. Further studies are required to validate the concept.

Post-operative complications following dental extractions at the School of Dentistry, University of Otago.

OBJECTIVES: To determine the frequency and correlates associations of post-extraction complications at a dental school. DESIGN: Retrospective review of patient records. SETTING: Exodontia clinic at the School of Dentistry, University of Otago, Dunedin. MAIN OUTCOME MEASURES: Provider characteristics, patient demographic characteristics, patient medical history, teeth extracted and occurrence of postoperative complications. RESULTS: Of the 598 extractions (540 routine and 58 surgical) which were undertaken in the audit period, 74 (12.4%) resulted in post-operative complications. Dry socket and post-operative pain were the major complications. A higher complication rate was found among patients treated by fourth-year undergraduate students than among those treated by more senior students or staff. Post-operative complications were not significantly associated with patients' ethnicity or medical history. CONCLUSION: The rate of postoperative complications at the Univeristy of Otago's Faculty of Dentistry is consistent with reports in existing literature and inversely associated with operators' experience.

The thickness of parietal bones in a new zealand sample of cadaveric skulls in relation to calvarial bone graft.

Objectives To evaluate the average thickness of the parietal bones in their different regions to identify the ideal site(s) for calvarial bone graft harvest. Methods and Materials Thickness of the parietal bones of 25 wet cranial vaults of New Zealand European origin was measured in 135 different locations using an electronic caliper. Analyses to identify the ideal harvest sites were conducted so that the sites fit the features of an ideal harvest site described in the literature as: (1) 6 mm of minimum thickness and (2) 2 cm away from the midline. Results and Conclusion The overall average thickness was 6.69 ± 0.22 mm. The average thickness at different sites within the same bone ranged from 2.85 to 6.93 mm. In keeping with previous studies, the report observed a progressive thickening of the parietal bone in medial and posterior directions. Of the 135 different locations measured, only 20% exceeded an average thickness of 6 mm as well as being 2 cm away from the sagittal midline. These locations were mainly located between 6 to 11 cm posterior to the coronal suture and 2 to 5 cm away from the sagittal suture. Conclusion Harvesting the calvarial bone graft in the area 6 to 11 cm posterior to the coronal suture and 2 cm away from the midline is recommended based on our study using cadaveric cranial vaults of New Zealand Europeans.

Influence of a pedicle flap design on acute postoperative sequelae after lower third molar removal.

Pain, swelling, trismus, and alveolar osteitis often occur after removal of impacted third molar teeth. To minimize these complications a number of mucoperiosteal flap designs have been advocated, but, to date, a pedicle flap design has not been evaluated. In a randomized prospective split mouth study, 52 participants had bilateral symmetrically impacted mandibular third molars removed over two sessions. A buccal envelope or pedicle flap was randomly assigned to the left or right third molar site. Pre-and postoperative pain and swelling were recorded using a standardized visual analogue scale, trismus was measured as the maximum inter-incisal opening distance in millimetres and dry socket was assessed clinically. Greater continuous pain, pain on maximum opening, and oro-facial swelling were recorded with the pedicle flap design. Continuous pain resolved significantly faster with this flap design (p<0.05). Trismus was similar for both flap designs (p>0.05). Five cases of alveolar osteitis occurred with the envelope flap whilst no cases developed with the pedicle flap, but the incidence was too small for statistical analysis. The pedicle flap improved some aspects of postoperative pain experience and reduced the incidence of alveolar osteitis, but further investigation with a larger sample size is required to evaluate its significance.

Common medications among dental outpatients: considerations in general dental practice.

OBJECTIVES: To provide information about the most common medications listed as being taken by dental patients presenting to an outpatient setting at a tertiary institution and to establish a list of the most common medications for review for the general dental practitioner. METHODS: A retrospective review was undertaken of 300 dental outpatient notes chosen from patients seen in the urgent dental care and exodontia clinics at the School of Dentistry in Dunedin. Data were recorded on patient age, medication list reported at the time of presentation and the number of medications. The ten most common medications encountered were listed in order of frequency, along with the ten most common prescription medications and the most common supplements or alternative remedies. A concise pharmacological synopsis for each of the ten most common medications was then presented as a review. RESULTS: The age range of patients was from 18 to 88 years, with a mean age of 43.2 years (median age 41 years). More than one-quarter were aged 20-29 years. Some 56% of patients reported taking at least one medication at the time of presentation. The greatest number of medications being taken by an individual patient was 15. Of 138 different medications identified, the most commonly reported included aspirin, paracetamol and omeprazole. A list of the ten most common medications was established for concise review, in order to outline aspects important to the general dental practitioner. CONCLUSIONS: This study provides information on the most common medications reported among dental outpatients presenting to a tertiary institution and highlights the need for general dental practitioners to be knowledgeable about them and their impact on dental treatment.

Interdisciplinary approach to the management of an 18-month-old burn victim in Afghanistan.

An 18-month-old boy with partial and full thickness burns to his upper face and scalp was treated by an interdisciplinary team at the Role 3 Multinational Medical Unit in Kandahar. A novel approach to his burn management is presented, highlighting some of the issues and constraints that military surgeons are faced with while on operational deployment in a theater of conflict.

Concordance between clinical and histopathologic diagnoses of oral mucosal lesions.

PURPOSE: To study the epidemiology of oral soft tissue lesions in New Zealand from 2002 to 2006 and to determine the concordance between the clinical diagnosis and the definitive histopathologic diagnosis achieved by general dental practitioners and by specialists. MATERIALS AND METHODS: The details from biopsy referrals and the corresponding histopathologic reports of oral soft tissue lesions were recorded into a statistical software package, and the concordance between the clinical diagnosis and histopathologic diagnosis was determined for all the lesions. RESULTS: Most biopsies were benign lesions, and both clinician groups achieved a high diagnostic concordance for these lesions. However, when considering all lesion types, the overall concordance for both groups was a moderate 50.6%, with little difference between specialists and general dental practitioners, although specialists were more accurate in diagnosing a malignant or premalignant lesion. CONCLUSIONS: The clinical and histopathologic concordance achieved by oral health practitioners in New Zealand appears to be moderate.

A nine-year review of orthognathic surgery at the University of Otago.

OBJECTIVE: To describe the demographic characteristics of patients undergoing orthognathic surgery at the University of Otago over a nine-year period. METHODS: The case notes of patients who underwent orthognathic surgery procedures at the University of Otago from 2001 to 2009 were reviewed retrospectively. This was augmented with a brief literature review of surgical considerations and complications in orthognathic surgery among older patients. RESULTS: The 92 patients included in the study were aged 15 to 56 years. The mean patient age increased over the nine-year observation period, from 22.1 years (sd, 9.4) during 2001-2003, 25.0 years (sd, 12.7) during 2004-2006, to 27.7 years (sd, 11.4) during 2007-2009. Most patients were from New Zealand European or European backgrounds, with only 5.5% identifying as Maori, and 3.3% as Asian. A female preponderance was observed (with a female:male ratio of 1.6:1). Complications were encountered with 24 patients (26.1%). Ten patients had long-term (lasting for one year or more) sensory nerve disturbance; all of those had undergone a mandibular bilateral sagittal split osteotomy (BSSO) procedure (they comprised 12.7% of all BSSO patients treated); half of those patients were over 35 years old, and four were over 40 years old. CONCLUSIONS: There has been an increase in the proportion of older patients undergoing orthognathic surgery at the University of Otago. Observations from this case series support findings from other studies demonstrating a higher rate of sensory nerve disturbance among older BSSO patients.

Influence of two different flap designs on incidence of pain, swelling, trismus, and alveolar osteitis in the week following third molar surgery.

OBJECTIVE: To investigate the influence of flap design on postoperative trismus, pain, and swelling. STUDY DESIGN: Thirty-two patients with bilateral symmetrically impacted mandibular third molars participated in a randomized prospective split mouth study. Two flap designs were used: a buccal envelope flap and a modified triangular flap. Postoperative pain was recorded using a standardized visual analog scale. Postoperative swelling was evaluated using laser scans of models of the patient's cheek taken before and two days after surgery, with the scan area being calculated using MatLab software. RESULTS: There were no statistical differences between the flap designs in terms of severity of postoperative pain or trismus. A statistically significant difference was observed in postoperative swelling at 2 days, with the modified triangular flap design being associated with increased swelling. The envelope flap design was associated with a higher incidence of alveolar osteitis. CONCLUSION: The flap designs used in this study did not adversely affect patients in terms of postoperative pain and trismus, and although greater extraoral swelling was seen with the modified triangular flap design, the clinical relevance is debatable.

Antibiotic prophylaxis in dialysis patients undergoing invasive dental treatment.

BACKGROUND AND AIMS: The role of antibiotic prophylaxis for invasive dental procedures in patients on dialysis therapy is unclear. We examined current clinical practice in Australia and New Zealand and compared our findings to a systematic review of the current literature. METHODS: Australian and New Zealand nephrology units were surveyed with regard to their use of antibiotic prophylaxis for dental procedures. A systematic review of the literature was performed by using an online web-based search engine (PubMed) using the key words: renal patients, dental and antibiotic prophylaxis. RESULTS: Forty-one per cent of respondents do not routinely give antibiotic prophylaxis to haemodialysis patients prior to dental surgery, but a majority (53%) would consider antibiotic prophylaxis if the patient had a synthetic arteriovenous fistula. CONCLUSIONS: The majority of clinicians follow the American Heart Association (AHA) guidelines with a single oral preoperative dose of 2 g amoxycillin or 600 mg clindamycin if patients are allergic to penicillin. From the literature and the data obtained by questionnaire, it would appear that renal patients receiving haemodialysis in Australia and New Zealand receive antibiotic prophylaxis prior to invasive dental procedures. The standard single dose of 2 g amoxycillin orally or 600 mg clindamycin orally 1 h preoperatively, as recommended by the AHA, is most frequently used. Peritoneal dialysis patients generally do not receive a prophylactic dose of antibiotics.