Do antibiotics prevent infection after third molar surgery? A network meta-analysis.

The aim of this systematic review was to determine whether antibiotics, compared to placebo, can prevent infection or dry socket after third molar surgery. A systematic review and network meta-analysis (NMA) was performed following registration of the protocol (CRD42021276266). Four databases and the grey literature were searched, and papers were selected based on the PICOS question. RoB 2 and GRADE were used to evaluate the risk of bias and certainty of the evidence, respectively. The NMA was performed using Stata. Of 58 randomized clinical trials identified, 34 were included in the NMA. Patients treated with amoxicillin (relative risk (RR) 0.56, 95% confidence interval (CI) 0.38-0.84; low quality of evidence) and those treated with metronidazole (RR 0.51, 95% CI 0.31-0.84; low quality of evidence) showed a lower risk of infection and dry socket when compared to patients given a placebo. Postoperative amoxicillin (750 mg) and amoxicillin plus clavulanate (500 mg + 125 mg, or 2000 mg + 125 mg), and preoperative metronidazole (800 mg) are useful to prevent infection or dry socket when compared to placebo. The low rate of infection after third molar surgery, the correct concept of antibiotic prophylaxis, and antibiotic resistance must be taken into account when choosing to treat healthy patients undergoing third molar surgery with antibiotics.

Complications after different methods for fixation of mandibular angle fractures: network meta-analysis of randomized controlled trials.

The aim of this review was to compare mandibular angle fracture fixation methods that were evaluated through randomized clinical trials considering postoperative complications. Additionally, different treatment methods were ranked based on their performance. A systematic review was performed based on the Cochrane and PRISMA guidelines. The quality of evidence and network meta-analysis were conducted using the GRADE tool and R software, respectively. Four databases were searched, and the papers were selected based on the PICOS strategy. A total of 3584 papers were found. After screening 15 papers were included. One plate placed on lateral border (tension zone) presented lower risk than one plate placed on superior border (tension zone) for infection [risk ratio (RR): 0.48, 95% confidence interval (CI): 0.33 to 0.71] and plate removal necessity (RR: 0.44, 95% CI: 0.28 to 0.69), with moderate quality of evidence. There were no significant differences among the mandibular angle fracture treatments for malocclusion and paraesthesia outcomes. In conclusion, one plate placed on the lateral border in the tension zone is the best choice regarding postoperative infection and plate removal necessity when fixing mandibular angle fractures. None of the tested fixation methods were associated with a significant risk of malocclusion and paraesthesia events.

Comparison between Erich arch bars and intermaxillary screws in maxillofacial fractures involving the dental occlusion: a meta-analysis.

This systematic review aimed to compare the Erich arch bars (EABs) with intermaxillary fixation (IMF) screws in maxillofacial fractures involving dental occlusion on perioperative parameters. Four electronic databases were searched: MedLine (Pubmed), Web of Science, VHL, and Cochrane Library. Inclusion criteria comprised clinical trials comparing the two IMF methods, assessing at least one of the outcomes: occlusal stability, oral hygiene, quality of life, time to apply and remove IMF appliances, and complications. Risk of bias was evaluated through the Cochrane risk of bias tool. Fifteen papers were included in the qualitative analysis and 12 of those in the meta-analysis. Times for EABs application (mean difference (MD) 46.83; 95% confidence interval (CI): 30.63-63.02) and removal (MD 22.89; 95% CI 14.61-31.17) were longer compared with IMF screws. There is higher risk of glove perforation (risk ratio (RR) 3.81; 95% CI 2.41-6.04) and lower risk of iatrogenic injuries (RR 0.21; 95% CI 0.09-0.48) when placing EABs compared with IMF screws. No significant differences in plaque index were found (MD 1.07; 95% CI -0.17 to 2.31). The quality of this evidence ranged from very low to low and was mainly compromised by risk of bias assessment. Further studies are necessary to evaluate transurgical IMF stability and postoperative occlusal quality and quality of life when comparing EABs with IMF screws.

Envelope or triangular flap for surgical removal of third molars? A systematic review and meta-analysis.

The aim of this systematic review was to compare the triangular and envelope flaps in mandibular third molar surgery with regard to pain, oedema, and trismus. Secondary outcomes assessed were dehiscence, ecchymosis, alveolar osteitis, periodontal condition, and surgical time. The PRISMA guidelines and recommendations in the Cochrane Handbook were followed, and the review was registered before commencement (PROSPERO; CRD42018112373). The literature search was conducted in the Web of Science, PubMed, Virtual Health Library, Cochrane Library, and Scopus databases and in the grey literature; randomized clinical trials, indexed through November 2018 were included. Three reviewers independently examined the studies. Twenty studies were included in the qualitative analysis, of which 18 were included in the meta-analyses. The flap design did not influence pain, oedema, trismus, dehiscence, or osteitis. The triangular flap was associated with a greater occurrence of postoperative ecchymosis (odds ratio 4.58, 95% confidence interval 1.34 to 15.91, I2=0) and lower periodontal probing depth on day 7 postoperative (standardized mean difference -1.36, 95% confidence interval -2.68 to -0.03, I2=88%) when compared to the envelope flap in mandibular third molar surgeries.

Effect of third molars in the line of mandibular angle fractures on postoperative complications: systematic review and meta-analysis.

The aim of this systematic review was to verify whether the presence of a lower third molar in the mandibular angle fracture line is associated with postoperative complications. An electronic survey was conducted in five databases. Eligibility criteria included observational and experimental studies that evaluated the association between the presence of the lower third molar in the fracture line of mandibular angle fractures and possible postoperative complications, including infection, paresthesia, necessity of plate removal, temporomandibular joint disorders, malocclusion, dehiscence, and non-union. Thirty-four papers were included in the qualitative analysis and 26 of those in the meta-analysis. The risk of bias of observational studies was assessed by Newcastle-Ottawa scale and of the clinical trials by Cochrane Collaboration risk-of-bias tool. Absence of the third molar was associated with a lower chance of postoperative infection in angle fractures compared to presence of the tooth (odds ratio 0.55, 95% confidence interval 0.34-0.88). No statistically significant difference between the groups was found for the other outcomes evaluated. The findings of this systematic review suggest that the absence of the third molar in the mandibular angle fracture line is associated with a lower postoperative infection rate when compared to angle fractures with a third molar present.

Acupuncture on anxiety and inflammatory events following surgery of mandibular third molars: a split-mouth, randomized, triple-blind clinical trial.

The aim of this study was to compare the effects of acupuncture and placebo acupuncture on the control of pain, oedema, and trismus following the extraction of third molars and on the control of preoperative anxiety. Sixteen patients (mean age 22.5±3.45years) each underwent four acupuncture sessions, one prior to each surgery and the others at 24, 48, and 72hours after each surgery (left and right tooth). Oedema was determined using measurements of the face and trismus was determined by maximum mouth opening at baseline and at 24, 48, 72hours and 7days following surgery. Postoperative pain was evaluated by the patients using a visual analogue scale (VAS) at 24, 48, and 72hours following surgery. Anxiety was evaluated using the State-Trait Anxiety Inventory and a VAS at baseline and before and after acupuncture prior to surgery. The statistical analysis was performed using the paired t-test and Wilcoxon test. Acupuncture showed a better performance in the control of oedema at 48hours (P=0.026), 72hours (P=0.046), and 7days (P=0.040) when compared to placebo. There was no statistically significant difference between the acupuncture and placebo groups in the control of pain, trismus, or anxiety.

Intramuscular injection of dexamethasone for the control of pain, swelling, and trismus after third molar surgery: a systematic review and meta-analysis.

This systematic review aimed to answer the following PICO question: Does the intramuscular injection of dexamethasone result in less pain, swelling, and trismus after mandibular third molar removal when compared to other routes of administration or a control group (saline solution injection or no treatment)? An electronic search was conducted in Virtual Health Library, PubMed, and Web of Science, through March 2018. Eligibility criteria included clinical trials. The search strategy resulted in 331 studies. Following the selection process, 15 articles were included in the systematic review; eight of these were included in the meta-analysis. Most of the studies had an unclear risk of bias (Cochrane Handbook assessment). Pain (mean difference (MD) -1.58, 95% confidence interval (CI) -1.99 to -1.16) and oedema (MD -1.76, 95% CI -2.38 to -1.14) were lower in the intramuscular dexamethasone group when compared to the control group. When compared to the submucosal route, the intramuscular route was more effective only for pain on the third postoperative day (MD -0.79, 95% CI -1.38 to -0.20). The results suggest that the intramuscular injection of dexamethasone may be an alternative route of administration, since it is effective at reducing pain and oedema when compared to non-steroidal treatment and has similar results to the submucosal route.

Influence of third molars in mandibular fractures. Part 2: mandibular condyle-a meta-analysis.

The aim of this systematic review was to investigate the influence of the presence and position of mandibular third molars in mandibular condyle fractures. An electronic search was conducted in PubMed, Scopus, Web of Science, Cochrane Library, and VHL, through January 2016. The eligibility criteria included observational studies. The search strategy resulted in 704 articles. Following the selection process, 13 studies were included in the systematic review and 11 in the meta-analysis. In terms of the risk of bias analysis, six studies presented ≤6 stars in the Newcastle-Ottawa scale assessment. The presence of a mandibular third molar decreased the probability of condylar fracture (cross-sectional and case-control studies: odds ratio (OR) 0.26, 95% confidence interval (CI) 0.17-0.40, I2=87.8%; case-control studies: OR 0.30, 95% CI 0.16-0.58, I2=91.6%). The third molar positions most favourable to condylar fracture according to the Pell and Gregory classification are class A (OR 1.32, 95% CI 1.09-1.61, I2=0%) and class I (OR 1.37, 95% CI 1.05-1.77, I2=32.8%). Class B (OR 0.69, 95% CI 0.49-0.97, I2=56.0%) and class II (OR 0.71, 95% CI 0.57-0.87, I2=0%) act as protective factors for condylar fracture. The results suggest that the presence of a mandibular third molar decreases the chance of condylar fracture and that the positions of the third molar most favourable for condylar fracture are classes A and I, with classes B and II acting as protective factors.

Influence of third molars in mandibular fractures. Part 1: mandibular angle-a meta-analysis.

The aim of this systematic review was to investigate the influence of the presence and position of mandibular third molars on angle fractures. An electronic search was conducted in the PubMed, Scopus, Web of Science, Cochrane Library, and VHL databases, through January 2016. The eligibility criteria included observational studies. The search strategy resulted in 704 articles. Following the selection process, 35 studies were included in the systematic review and 28 in the meta-analysis. Twenty studies presented a score of ≤6 stars in the Newcastle-Ottawa scale assessment, indicating a risk of bias in the analysis. The presence of a mandibular third molar increases the chance of an angle fracture (case-control and cross-sectional studies: odds ratio (OR) 3.83, 95% confidence interval (CI) 3.02-4.85, I2=83.1%; case-control studies: OR 3.27, 95% CI 2.57-4.16, I2=81.3%). The third molar positions most favourable to angle fracture according to the Pell and Gregory classification are class B (OR 1.44, 95% CI 1.06-1.96, I2=87.2%) and class II (OR 1.67, 95% CI 1.36-2.04, I2=72.4%). Class A (OR 0.60, 95% CI 0.45-0.81, I2=87.1%) and class I (OR 0.51, 95% CI 0.37-0.71, I2=89.4%) act as protective factors for angle fracture. The results suggest that the presence of the third molar increases the chance of angle fracture by 3.27 times and that the most favourable positions of the third molar for angle fracture are classes B and II, whilst classes A and I act as protective factors.

Pre-emptive effect of dexamethasone and methylprednisolone on pain, swelling, and trismus after third molar surgery: a split-mouth randomized triple-blind clinical trial.

The aim of this study was to compare the effect of dexamethasone 8 mg and methylprednisolone 40 mg for the control of pain, swelling, and trismus following the extraction of impacted third molars. Sixteen healthy patients with a mean age of 20.3 (standard deviation 1.25) years received a single oral dose of either drug 1 h prior to each surgical procedure (left and right teeth). At 24, 48, and 72 h and 7 days following surgery, swelling was determined using linear measurements on the face and trismus was determined by maximal mouth opening. Postoperative pain was self-recorded by the patients using a visual analogue scale at 8-h intervals for a period of 72 h. Data analysis involved descriptive statistics and the Wilcoxon, and paired t tests (P < 0.05). Dexamethasone controlled swelling better than methylprednisolone at all postoperative evaluations (P < 0.02) and led to greater mouth opening 48 h after surgery (P = 0.029). No statistically significant difference was found between drugs with regard to pain. In conclusion, pre-emptive dexamethasone 8 mg demonstrated better control of swelling and limited mouth opening in comparison to methylprednisolone 40 mg, with no differences between drugs regarding pain control.

Autologous incubated macrophage therapy in acute, complete spinal cord injury: results of the phase 2 randomized controlled multicenter trial.

STUDY DESIGN: Randomized controlled trial with single-blinded primary outcome assessment. OBJECTIVES: To determine the efficacy and safety of autologous incubated macrophage treatment for improving neurological outcome in patients with acute, complete spinal cord injury (SCI). SETTING: Six SCI treatment centers in the United States and Israel. METHODS: Participants with traumatic complete SCI between C5 motor and T11 neurological levels who could receive macrophage therapy within 14 days of injury were randomly assigned in a 2:1 ratio to the treatment (autologous incubated macrophages) or control (standard of care) groups. Treatment group participants underwent macrophage injection into the caudal boundary of the SCI. The primary outcome measure was American Spinal Injury Association (ASIA) Impairment Scale (AIS) A-B or better at ≥6 months. Safety was assessed by analysis of adverse events (AEs). RESULTS: Of 43 participants (26 treatment, 17 control) having sufficient data for efficacy analysis, AIS A to B or better conversion was experienced by 7 treatment and 10 control participants; AIS A to C conversion was experienced by 2 treatment and 2 control participants. The primary outcome analysis for subjects with at least 6 months follow-up showed a trend favoring the control group that did not achieve statistical significance (P=0.053). The mean number of AEs reported per participant was not significantly different between the groups (P=0.942). CONCLUSION: The analysis failed to show a significant difference in primary outcome between the two groups. The study results do not support treatment of acute complete SCI with autologous incubated macrophage therapy as specified in this protocol.

Association between the presence of a partially erupted mandibular third molar and the existence of caries in the distal of the second molars.

The objective of this study was to verify, using periapical radiographs, whether a partially erupted mandibular third molar is a factor in the presence of dental caries on the distal surface of the adjacent second molar. Two-forty six high quality periapical radiographs were selected, each showing a partially erupted mandibular third molar. The variables analyzed were: tooth number; gender; age; radiographic presence of caries on the distal surface of the adjacent molar; Pell and Gregory classification; Winter classification; angulation and distance between the second and mandibular third molar. The examiners were previously calibrated to collect data (kappa statistics from 0.87 to 1.0). The prevalence rate of caries on the distal surface of the second molar was 13.4%. In the logistical multivariate regression analysis, the angulation (OR=8.5; IC95%: 1.7-43.8; p=0.011) and the gender (OR=3.3; IC95%: 1.4-7.7; p=0.005) remained statistically significant after an age adjustment was made. The results indicate that the presence of a partially erupted mandibular third molar with an angulation of 31 degrees or more, is a risk factor for caries on the distal surface of the mandibular second molars.

Markers of pluripotency and differentiation in human neural precursor cells derived from embryonic stem cells and CNS tissue.

Cell transplantation therapies for central nervous system (CNS) deficits such as spinal cord injury (SCI) have been shown to be effective in several animal models. One cell type that has been transplanted is neural precursor cells (NPCs), for which there are several possible sources. We have studied NPCs derived from human embryonic stem cells (hESCs) and human fetal CNS tissue (hfNPCs), cultured as neurospheres, and the expression of pluripotency and neural genes during neural induction and in vitro differentiation. mRNA for the pluripotency markers Nanog, Oct-4, Gdf3, and DNMT3b were downregulated during neural differentiation of hESCs. mRNA for these markers was found in nonpluripotent hfNPC at higher levels compared to hESC-NPCs. However, Oct-4 protein was found in hESC-NPCs after 8 weeks of culture, but not in hfNPCs. Similarly, SSEA-4 and CD326 were only found in hESC-NPCs. NPCs from both sources differentiated as expected to cells with typical features of neurons and astrocytes. The expressions of neuronal markers in hESC-NPCs were affected by the composition of cell culture medium, while this did not affect hfNPCs. Transplantation of hESC-NPC or hfNPC neurospheres into immunodeficient mouse testis or subcutaneous tissue did not result in tumor formation. In contrast, typical teratomas appeared in all animals after transplantation of hESC-NPCs to injured or noninjured spinal cords of immunodeficient rats. Our data show that transplantation to the subcutaneous tissue or the testes of immunodeficient mice is not a reliable method for evaluation of the tumor risk of remaining pluripotent cells in grafts.

A phase 2 autologous cellular therapy trial in patients with acute, complete spinal cord injury: pragmatics, recruitment, and demographics.

STUDY DESIGN: Post hoc analysis from a randomized controlled cellular therapy trial in acute, complete spinal cord injury (SCI). OBJECTIVES: Description and quantitative review of study logistics, referral patterns, current practice patterns and subject demographics. SETTING: Subjects were recruited to one of six international study centers. METHODS: Data are presented from 1816 patients pre-screened, 75 participants screened and 50 randomized. RESULTS: Of the 1816 patients pre-screened, 53.7% did not meet initial study criteria, primarily due to an injury outside the time window (14 days) or failure to meet neurological criteria (complete SCI between C5 motor/C4 sensory and T11). MRIs were obtained on 339 patients; 51.0% were ineligible based on imaging criteria. Of the 75 participants enrolled, 25 failed screening (SF), leaving 50 randomized. The primary reason for SF was based on the neurological exam (51.9%), followed by failure to meet MRI criteria (22.2%). Of the 50 randomized subjects, there were no significant differences in demographics in the active versus control arms. In those participants for whom data was available, 93.8% (45 of 48) of randomized participants received steroids before study entry, whereas 94.0% (47 of 50) had spine surgery before study enrollment. CONCLUSION: The 'funnel effect' (large numbers of potentially eligible participants with a small number enrolled) impacts all trials, but was particularly challenging in this trial due to eligibility criteria and logistics. Data collected may provide information on current practice patterns and the issues encountered and addressed may facilitate design of future trials.

Osteopetrosis and osteonecrosis in snake Boa constrictor / Osteopetrose e osteocondrose em serpente Boa constrictor

Uma jibóia (Boa constrictor), de onze anos de cativeiro, apresentou à seis meses um histórico de aumento de volume ao longo da coluna vertebral e perda progressiva dos movimentos e de apetite. Exames radiológicos revelaram aumento da opacidade, áreas de excrescências ósseas e inúmeras fraturas ao longo da coluna. Devido o prognóstico desfavorável, a serpente foi eutanasiada. À necropsia, aumento de volume com estenose do canal vertebral e compressão da medula espinhal foram observados, juntamente com fraturas completas de corpos vertebrais. O diagnóstico de osteopetrose e osteonecrose foi firmado à histologia.

Solid human embryonic spinal cord xenografts in acute and chronic spinal cord cavities: a morphological and functional study.

While therapeutic spinal cord grafting procedures are of interest in the chronic spinal cord injury stage, previous experimental grafting studies, including human spinal cord tissue, have mainly focused on the acute stage. Therefore, solid human embryonic spinal cord grafts were implanted in acute or chronic spinal cord aspiration cavities of immunodeficient rats to compare the morphological and locomotor outcome to that of lesion alone cases. Locomotor function was assessed using the Basso, Beattie, and Bresnahan open-field locomotor rating scale up to 6 months, while the morphological evaluation of graft survival, growth, and integration was performed at 6 weeks or 6 months after implantation. Graft survival was 94% in both lesion models, while graft growth was enhanced in the chronic compared to the acute cavity group. Human specific Thy-1 and neurofilament immunoreactive fibers were observed up to 7 mm into host white matter, while aminergic fibers were observed up to 1 mm into the grafts. Abundant calcitonin gene-related peptide immunoreactive fibers in the grafts in the absence both of immunoreactive cell bodies and colocalized human-specific neurofilament immunoreactivity, suggested host fiber ingrowth. At 6 months, the grafted cases presented less central canal deformation and lower glial fibrillary acidic protein immunoreactivity at the host cavity border compared to that of the nongrafted cases. The strong compensatory regain of locomotor function after unilateral spinal cord lesions was not affected by the human spinal cord grafts. In conclusion, solid human embryonic spinal cord tissue transplanted to a cavity in the adult injured spinal cord results in beneficial morphological effects in both the acute and chronic spinal cord lesion.

MHC antigen expression in human first trimester spinal cord with implications for clinical transplantation procedures.

We report human leukocyte antigen (HLA) class I expression in 5-17% and class II in 0-9% of first trimester human spinal cord cells. After 8 days in culture with gamma-interferon, >87% of the spinal cord cells expressed HLA class II. However, mixed cultures of adult human peripheral lymphocytes and immature human spinal cord cells, showed no induction of lymphocyte proliferation prior to or after gamma-interferon exposure in culture. In conclusion, we report non-immunogenic expression of HLA antigens in the human first trimester spinal cord.

Surgical treatment of posttraumatic cystic and tethered spinal cords.

Posttraumatic syringomyelia as a cause of progressive neurologic deterioration has been well described. More recently, the noncystic posttraumatic tethered cord has been associated with identical progressive neurologic deterioration. A retrospective analysis of patients treated surgically with spinal cord untethering and/or cyst shunting to arrest a progressive myelopathy from a posttraumatic tethered and/or cystic cord was performed. Emphasis was on outcome using the American Spinal Injury Association (ASIA) sensory and motor scoring systems. During an 18-month period from May 1993 to December 1994, 70 patients with spinal cord injury were operated upon for tethered and/or cystic spinal cords because of a progressive myelopathy and deteriorating ASIA sensory/motor scores. Fifty-nine patients had follow-up data 1 year postoperatively. At the 1 year follow-up, there was small improvement in light touch sensory scores (0.67 points), pinprick scores (1.3 points), and motor scores (0.41 points) demonstrating that the progression of the myelopathic process was arrested. Thirty-four of these 59 patients had no previous surgery to their spinal cords. At 1 year follow-up, light touch scores improved on average 2.38 points, pinprick scores 3.88 points (p < 0.05), and motor scores 1.47 points, suggesting better outcome with first-time surgery. Of this latter group, 64.3% regained a lost function, 62.5% saw improvement in spasticity, 55.6% had substantial improvement in neurogenic pain, and 95.8% felt that surgery prevented further neurologic deterioration.

Obliteration of a posttraumatic spinal cord cyst with solid human embryonic spinal cord grafts: first clinical attempt.

Cystic lesions of the spinal cord (syringomyelia) may occur after spinal cord injury. Posttraumatic syringomyelia may result in a myelopathy causing symptoms of sensory and motor loss, as well as worsening spasticity, pain, hyperhidrosis, and autonomic dysreflexia. Shunting of the cyst cavity along with untethering of the scarred spinal cord is widely accepted as the treatment of choice. However, the long-term stabilization of the progressive myelopathy caused by a posttraumatic cyst is suboptimal because of arachnoidal rescarring, shunt tube blockage, and cyst reexpansion. A new neurosurgical strategy to overcome the complication of cyst reexpansion was designed. Experimental studies have shown the successful use of embryonic spinal cord grafts, including human grafts, to obliterate induced spinal cord cavities in rats. The authors report the first use of solid human embryonic spinal cord grafts to successfully obliterate 6 cm of a large cyst cavity in a patient becoming myelopathic from a posttraumatic cyst. The grafts are well visualized by MRI to the 7-month postoperative follow-up and cyst obliteration is seen in the region where the grafts were placed.

The diagnosis and treatment of pediatric lumbar spine injuries caused by rear seat lap belts.

Over the past 3 years, during a time when seat belt use has increased, we have managed nine midlumbar spine fractures in children caused by standard rear seat lap belts. Children with a lap belt injury typically complained of abdominal and back pain, and the nature of their injuries was evident by the presence of a belt-shaped abrasion across the lower abdomen. Midlumbar spine fracture may be associated with paraplegia and life-threatening visceral injury. If the spine is analyzed as a beam, the full spectrum of the reported injuries is predictable. This study shows that the rear seat belts installed as standard equipment do not meet the special needs of children. Rear seat lap belts are better than no restraints, but the addition of a shoulder restraint is strongly advocated to reduce lumbar spine injury.