Hemostatic agents in endodontic surgery of maxillary molars: A randomized controlled pilot study of polytetrafluoroethylene (PTFE) strips as an adjunct to epinephrine impregnated gauze versus aluminum chloride

BACKGROUND: Hemostasis is of critical importance in endodontic surgery. Studies on bleeding control in maxillary molars are scarce. The present study compares the efficacy of two hemostatic techniques in controlling bleeding in endodontic surgery. MATERIAL AND METHODS: A randomized two-arm pilot study involving 30 patients with peri-radicular lesions in maxillary molars (first and second molars) was carried out including the following hemostatic agents: polytetrafluoroethylene (PTFE) strips as an adjunct to epinephrine impregnated gauze (test group; n = 15) and aluminum chloride (Expasyl(TM)) (control; n = 15). Bleeding control was independently assessed by the surgeon and by two blinded observers before and after application of the hemostatic agent, and was classified as either adequate (complete bleeding control) or inadequate (incomplete bleeding control). RESULTS: Bleeding control was similar in both groups. Simple binary logistic regression analysis failed to identify variables affecting bleeding control. Only the height of the keratinized mucosal band (≥ 2 mm) suggested a decreased risk of inadequate bleeding control of up to 89% (OR = 0.11; p = 0.06). CONCLUSIONS: No difference in the efficacy of bleeding control was observed between PTFE strips as an adjunct to epinephrine impregnated gauze and aluminum chloride in maxillary molars

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Efficacy of infiltrative local anesthesia and inferior alveolar nerve block in periapical surgery of lower premolars and molars: A preliminary report.

BACKGROUND: The aims of this study were: 1) compare the amount of anesthesia used with the anesthetic technique; 2) relate the quantity of anesthesia needed with the level of anxiety of the patient; 3) study the relationship between the anesthetic technique and the level of hemostasis; 4) correlate the amount of anesthesia with patient and tooth dependent variables. MATERIAL AND METHODS: A randomized controlled trial was designed with two parallel groups according to the anesthetic technique: infiltrative local anesthesia (infiltrative group) and inferior alveolar nerve block (block group). The following variables were collected: sex, age, smoking habits, plaque index, symptoms, signs, position of the tooth and amount of anesthesia. Before surgery, all patients were asked to assess their anxiety on a six-item questionnaire, the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The analysis of the hemorrhage control of aluminum chloride was judged by the surgeon and two examiners independently and recorded it as: 0 (no hemorrhage control), 1 (slight but apparent intermittent bleeding persisted after application of the material), or 2 (complete hemorrhage control). RESULTS: Twenty patients were included in this preliminary report. The amount of anesthesia used was lower in block group and in less anxious patients, although these results did not reach statistical significance. A relationship was found between the quantity of anesthesia used and a good hemostasis of the bony crypt before the application of the hemostatic agent (p<.05); and between elderly patients and a lower amount of anesthetic reinforcement (p<.05). CONCLUSIONS: Based on these preliminary results, we can conclude that no statistical significance difference was found between the amount of anesthesia used and the anesthetic technique or the anxiety. A relationship was found between hemostasis of the bony crypt and the quantity of anesthesia used; and between younger patients and a greater amount of anesthetic reinforcement. Key words:Anesthesia, anxiety, endodontic surgery, hemostasis, hemostatic agents,periradicular surgery.

Pain and quality of life after endodontic surgery with or without advanced platelet-rich fibrin membrane application: a randomized clinical trial.

BACKGROUND: Clinical evidence of the autologous platelet concentrates effects on the patient-reported outcome measures (PROMs) after endodontic surgery is still limited. OBJECTIVES: To investigate the effect of the advanced platelet-rich fibrin (A-PRF+) membrane application upon patient postoperative pain, and quality of life in endodontic surgery. MATERIALS AND METHODS: A two-parallel-arm randomized clinical trial was made comparing endodontic surgery with or without A-PRF+ as adjunctive treatment. Fifty individuals comprehending 50 apical lesions (second premolar to the second premolar) of upper maxilla were included. Pain perception and quality of life (functional limitations and other symptoms) were assessed 1 week after surgery using a visual analog scale and a Likert scale-based questionnaire. Descriptive analysis was done using χ2 and t test. Binary logistic regression, ANOVA-type statistic, and GEE analysis were used for inferential analysis. RESULTS: Pain perception was mild in both groups [A-PRF+ 12.7 ± 8.5] versus [no A-PRF+ 20.7 ± 16.3]; it proved less variable during the first 4 days in test group, showing lower extreme pain values (p = 0.096). Analgesic use was similar in both groups. Controls reported significantly worse sleep and speech functions (p < 0.05). Bleeding and bad taste/breath were the most discriminative symptoms. CONCLUSIONS: Postoperative pain perception was mild in endodontic surgery of the upper anterior maxilla. Differences in pain perception were not statistically significant. The use of A-PRF+ afforded less variable pain perception than in the controls. Altered quality of life parameters were more prevalent in the control group and prove significant for speech and sleep functions. CLINICAL RELEVANCE: Patient-related outcomes are of utmost importance in clinical practice. The use of A-PRF+ provides an affordable and safe alternative to improve postoperative quality of life in endodontic surgery.

Comparison of diagnostic accuracy between periapical and panoramic radiographs and cone beam computed tomography in measuring the periapical area of teeth scheduled for periapical surgery. A cross-sectional study.

BACKGROUND: The aim of the study was compare the sensitivity and measurements obtained from teeth with apical lesions scheduled for periapical surgery using three different diagnostic methods: periapical radiography (Gendex Expert DC), panoramic radiography (Planmeca® Promax 3D Classic) and cone beam computed tomography (CBCT) (Planmeca® Promax 3D Classic). MATERIAL AND METHODS: This cross-sectional study involved 35 patients (45 teeth) scheduled for periapical surgery in which periapical radiographs, panoramic radiographs and CBCT scans had been obtained. The images were used to analyze the maximum vertical and horizontal dimension and the resulting areas of the periapical lesions based on the three diagnostic methods. RESULTS: The two-dimensional techniques (periapical radiography and panoramic radiography) yielded a sensitivity of 82% versus 100% in the case of CBCT. The mean vertical dimension of the apical areas was 5.48 mm with periapical radiography and 5.04 mm with panoramic radiography - the difference with respect to CBCT being statistically significant (6.36 mm for the coronal sections). There were no significant differences among the three techniques in terms of horizontal dimension (p>0.05) or lesion area. CONCLUSIONS: The sensitivity of periapical radiolucencies detected using CBCT was significantly greater than with the two-dimensional imaging techniques. Significant differences between the latter and CBCT were only observed in the case of the vertical measurements. Key words:Periapical lesion, apicoectomy, CBCT, periapical radiography, panoramic radiography.

Hemostatic Agents in Endodontic Surgery: A Randomized Controlled Pilot Study of Polytetrafluoroethylene Strips as an Adjunct to Epinephrine Impregnated Gauze Versus Aluminum Chloride.

INTRODUCTION: Bleeding control is an important aspect in endodontic surgery. Two hemostatic techniques were compared with regard to their efficacy to bleeding control in endodontic surgery. METHODS: A randomized, 2-arm, parallel pilot study involving 30 patients with periradicular lesions was performed including the following hemostatic agents: polytetrafluoroethylene strips as an adjunct to epinephrine-impregnated gauze (test group, n = 15) and aluminum chloride (control, n = 15). Bleeding control was independently assessed by the surgeon and 2 blinded observers before and after application of the hemostatic agent. Bleeding control was classified either as adequate (complete bleeding control) or inadequate (incomplete bleeding control). RESULTS: Hemostasis in both groups proved similar. Simple binary logistic regression analysis failed to identify variables affecting bleeding control. Only the height of the keratinized mucosa band (≥2 mm) suggested a risk reduction for an inadequate bleeding control up to 79% (odds ratio = 0.21, P > .05). CONCLUSIONS: No differences in the efficacy of bleeding control were observed between polytetrafluoroethylene strips as an adjunct to epinephrine-impregnated gauze and aluminum chloride.

Aluminum Chloride versus Electrocauterization in Periapical Surgery: A Randomized Controlled Trial.

INTRODUCTION: The aim of this study was to evaluate the efficacy of 2 hemostatic agents in periapical surgery and its relationship with patient- and tooth-dependent variables. METHODS: A prospective study was designed with 2 randomized parallel groups established according to the hemostatic agent used: aluminum chloride or electrocauterization. The surgeon and 2 independent blinded observers examined the initial and final bleeding and recorded it as 0 (no hemorrhage control), 1 (slight but apparent intermittent bleeding), or 2 (complete hemorrhage control). The following patient- and tooth-dependent variables were collected: sex, age, smoking habit, plaque index, and position. RESULTS: Sixty patients with a periapical lesion in the esthetic zone were enrolled in this study and divided into 2 groups of 30 patients. In the aluminum chloride group, complete hemorrhage control was achieved in 24 patients, and in the electrocauterization group, it was achieved in 18 patients (P < .05). A relationship between sex and the effectiveness of hemostasis was found; a female patient increases the possibility of achieving complete hemorrhage control. CONCLUSIONS: Hemorrhage control was better in the aluminum chloride group than in the electrocauterization group as well as in female patients compared with male patients.

Influence of Hemostatic Agents in the Prognosis of Periapical Surgery: A Randomized Study of Epinephrine versus Aluminum Chloride.

INTRODUCTION: Several variables have been associated with a better prognosis of periapical surgery. The aim of this study was to evaluate the influence of 2 hemostatic agents on the prognosis of periapical surgery at 12 months. METHODS: A prospective study was designed with 2 randomized parallel groups established depending on the hemostatic agent used: epinephrine or aluminum chloride. The analysis of the hemorrhage control was recorded as 0 (no hemorrhage control), 1 (slight but apparent intermittent bleeding persisted after application of the material), or 2 (complete hemorrhage control). At 12 months, periapical lesion healing was determined clinically and radiologically as success, improvement, or failure. RESULTS: Ninety-five patients (67 women and 28 men) with periapical lesions involving a single tooth were enrolled in this study; in 45 teeth, epinephrine was used and in 50 teeth aluminum chloride. In the epinephrine group, 28 teeth were classified as successes, 10 as improvements, and 7 as failures. In the aluminum chloride group, 34 teeth were classified as successes, 11 as improvements, and 5 as failures. No statistically significant difference was found. CONCLUSIONS: The present study found no association between the use of epinephrine or aluminum chloride as hemostatic agents on the prognosis of periapical surgery. The efficacy of hemostatic agents at the time of surgery showed no relationship with the healing outcome.

Accuracy of Implant Placement with Computer-Guided Surgery: A Systematic Review and Meta-Analysis Comparing Cadaver, Clinical, and In Vitro Studies.

PURPOSE: The aim of this systematic review was to analyze the accuracy of implant placement using computer-guided surgery and to compare virtual treatment planning and outcome in relation to study type (in vitro, clinical, or cadaver). A further objective was to compare the accuracy of half-guided implant surgery with that of full-guided implant surgery. MATERIALS AND METHODS: A PubMed search was performed to identify studies published between January 2005 and February 2015, searching the keywords "reliability AND dental implant planning" and "accuracy dental implant planning." Inclusion criteria were established a priori. Horizontal coronal deviation, horizontal apical deviation, angular deviation, and vertical deviation were analyzed. RESULTS: A total of 186 articles were reviewed, and 34 fulfilled the inclusion criteria. Information about 3,033 implants was analyzed in 8 in vitro studies (543 implants), 4 cadaver studies (246 implants), and 22 clinical studies (2,244 implants). Significantly less horizontal apical deviation and angular deviation were observed in in vitro studies compared to clinical and cadaver studies, but there were no statistically significant differences in apical coronal deviation or vertical deviation between the groups. Compared to half-guided surgery, full-guided implant surgery showed significantly less horizontal coronal deviation for cadaver studies, significantly less horizontal apical deviation for clinical studies, and significantly less angular deviation for both clinical and cadaver studies. CONCLUSION: Implant placement accuracy was lower in clinical and cadaver studies compared with in vitro studies, especially in terms of horizontal apical deviation and angular deviation. Full-guided implant surgery achieved greater accuracy than half-guided surgery.

Periapical implant lesion: A systematic review

Purpose: The aim of this study was to systematically review the evidence for periapical implant lesion, which makes a patient more susceptible to the periapical lesion, frequency, symptoms, signs (including radiological findings) and possible treatment options. Material and Methods: A systematic literature review and analysis of publications included in PubMed, Embase and Cochrane; articles published until March 2016; with a populations, exposures and outcomes (PEO) search strategy was performed, focused on the issue: 'In patients with periapical lesion to the implant during the osseointegration, what symptoms, signs, and changes in complementary examination manifested, for according to that stage, be intervened with the appropriate approach? '. The set criteria for inclusion were peer-reviewed articles. Results: From a total of 212 papers identified, 36 studies were included in this systematic review, with 15461 implants evaluated and 183 periapical implant lesions. Which 8 papers included more than 5 cases and 28 included equal or less than 5 cases. Analysis of the papers revealed that periapical implant lesion is classified according to evolution stages into acute (non-suppurated and suppurated) and subacute (or suppurated-fistulized). In the acute stage and in the subacute if there is no loss of implant stability, the correct treatment approach is implant periapical surgery. In the subacute stage associated with implant mobility the implant must be removed. Conclusions: Evidence on the subject is very limited, there are few studies with small sample, without homogeneity of criteria for diagnosing the disease and without design of scientific evidence. Currently etiology lacks consensus. The early diagnosis of periapical implant periapical lesions during the osseointegration phase and early treatment, will lead to a higher survival rate of implants treated, hence preventing the need for implant extraction (AU)

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Hemostatic Agents in Periapical Surgery: A Randomized Study of Gauze Impregnated in Epinephrine versus Aluminum Chloride.

INTRODUCTION: Adequate bleeding control is essential for the success of periapical surgery. The aim of this study was to evaluate the effects of 2 hemostatic agents on the outcome of periapical surgery and their relationship with patient and teeth parameters. METHODS: A prospective study was designed with 2 randomized parallel groups, depending on the hemostatic agent used: gauze impregnated in epinephrine (epinephrine group) and aluminum chloride (aluminum chloride group). The analysis of the hemorrhage control was judged before and after the application of the hemostatic agents by the surgeon, and 2 examiners independently recorded it as adequate (complete hemorrhage control) or inadequate (incomplete hemorrhage control). RESULTS: Ninety-nine patients with a periradicular lesion were enrolled in this study and divided into 2 groups: gauze impregnated in epinephrine in 48 patients (epinephrine group) or aluminum chloride in 51 (aluminum chloride group). In epinephrine group adequate hemostasis was achieved in 25 cases, and in aluminum chloride group it was achieved in 37 cases (P < .05). CONCLUSIONS: The outcome was better in the aluminum chloride group than in the gauze impregnated in epinephrine group.

Coronectomy of impacted mandibular third molars: A meta-analysis and systematic review of the literature

BACKGROUND: Coronectomy is an alternative to complete removal of an impacted mandibular third molar. Most authors have recommended coronectomy to prevent damage to the inferior alveolar nerve during surgical extraction of lower third molars. The present study offers a systematic review and metaanalysis of the coronectomy technique. MATERIAL AND METHODS: A systematic review and meta-analysis was performed based on a PubMed and Cochrane databases search for articles published from 2014 and involving coronectomy of mandibular third molars located near the inferior alveolar nerve canal, with a minimum of 10 cases and a minimum follow-up period of 6 months. After application of the inclusion and exclusion criteria, a total of 12 articles were included in the study. Results and DISCUSSION: Coronectomy results in significantly lesser loss of sensitivity of the inferior alveolar nerve and prevents the occurrence of dry socket. No statistically significant differences were observed in the incidence of pain and infection between coronectomy and complete surgical extraction. After coronectomy, the remaining tooth fragment migrates an average of 2 mm within two years. CONCLUSIONS: Coronectomy is indicated when the mandibular third molar is in contact with the inferior alveolar nerve and complete removal of the tooth may cause nerve damage

Influence of the prosthetic arm length (palatal position) of zygomatic implants upon patient satisfaction

BACKGROUND: To assess the influence of the prosthetic arm length (palatal position) of zygomatic implants upon patient comfort and stability, speech, functionality and overall satisfaction. MATERIAL AND METHODS: A retrospective clinical study was made of patients subjected to rehabilitation of atrophic maxilla with complete maxillary implant-supported fixed prostheses involving a minimum of two zygomatic implants (one on each side) in conjunction with premaxillary implants, and with 12 months of follow-up after implant loading. Subjects used a VAS to score general satisfaction, comfort and stability, speech and functionality, and the results were analyzed in relation to the prosthetic arm length of the zygomatic implants 12 months after prosthetic delivery. RESULTS: Twenty-two patients participated in the study, receiving 22 prostheses anchored on 148 implants (44 were zygomatic and 94 were conventional implants). The mean right and left prosthetic arm length was 5.9±2.4 mm and 6.1±2.7 mm, respectively, with no statistically significant differences between them (p = 0.576). The mean scores referred to comfort/retention, speech, functionality and overall satisfaction were high - no correlation being found between prosthetic arm length and patient satisfaction (p = 0.815). CONCLUSIONS: No relationship could be identified between prosthetic arm length (palatal position) and patient satisfaction

Implant treatment in atrophic posterior mandibles: vertical regeneration with block bone grafts versus implants with 5.5-mm intrabony length.

PURPOSE: To retrospectively compare the outcomes of implants placed in posterior mandibles vertically regenerated with onlay autogenous block bone grafts and short dental implants. MATERIALS AND METHODS: Consecutive patients with vertical bone atrophy in edentulous mandibular posterior regions (7 to 8 mm of bone above the inferior alveolar nerve) were treated with either implants placed in regenerated bone using autologous block bone grafts (group 1) or short implants (with 5.5-mm intrabony length) in native bone (group 2) between 2005 and 2010 and followed for 12 months after loading. The procedure used was the established treatment protocol for this type of patient at the Oral Surgery Unit (University of Valencia, Spain) at the time of surgery. All grafts were obtained using piezosurgery. The outcomes assessed were: complications related to the procedure, implant survival, implant success, and peri-implant marginal bone loss. Statistical analysis was done using the Fisher exact test and the Mann-Whitney test. RESULTS: Thirty-seven patients were included, 20 (45 implants) in group 1 and 17 (35 implants) in group 2. In group 1, 13 implants were less than 10 mm long (2 were 7 mm and 11 were 8.5 mm), and 32 were 10 mm or longer; the diameter was 3.6 mm in 6 implants, 4.2 mm in 31, and 5.5 mm in 8. In group 2 all implants were 7 mm long; the diameter measured 4.2 mm in 14 implants and 5.5 mm in 21 implants. Complications related to the block bone grafting procedure were temporary hypoesthesia in one patient, wound dehiscence with graft exposure in three patients, and exposure of the osteosynthesis screw without bone graft exposure in one patient. After 12 months, implant survival rates were 95.6% in group 1 and 97.1 % in group 2; success rates were 91.1% and 97.1%, respectively. The average marginal bone loss was 0.7 ± 1.1 mm in group 1 and 0.6 ± 0.3 mm in group 2. CONCLUSIONS: When residual bone height over the mandibular canal is between 7 and 8 mm, short implants (with 5.5-mm intrabony length) might be a preferable treatment option over vertical augmentation, reducing chair time, expense, and morbidity.

Buccal bone crest dynamics after immediate implant placement and ridge preservation techniques: review of morphometric studies in animals.

PURPOSE: To review morphometric studies performed in animals assessing the dynamics of the buccal bone crest after immediate implant placement and ridge preservation techniques. MATERIAL AND METHOD: A bibliographic search in PubMed was performed. Studies that analyzed morphometrically in animals the buccal bone crest dynamics after immediate implant placement or ridge preservation techniques were included. Twenty-five studies met the inclusion criteria. RESULTS: Immediate implant placement does not prevent the resorption of the buccal bone crest. To minimize this resorption, 2 mm width of the buccal bone crest, palatal/lingual implant placement, and an adequate implant diameter for the width of the ridge are required. The regeneration of the gap after immediate implant placement limits the resorption of the buccal bone crest. Flap elevation and implant surface showed no relation with this resorption. Ridge preservation techniques associated with mucogingival surgery minimize buccal bone crest resorption. Biomaterials are more effective than autograft. CONCLUSIONS: Immediate implant placement does not prevent the resorption of the buccal bone crest after dental extraction. Ridge preservation techniques minimize this resorption.

Comparative split-mouth study of the anesthetic efficacy of 4% articaine versus 0.5% bupivacaine in impacted mandibular third molar extraction.

OBJECTIVE: The purpose of this study was to compare the clinical efficacy of articaine at 4% (epinephrine 1:100,000) with bupivacaine at 0.5% (epinephrine 1:200,000) for surgical extraction of impacted mandibular third molars. STUDY DESIGN: This was a randomized, double blind, split-mouth, clinical trial. Thirty-six patients took part and underwent extraction of 72 lower third molars. The variables studied were: anesthetic latency time, intra-operative bleeding, anesthetic quality, hemodynamic changes during the surgical intervention, anesthetic duration in the soft tissues, post-operative analgesia and post-operative pain at 2, 6, 12 and 24 hours using a visual analogue scale, as well as any need for additional rescue medication. RESULTS: Latency time was 2.0 minutes for articaine and 3.1 minutes for bupivacaine, with statistically significant difference (p<0.05). Bleeding was greater when bupivacaine was used (p<0.05) and anesthetic quality was greater with articaine (p<0.05). The duration of soft tissue anesthesia was longer with bupivacaine (p<0.05). Differences in post-operative analgesia, haemodynamic changes, post-operative pain and the quantity of rescue medication consumed were not statistically significant (p>0.05). CONCLUSIONS: Articaine showed greater clinical efficacy than bupivacaine, reducing latency time, bleeding, anesthetic duration in the soft tissues and achieving higher anesthetic quality, requiring less reinforcement during surgery than bupivacaine. Key words:Articaine, bupivacaine, anesthetic efficacy, impacted mandibular third molar.

Implant periapical lesion: Diagnosis and treatment

The implant periapical lesion is the infectious-inflammatory process of the tissues surrounding the implant apex. It may be caused by different factors: contamination of the implant surface, overheating of bone during drilling, preparation of a longer implant bed than the implant itself, and pre-existing bone disease. Diagnosis is achieved by studying the presence of symptoms and signs such us pain, swelling, suppuration or fistula; in the radiograph an implant periapical radiolucency may appear. A diagnostic classification is proposed to establish the stage of the lesion, and determine the best treatment option accordingly. The following stages are distinguished: acute apical periimplantitis (non-suppurated and suppurated) and subcacute (or suppurated-fistulized) apical periimplantitis. The most adequate treatment of this pathology in the acute stage and in the subacute stage if there is no loss of implant stability is apical surgery. In the subacute stage, if there is implant mobility, the extraction of the implant is necessary (AU)

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Implant periapical lesion: diagnosis and treatment.

The implant periapical lesion is the infectious-inflammatory process of the tissues surrounding the implant apex. It may be caused by different factors: contamination of the implant surface, overheating of bone during drilling, preparation of a longer implant bed than the implant itself, and pre-existing bone disease. Diagnosis is achieved by studying the presence of symptoms and signs such us pain, swelling, suppuration or fistula; in the radiograph an implant periapical radiolucency may appear. A diagnostic classification is proposed to establish the stage of the lesion, and determine the best treatment option accordingly. The following stages are distinguished: acute apical periimplantitis (non-suppurated and suppurated) and subcacute (or suppurated-fistulized) apical periimplantitis. The most adequate treatment of this pathology in the acute stage and in the subacute stage if there is no loss of implant stability is apical surgery. In the subacute stage, if there is implant mobility, the extraction of the implant is necessary.

Peripheral giant cell granuloma associated with dental implants: clinical case and literature review.

Peripheral giant cell granuloma (PGCG) associated to dental implants is a very infrequent peri-implant soft-tissue complication, with only 11 cases recorded in the literature to date. The present study describes a 54-year-old woman presenting a swelling of the alveolar margin in the fourth quadrant in relation to a fixed prosthesis cemented over implants. Treatment consisted of complete resection of the lesion with implantoplasty of the exposed implant threads. The diagnosis of PGCG was confirmed by histological study, and no relapse has been recorded after 12 months of follow-up.