The Role of Different Techniques to Enhance Periodontal Healing After Third Molar Surgery: A Review Article
Abdurrahman A. Al-Samman - BDS, MSc (OMFS)
Salahiddin Health Directorate, Ministry of Health | Iraq | firstname.lastname@example.org
Khudhair A. Abd - BDS, HDD (Perio)
Ministry of Health | Iraq
Impacted third molar (M3) surgery result in periodontal complications on the distal surface of the adjacent second molar (M2). This study was conducted to review the effect of different techniques in terms of periodontal status of the preceding M2 after lower M3 surgery. The PubMed database was searched for the related studies with a minimum follow-up period of three months. The results revealed that bone substitutes and guided tissue regeneration technique show conflicting results, however, they may be valuable in high-risk group of patients. The effect flap design is uncertain. Platelet-rich plasma gel along with the curettage of the distal radicular surface of the M2 improves periodontal healing. Anchor suture might be a better technique to use to maintain healthy periodontium after M3 surgery.
Periodontal healing, Third molar surgery, Bone substitute, Flap design, GTR, PRP.
The optimal management of impacted mandibular third molars (M3s) continues to challenge clinicians. An important issue to address is the risk of developing periodontal defects on the distal aspect of mandibular second molars (M2s) after M3 extraction.1
Several well-performed longitudinal studies have documented that extraction of M3 may result in bony periodontal defects on the distal surface of the adjacent second molar.2-6
Risk factors associated with bone loss following lower third molar extraction included age, direction of eruption, preoperative bony defects, and resorption of the M2 root surface.2
While several different treatment strategies have been proposed to decrease the risk for developing periodontal defects following M3 extraction, this study discus the commonly used strategies.
Authors proposed placing a graft of demineralized bone powder (DBP) at the time of M3 extraction to prevent the development of bony defects on the distal aspect of M2. Dodson7 in a pilot study, where 7 young patients enrolled with a mean age of 21.7 ± 3.7years, documented a statistically significant improvement in clinical attachment levels in disto-buccal aspect of M2 adjacent to the DBP grafted M3 extraction sites. The same author in another study8 considered only the subjects aged ≥ 26 years and concluded that DBP therapy did not offer predictable benefit. However, when concurrent high-risk factors are present (age ≥ 26 years, mesioangular or horizontal impactions, and preexisting periodontal defect defined as attachment level ≥ 3mm), patients may benefit from the use of DBP placed at the time of M3 extraction to enhance periodontal healing.9 The same results obtained by Hassan et al.10 when inorganic xenograft, composed of resorbable inorganic bovine hydroxyapatite, used as graft material in combination with a membrane for high risk subjects. Sammartino et al.11 grafted mandibular third molar extraction sites with only bovine porous bone mineral and with bovine porous bone mineral plus collagen membrane. Their results showed that both treatment modalities are successful in probing pocket depth (PPD) reduction and increased clinical attachment level (CAL) gain. But, in the study performed by Etiene et al.12 they reported that socket grafting with xenogeneic materials did not change the bone height and bone radiographic density in the long-term. The summery of bone substitute effects on bone regeneration in the different studies appear in (Table 1).
Every mucoperiosteal flap reflection may induce loss of alveolar bone 13-15 and compromise periodontal status.13 The effects of flap design on the postoperative periodontal health status of M2 were widely investigated by many researchers. Although Stephens et al.16 have shown a decrease in PPD 3 months following third molar extractions using two types of flaps. However, there was no significant difference between the two flap designs examined. Observations of other studies over one to four years showed that after one year, there was no difference in relation to preoperative bone level of second molars17 and after 4 years there was an improvement in bone defects compared with two years postoperatively.5 Jakse et al.13 in the evaluation of the two different flap designs, demonstrated that the Szmyd flap considerably influences primary wound healing. The modified triangular flap is significantly less conducive to the development of wound dehiscence when compared with classic envelop flap. Also in 2003, Suarez-Cunqueiro et al.18 compared the effect of marginal and paramerginal flap on wound healing. The results showed that the use of the marginal flap in impacted third molar surgery resulted in better primary wound healing. Although the paramarginal flap has less PPD in the initial stages, there was no difference after the early follow-ups. This was further corroborated by Kirtiloğlu et al.14 as they concluded that the modified Szmyd flap has better primary periodontal healing than the 3-cornered flap 4 weeks after surgery, but did not influence it at 12 months. Rosa et al. did not demonstrate any statistically significant differences in measurements of PD, CAL, or bone level for the two types of flaps (Szmyd vs. 3-cornered flap) used in surgery.19 These results are in agreement with those of Arta et al.20 Quee et al.21and Schofield et al.22
The effect of flap design on periodontal health in the different studies is summarized in (Table2).
Guided Tissue Regeneration
Authors suggest that cells necessary for the regeneration of periodontal attachment apparatus appear to originate from the periodontal ligament.23,24 Studies on periodontal wound healing have resulted in the development of the treatment modality Guided Tissue Regeneration (GTR).24-28 A variety of GTR materials have been used such as non-resorbable (Gore-Tex®) and the resorbable barrier (GUIDOR matrix barrier®).29 Many clinical trials studied the effectiveness of GTR techniques in the enhancement of periodontal healing distal to M2 after surgical removal of impacted M3 molars. Oxford et al.30 used a non-resorbable GTR material in 12 patients with bilateral soft tissue impacted M3 and concluded that the use of barrier material did not provide statistically significant differences in CAL gain when comparing experimental versus control sites. However, the benefit of this technique was clinically evident when considering direct distal sites with initially deep probing depths. Also there were no significant improvement in PPD and alveolar bone level in a high-risk group of patients when a resorbable GTR membrane used in M3 extraction sockets by Karapataki et al.31 These results were inconsistent with two studies of Dodson when suggested that GTR therapy did not offer predictable benefit over no treatment.8,9 Conversely, Pecora et al.32 demonstrated a clinically and statistically significant benefit of non-resorbable GTR therapy over no treatment in subjects with multiple risk factors for M2 periodontal defects after M3 removal. By using resorbable membrane, the same results were obtained by Aimetti and Romano.33 Also Karapataki et al.34 in another study, after placing resorbable or non-resorbable membranes in 19 patients their M3 extracted before 5 years or more they found statistically significant differences in the postoperative probing depth and attachment level. The effect of GTR material on bone regeneration in the different studies appears in (Table3).
Whitman et al. first introduced Platelet-rich plasma (PRP) to the oral surgery community in 1997. It is a material containing many autologous growth factors, such as platelet-derived growth factors (PDGF) and transforming growth factor β.35-37
The researchers studied the value PRP on the periodontal healing of M2 after surgical extraction of M3. Sammartino et al.38 showed that PRP is effective in reducing PD and improving attachment level, also inducing and accelerating bone regeneration at histological level but not clinically relevant. Nevertheless, it has a non-significant effect on gum recession measured 4 months after surgery. Similarly, Sammartino et al.39 when they compare PRP vs PPR with resorbable membrane indicating that the use of resorbable membrane did not confer any additional clinical benefit to the reconstructive effort. However, the improvement of bone level and bone density was a documented effect of PRP in other studies.40-43 PRP also founded to accelerate wound healing through other studies.41-43 But Das et al reported no effect on wound healing and this may be attributed to small-sized sample study.40 The effect of PRP on periodontal health in the available studies is summarized in (Table 4).
Scaling and Root Planning
Recommendation of scaling and root planning after the extraction of the lower third molar is based on the fact that the distal root surface of lower second molar is often denuded and consequently exposed to bacteria and toxins. Not removing this layer of contaminated cementum could impair periodontal healing and bone regeneration.44,45
Pons-Vicente et al.46 studied the effect of manual versus ultrasonic scaling of lower M2 on PD following M3 extraction. Both techniques are valuable in reducing probing depth but no significant difference that favor any one over another. Leung et al.47 when they compared the two treatment modalities, obtained the same results.
The beneficial effect of scaling and root planning on the distal root surface of the M2 after extracting the M3 in order to improve CAL and reducing PD were also documented in previous studies.17,44,48 Scaling and root planning of the distal root surface were also founded to reduce bony defects related to lower M2 were also reported.17,46 However, other reports that found no significant improvement in the periodontal health of the M2 scaled and root planed after M3 extraction.49,50
The summery of scaling and root planning effect on periodontal health in different available studies appear in (Table 5).
The simple loop suture is a widely used suturing technique and usually preferred by surgeons evaluating the effect of third molar removal on the periodontal health of the adjacent second molar.14,18,51,52 The anchor suture is another suturing technique that has been reported as one of the best suturing techniques to close a flap located in an edentulous area mesial or distal to a tooth.53 Limited studies have evaluated the effect of this suturing technique on periodontal health status of M2. Cetinkata et al.54 suggested that anchor suture, when compared with simple loop technique, significantly reduces PD and improves CAL and might be a better technique to maintain healthy periodontium after the extraction of impacted M3. Kareem et al.55 also favoring the use of anchor suture technique over simple loop or figure-eight suturing technique. The previous two studies are summarized in (Table 6).
The routine application of interventions to improve the periodontal parameters on the distal of the M2 at the time of M3 removal is not indicated for all subjects. There seems to be subjects at increased risk for periodontal defects after M3 removal (i.e., age ≥26 years, pre-existing periodontal defects [AL ≥3mm or PDs ≥5mm], and a horizontal or mesioangular impaction). In the setting of having all three risk factors present, there seems to be a predictable benefit to treating the dentoalveolar defect at the time of extraction.56
Bone Substitutes: There are conflicting results about the effect of bone grafting material; however, they may be valuable in high-risk group of patients.
Flap design: flap design in lower third molar surgery influences primary wound healing but does not seem to have a lasting effect on the health of the periodontium on the distal of the second molar.
GTR Therapy: It seems not to offer predictable benefit. However, the benefit of this technique was clinically evident when considering cases with initially deep probing depths.
PRP: Provide a definite improvement in soft tissue healing and effective in inducing and accelerating bone regeneration after M3 molar surgery.
Scaling and root planning of the radicular surface of M2 together with oral hygiene control improves periodontal healing. There are no additional benefits in using ultrasound over the manual scaling and root planning.
Suturing Technique: Anchor suture might be a better technique to use to maintain healthy periodontium after the extraction of impacted M3. The efficacy of anchor suturing technique need to be proved by further controlled studies.
The author gratefully acknowledges Dr. Amina Al-Ghannam for her assistance in providing references.
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