Outcomes of mandible fracture treatment at an academic tertiary hospital: a 5-year analysis.

PURPOSE: To analyze the outcomes of mandible fractures treated using open reduction and internal fixation. PATIENTS AND METHODS: We performed a retrospective chart review of the medical records from patients with mandibular fractures treated surgically during a 5-year period for demographics, systemic illness, history of substance abuse, etiology, fracture location, any associated facial injury, type and timing of repair, antibiotic treatment, and interval to repair. The development of complications such as infection, malunion or nonunion, hardware failure, and wound dehiscence were recorded. RESULTS: Of the 560 patients, adequate data were collected for 363 patients. Of the patients, 60% were white. The male/female ratio was 7.4:1. Systemic illness was noted in 10.5% of the cohort. More than 80% of the subjects had sustained their injury because of assault. The mandible angle was the most common site of fracture (56%). Most (64%) of the patients had sustained multiple fractures. When multiple sites were involved, the angle and body were more commonly involved. The overall complication rate was 26.45%. Hardware failure (15.4%) was the most common complication, followed by infection (15.15%). The revision rate was 8.1% in this cohort. Antibiotic usage and the infection rate were not statistically associated with each other. A greater complication rate was noted among smokers (P = .0072) and patients with systemic illness (P = .0495). CONCLUSIONS: A greater rate of hardware failure was noted in our study. The use of antibiotics did not decrease the incidence of infections. Smokers and patients with systemic medical conditions had a greater risk of complications. Finally, a slight delay in surgical repair was not related to an increased complication rate.

Depth of penetration of methylene blue in mandibular cortical bone.

BACKGROUND: Surgeons treating keratinizing odontogenic tumors (KOT) and other intrabony lesions frequently use methylene blue as an adjunct in peripheral ostectomy in estimating the depth of bone that has been removed. Depth of methylene blue penetration in cortical bone has not been evaluated. STUDY DESIGN: Specimens of mandible harvested from 9 fresh unembalmed cadaveric mandibles were stained with methylene blue. A microcaliper was used to measure total thickness of the cortical specimen along with the amount of dye penetration within the cortical block to the nearest 0.1 mm. RESULTS: Average depth of dye penetration was 0.48 mm in the symphysis. Average dye penetration was 0.53 mm in the body. Average depth of penetration of 0.42 mm in the angle. CONCLUSIONS: The use of methylene blue as a depth gauge to ensure adequate ostectomy with a single application of the dye may be inadequate to ensure complete removal of lesion from bony wall.

Complications of third molar surgery and their management.

The frequency and severity of untoward events associated with surgical procedures are influenced by multiple factors that may be related to the procedure, patient, and/or surgeon. Not every third molar needs to be removed. Full bony impacted lower third molars well below the cervical margin of the second molar crowns should be considered for retention. Certain deviations from normal healing should be considered to be complications. Risk factors associated with third molar removal should be carefully established and explained to the patient. Third molar surgery has a predictable postsoperative course for the average patient.

Is there pathology associated with asymptomatic third molars?

PURPOSE: The purpose of this article was to estimate the proportion of patients with asymptomatic third molars (M3s) and evidence of disease at baseline and to measure the health risks of retained M3s in the long term. MATERIALS AND METHODS: A literature search was conducted using Google Scholar. Search terms included third molars and periodontitis, pericoronitis, caries, odontogenic cysts or tumors, and infections. To be included in this review, studies were limited to prospective studies with samples of at least 50 subjects and a follow-up longer than 1 year. RESULTS: Periodontal pathology was associated with asymptomatic M3s. At baseline, 25% of 329 asymptomatic subjects enrolled in studies had at least 1 probing depth (PD) of at least 5 mm in the M3 region, distal of the second molars, or around the M3s, with at least 1-mm attachment lost in each patient. PDs deeper than 5 mm were associated with an attachment loss of at least 2 mm in 80 of 82 subjects. The clinical findings of increased periodontal PDs and periodontal attachment loss coupled with the colonization of periodontal pathogens supported the concept that clinical and microbial changes associated with the initiation of periodontitis may present first in the M3 region in young adults. For subjects with a baseline PD of at least 4 mm in the M3 region or baseline "orange and red" complex periodontal bacteria of at least 10(5), the odds were significantly increased for the progression of periodontal disease in the M3 region. The visible presence of M3s in young adults was significantly associated with periodontal inflammatory disease in non-M3s. CONCLUSION: The data suggest that the absence of symptoms associated with retained M3s does not equal the absence of disease or pathology. The clinical implications of these findings suggest that patients who elect to retain their M3s should have regular periodic clinical and radiographic examinations to detect disease before it becomes symptomatic.

Prevalence of third molars with caries experience or periodontal pathology in young adults.

PURPOSE: We assessed the prevalence of caries experience and periodontal pathology on asymptomatic third molars in young adults. SUBJECTS AND METHODS: Healthy subjects with 4 asymptomatic third molars were enrolled in an institutional review board-approved study during a 5-year period. Full mouth periodontal probing, 6 sites per tooth, was the measure of clinical periodontal status. The presence or absence of occlusal caries experience (carious lesions or restorations, including sealants) on third molars and on any surface of the first and second molars were assessed using a visual-tactile examination and panoramic radiographs. The primary outcome measures were at least 1 periodontal probing depth of at least 4 mm versus none and caries experience versus no caries experience. RESULTS: The data were analyzed from 409 subjects, who averaged 25 years old. More subjects were female (53%) and white (76%). More subjects had at least 1 periodontal probing depth of 4 mm or deeper on a third molar (55%) than on the distal of a second molar (46%). These findings were more likely to be detected around a third molar in subjects with all third molars at the occlusal plane (72%) than in subjects with at least one third molar below (33%). Overall, fewer subjects were affected by third molar caries experience than first or second molars (24% vs 73%, respectively). Of the subset of subjects with all four third molars at the occlusal plane, 26% were affected by both third molar periodontal pathology and caries experience and 16% were caries and periodontal pathology free. CONCLUSIONS: In these cross-sectional analyses, periodontal pathology was detected more frequently on third molars than on first and second molars and caries experience was detected more frequently on first and second molars than on third molars.

Third molars and periodontal pathology in American adolescents and young adults: a prevalence study.

PURPOSE: To assess the association between visible third molars and the prevalence of periodontal inflammatory disease of non-third molars. PATIENTS AND METHODS: Subjects aged 14 to 45 years with 4 asymptomatic third molars were enrolled in an institutional review board-approved study. Subjects were classified based on whether at least 1 third molar was visible or all third molars were not visible. Full-mouth periodontal probing depth (PD) data, with 6 sites per tooth, were obtained as a measure of a subject's periodontal status. At least 1 non-third molar PD of 4 mm or greater was indicative of periodontal inflammatory disease. Outcomes for the respective groups were compared by use of Cochran-Mantel-Haenszel row mean score statistics. The level of significance for differences was set at .05. RESULTS: The 342 subjects in the visible group were significantly older, with a median age of 26 years (interquartile range, 22.4-32.2 years), as compared with the 69 subjects in the not visible group, with a median age of 21 years (interquartile range, 18.8-24.9 years) (P < .01). The proportion of males and females was not statistically different between groups (P > .05). Most subjects were white. Significantly more subjects with at least a college education were in the visible group than in the not visible group (P < .01). The rate of tobacco use was low and did not differ between groups. Subjects in the visible group were significantly more likely to have at least 1 PD of 4 mm or greater on non-third molars than those in the not visible group: 59% versus 35%. In both groups, first/second molars were more affected than nonmolars when we controlled for differences in age between groups. CONCLUSIONS: The visible presence of third molars in adolescents and young adults was significantly associated with periodontal inflammatory disease of non-third molars.

Body mass index and the risk of postoperative complications with dentoalveolar surgery: a prospective study.

OBJECTIVES: Obesity is a disease that affects millions of Americans. Sixty-nine million Americans are considered to be overweight including at least 1 in 5 children. Overweight and obesity as risk factors for complications associated with dentoalveolar surgery have not been extensively studied. The purpose of this study was to prospectively investigate the frequency and the nature of postoperative complications in obese patients receiving ambulatory dentoalveolar surgery. STUDY DESIGN: Patients undergoing dentoalveolar outpatient ambulatory surgery at the University of Cincinnati Oral and Maxillofacial Surgery Clinic from January 10, 2005 to December 7, 2005 were enrolled in a prospective study. At the preoperative visit, height, weight, and age were recorded. The body mass index (BMI) was calculated and patients were divided into weight categories based on CDC and WHO classifications. Unfavorable outcomes studied included number of postoperative visits, infections, alveolar osteitis, soft and hard tissue problems, and postoperative bleeding. Complication categories were created for all complications identified during postoperative exams and t tests were performed to see if increased BMI correlated to higher postoperative complication rates, if multiple complications correlated to increased BMI, and to see if individual postoperative complication groups and BMI correlated. Because it was thought that complications would increase the number of postoperative exams for a particular patient, simple linear regression was used to see if BMI correlated to increased number of postoperative visits. RESULTS: No significant differences were noted in number of postoperative complications when comparing patients' BMIs (t = -0.62, P = .5350). Simple linear regression analysis showed that increased BMI did not predict increased number of postoperative visits. Increased age was the only predictor of increased postoperative complication risk (t = -3.17, P = .0016) and of increased number of postoperative visits (t = -16.35, P < .0001, and P < .0001 by nonparametric Wilcoxon rank sum test). CONCLUSIONS: The BMI is not statistically correlated to higher postoperative complication rates or increased number of postoperative visits. Obesity remains an important risk factor for dentoalveolar ambulatory outpatient anesthesia; however, it is not associated with poorer postoperative complication rates.

Osteonecrosis of the jaw.

The first bisphosphonate (etidronate) was approved by the FDA in 1977; alendronate was approved in 1995 for the prevention and treatment of osteoporosis. Bisphosphonates have emerged as the agents of choice for the treatment of osteoporosis and have proved useful in the treatment of skeletal complications of malignancy (hypercalcemia, bone metastases) and have been used long-term in millions of patients. Osteonecrosis of the jaw (ONJ) is a newly described condition (2003) defined as exposed bone in the maxillofacial area, not associated with radiation or any other known cause and not healing for 8 weeks. Most cases have followed dental extraction, another invasive dental procedure, or poorly fitting dentures. Although most cases are painful and it can be progressive, approximately one-third of cases are painless and some do resolve. Although ONJ occurs exclusively or almost exclusively in patients receiving bisphosphonate therapy, a causal association has not been shown, and the mechanism is not clear. In patients receiving high-dose i.v. bisphosphonates for malignant diseases, ONJ may occur in 5 to 10% over 3 years. It does occur in patients receiving oral or i.v. bisphosphonates for osteoporosis, but is rare in that setting; about 1 case per 100,000. Treatment is conservative (antimicrobial mouthwash, antibiotics for secondary infection, limited debridement). Preventive strategies should include good dental hygiene for all patients and completion of elective invasive dental procedures before initiating high-dose i.v. bisphosphonate therapy for cancer. Patients with osteoporosis receiving lower-dose bisphosphonate therapy do not require special precautions, but should be informed of the low risk of this complication.

Third molar removal: an overview of indications, imaging, evaluation, and assessment of risk.

Asymptomatic third molars may have associated periodontal pathology that may not be limited to the third molar region and have a negative impact on systemic health. Third molars should be considered for removal when there is clinical, radiographic, or laboratory evidence of acute or chronic periodontitis, caries, pericoronitis, deleterious effects on second molars, or pathology. Radiographic findings of extreme locations of impacted teeth, dense bone, dilacerated roots, large radiolucent lesions associated with impactions, and lower third molar apices in cortical inferior border bone are predictive of more complex surgery. Certain demographic and oral health conditions available to the surgeon before surgery and intraoperative circumstances are predictive of delayed recovery for health-related quality of outcomes and delayed clinical outcomes after third molar surgery.

The impact of intravenous corticosteroids with third molar surgery in patients at high risk for delayed health-related quality of life and clinical recovery.

PURPOSE: To compare recovery for clinical and health-related quality of life (HRQOL) outcomes after third molar surgery in patients predicted to be at risk for delayed recovery, treated with or without intravenous (IV) corticosteroids at surgery. PATIENTS AND METHODS: Patients at least 18 years of age and with all 4 third molars below the occlusal plane were given IV corticosteroids just before third molar surgery. Clinical and HRQOL outcomes of these patients were compared with those of a nonconcurrent control group who did not receive corticosteroids. No antibiotics were administered. The control group was selected using the same criteria and treated under the same surgical protocol as the corticosteroid group. Differences between the groups were assessed with Cochran-Mantel-Haenszel row mean score statistics. RESULTS: Sixty patients were in each cohort. The incidence of delayed clinical recovery, a postsurgery visit with treatment, was higher in the control group compared with the corticosteroid group. In the corticosteroid group, 6 patients (10%) had 1 postsurgery visit with treatment. In the control group without corticosteroids, 17 patients (28%) had at least 1 postsurgery visit with treatment (P = .01). Compared with the control group, nausea tended to bother patients less on postsurgery day 1 (P = .07); sleep was improved on postsurgery days 1 through 4 (P < .05). Though not statistically significant, corticosteroids reduced the patients reported recovery by at least 1 day for pain, lifestyle, and oral function. CONCLUSION: Administration of IV corticosteroids before third molar surgery without antibiotics does not hamper clinical recovery even when healthy adult patients are predicted to have delayed recovery. Overall, IV corticosteroid administration had a limited, but beneficial effect on HRQOL outcomes.

Obesity and the practice of oral and maxillofacial surgery.

OBJECTIVES: Obesity is a disease that affects approximately 51 million Americans. The purpose of this paper is to establish the frequency of overweight and obese patients in an urban inner city oral and maxillofacial surgery (OMS) center, to provide an overview of the commonly applied standards and methods of establishing obesity, and to discuss the clinical and surgical implications that obesity has on the dispensing of office oral and maxillofacial surgical and anesthetic care. STUDY DESIGN: Consecutive patients presenting with oral and maxillofacial health needs were routinely screened for sex, age, blood pressure, pulse, height, and weight. Body Mass Index (BMI) was calculated in pounds using a standard mathematical formula for adults. Comparative statistical methods were used to depict the data. RESULTS: The study included 520 patients. The average age of all patients was 34.55 years, average height was 66.58 inches, and average weight was 176.71 lbs with an average BMI of 28.5. One hundred ninety-four females (67%) were recorded as overweight and 130 females (45%) were recorded as obese (BMI>30). Fewer males were overweight (55%) or obese (25%). CONCLUSIONS: Sixty-five percent of the patients observed in this study were judged as overweight or obese compared to a national average of 61%. Females of all ages were more likely to be overweight or obese compared to males. The complexities of treating a substantial number of obese patients in an OMS practice deserve more study.

The impact of intravenous antibiotics on health-related quality of life outcomes and clinical recovery after third molar surgery.

PURPOSE: We sought to compare recovery for clinical and health-related quality of life (HRQOL) outcomes after third molar surgery in patients treated with or without intravenous antibiotics at surgery. PATIENTS AND METHODS: Fifty-six patients at least 18 years of age and with all 4 third molars below the occlusal plane, treated at 3 clinical centers, were given intravenous antibiotics just before third molar surgery. Clinical and HRQOL outcomes of these patients were compared with those of a nonconcurrent control group (n = 60 patients) who did not receive antibiotics. The control group was selected using the same criteria and treated under the same surgical protocol as the antibiotic group. Differences between the groups were assessed with Cochran-Mantel-Haenszel row mean score statistics. RESULTS: The incidence of delayed clinical recovery defined as a postsurgery visit with treatment was higher in the control group compared with the antibiotic group. In the antibiotic group, 4% had 1 postsurgery visit with treatment; no patient had 2 visits. In the control group without antibiotics, 28% had at least 1 postsurgery visit with treatment (P <.0001) and 13% had at least 2 postsurgery visits with treatment. No statistically significant differences in HRQOL outcomes were found between the 2 groups. CONCLUSIONS: Administration of intravenous antibiotics before third molar surgery may improve clinical recovery in healthy adult patients with all 4 third molars below the occlusal plane, a presenting characteristic that has been suggested as a risk factor for delayed recovery. The findings from this exploratory trial indicate that evaluation of the effectiveness of systemic antibiotic administration with third molar surgery in a randomized, multi-intervention, explanatory clinical trial is warranted.

Applicants' opinions about the selection process for oral and maxillofacial surgery programs.

PURPOSE: This study was conducted to investigate the characteristics of and opinions about the selection process of applicants to residency programs in oral and maxillofacial surgery (OMS) in the year 2000. The current investigation paralleled a survey completed in the 1970s, with additional questions to assess contemporary curriculum and surgical training evolution. Differences from the previous (1976) survey, a profile of applicants in 2000, and characteristics of OMS residency programs that applicants view as attractive are discussed. SUBJECTS AND METHODS: Questionnaires were sent to 307 applicants to OMS residency programs registered in the dental matching program. To provide a more direct comparison of the study completed in 1977, the current questionnaire used the original survey as a model. It was divided into 6 sections: general information, information from the formal application and letters of recommendation, the interview, the selection process, the characteristics applicants were seeking in a program, and a retrospective review of programs visited. RESULTS: In this study, 118 responses were received, representing 38% of the total. Respondents were predominately men (86%) and single, and attended dental school in all regions of the United States and the world. Respondents listed geographic location (65%) and national reputation (58%) as important factors for selecting programs to which to apply. Many respondents felt that a previous dental internship (85%), national board scores (83%), and class rank (79%) would be considered important in screening applicants for interview. A program's reputation, personalities of residents and attending staff, and clinical material were ranked as important factors contributing to program selection. Fifty-three of the 79 successful applicants reported that they were matched with their first-choice institution. Sixty percent of programs were considered worthy of revisiting by the respondents. CONCLUSIONS: Respondents in 2000 had more knowledge of the selection process before interviewing and submitted 2 times the number of applications than applicants in 1977. When selecting programs to which to apply, current applicants were less influenced by geographic location and the recommendations of other dentists. Applicants were attracted to programs that they perceive to have a good reputation and abundant clinical material. Residencies that convey a friendly atmosphere, favorable interpersonal skills of enrolled residents, and appealing personalities of the faculty were more attractive to candidates.

Microbial complexes detected in the second/third molar region in patients with asymptomatic third molars.

PURPOSE: Our goal was to report the detection and levels of pathogenic bacteria in subgingival plaque samples taken from the distal of all second molars in 295 patients with asymptomatic third molars. PATIENTS AND METHODS: Data assessing oral health were collected from each of these healthy patients (ASA Classes I and II). Probing depth (PD), at 6 sites per tooth, including third molars, was obtained to determine periodontal status. Subgingival plaque samples were taken from the distal of all second molars before periodontal probing. The presence and levels of 11 bacterial species were determined using whole chromosomal DNA probes and checkerboard DNA-DNA hybridization. Detected bacterial species were grouped into clusters of periodontal pathogens designated as "red" or "orange" complex microorganisms as described by Socransky et al (J Clin Periodontal 25:134, 1998) who found an association of these specific microorganisms with periodontitis. RESULTS: As a group these relatively young patients were periodontally healthy. "Orange and red" complex microorganisms were detected at levels equal to or greater than 10(5) more often if patients had a PD equal to or greater than 5 mm with periodontal attachment loss at the distal of second molars or around third molars at their entry examination. In patients with no PD equal to or greater than 5 mm in the third molar region, "orange and red" complex microorganisms were detected at levels equal to or greater than 10(5) more frequently than would be anticipated in patients with little clinical evidence of periodontal disease. CONCLUSIONS: The clinical findings of increased periodontal PDs and periodontal attachment loss coupled with colonization of periodontal pathogens support the concept that clinical and microbial changes associated with the initiation of periodontitis may present first in the third molar region in young adults.

Periodontal pathology associated with asymptomatic third molars.

PURPOSE: We report the prevalence of periodontal probing depth (PD) as a clinical measure of the extent of periodontitis associated with asymptomatic third molars at the initial examination in a cohort of patients enrolled in an institutional review board-approved longitudinal clinical trial. PATIENTS AND METHODS: Three hundred twenty-nine healthy patients were enrolled during a 30-month period. Full mouth periodontal probing that included third molars was conducted to determine periodontal status. Panoramic radiographs were taken to assess the degree of eruption of the third molars and the angulation of third molars compared with the adjacent second molar. Vertical bitewing radiographs were analyzed to detect alveolar bone levels relative to the cementoenamel junction on the distal of second molars. RESULTS: Twenty-five percent (82 of 329) of all enrolled patients, and 34% (14 of 41) of black patients, had at least one PD equal to or greater than 5 mm on the distal of a second molar or around a third molar. PD equal to or greater than 5 mm was associated with periodontal attachment loss of at least 1 mm in every patient; PD equal to or greater than 5 mm was associated with attachment loss equal to or greater than 2 mm in 80 of 82 patients. A higher proportion of patients 25 years old or older had a PD equal to or greater than 5 mm on the distal of second molars or around third molars compared with patients younger than 25 years (33% vs 17%, P =.002). The distals of second molars and third molars in the mandible were affected more often than in the maxilla (25% vs 5%, P =.0001). CONCLUSIONS: Our data indicating that 25% of patients with retained asymptomatic third molars have considerable periodontal pathology in the third molar region were unexpected. National epidemiologic surveys indicate a much lower rate of periodontitis in the population younger than 35 years.

Inflammatory mediators and periodontitis in patients with asymptomatic third molars.

PURPOSE: Our goal was to report the detection and levels of gingival crevicular fluid (GCF) inflammatory mediators, sampled at the mesial of 4 first molars and distal of 4 second molars, in 316 patients with asymptomatic third molars. PATIENTS AND METHODS: Levels of GCF inflammatory mediators, interleukin (IL)-1 beta and prostaglandin (PG)E(2), were determined and log transformed for each patient. Z scores were calculated using the mean and standard deviation of the log values for the entire sample of 316 patients. The log mediator levels and Z scores of patients who had probing depths (PDs) less than 5 mm (n = 238) were compared with patients with at least 1 PD equal to or greater than 5 mm (n = 78) on the distal of second molars or around third molars. A periodontal Composite GCF Inflammation Score was calculated for each patient by summing the Z scores obtained for IL-1 beta and PGE(2) for that patient. RESULTS: The levels of GCF IL-1 beta and PGE(2) were higher if a patient had a PD equal to or greater than 5 mm in the third molar region. The Composite GCF Inflammation Score indicated "elevated inflammation" if a PD equal to or greater than 5 mm was found in the third molar region as well. CONCLUSIONS: These data suggest that asymptomatic patients with PD equal to or greater than 5 mm in the third molar region with associated periodontal attachment loss have increased levels of biochemical mediators of inflammation compared with patients with PD less than 5 mm. These findings are consistent with the concept that early periodontitis in young adults that initiates in the third molar region is associated with increases in key inflammatory mediators.