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Ostectomy versus

osteotomy with
repositioning of the
vestibular cortical in
periapical surgery of
mandibular molars: A
Berta Garca-Mira , Barbara Ortega-Snchez ,
preliminary
study
Maria Penarrocha-Diago , Miguel Penarrocha Diago
Med Oral Patol Oral Cir Bucal. 2010 Jul 1;15 (4):e628-32

Introduction

In periapical surgery (PS), in order to eliminate the


inflammatory apical tissue, form the root-end cavity
and achieve proper sealing of the apical foramen with
rootend filling , it is necessary to eliminate the
periapical bone via ostectomy ).

This removal should be the minimum necessary to


allow access to the entire lesion and enable visual
control of the apices to the affected roots .

Due to the greater thickness of the vestibular cortical in


this region, access to the mandibular molar root apices
requires a large ostectomy, occasionally leaving
extensive bone defects

Aim and objective

The aim was to make a preliminary study


of the morbidity and prognosis following
PS using ostectomy or by osteo-tomy
with repositioning of the vestibular
cortical bone.

Material and Methods

Retrospective clinical study


89 patients underwent PS on mandibular molars
between May 1999 and June 2004.
6 patients excluded for non-completion of the
pain and swelling scales,
6 for not following the postoperative indications
2 for having an incomplete follow up (less than
12 months).
75 patients(18 male 57 female), with 87
mandibular molars, 107 lesions and 200 canals
were included in the study.

Two groups

Group1 (G1) treated with ostectomy


Group 2(G2) treated by osteotomy

mandibular molars apicoectomized using


ultrasound,
minimum follow up of 12 months
Group 2 comprised patients treated by
osteotomy with repositioning of the cortical bone
when the vestibular cortical was intact and the
teeth apices were more than 8 mm from the
mandibular canal.

Surgical procedure

All operations were carried out by the same


surgeon
local anesthesia articaine at 4% and
1:100,000 adrenaline
The ostectomy was made using a 0.27 mm
round tungsten carbide drill
The osteotomy window was formed using
trephine burrs

The cortical bone was raised with the aid of a surgical


hammer and chisel.

The bony lid was replaced following apicoectomy and


root-end filling.

Ultrasound tips for periapical surgery were used to form


the root-end cavity, root-end filling was made with zincfree silver amalgam

All patients were prescribed the same postoperative


medication:

Amoxicillin 500 mg/8 hours for 7 days;


Ibuprofen 600 mg/8 hours for 3 days,
Mouthwash with chlorhexidine at 0.12% 3 times a day for 7
days.

Pre op

Follow up

Osteoctomy

Intra op

Post op after 12 months

Pre op

Osteoto
my

Intra op

Intra op root end filling Radiograph following surgery Post-op after 12 month

Data collection

The number of operated teeth and lesions was recorded.

size of the ostectomy and osteotomy measured by digital


caliper the sizes were classified

Postoperative pain was recorded on a 4-point descriptive scale ,

less than 1 cm2, between 1 and 2 cm2, and greater than 2 cm2.

1 absence of pain; 2 slight; 3 moderate; 4 intense pain).

Swelling recorded as

1 absent (no swelling); 2 slight (intraoral swelling at the operated


area); 3 moderate (moderate) intraoral swelling at the operated
area); 4 intense (intensive extraoral swelling extending beyond the
operatedarea)

pain and swelling were recorded by each


patient 2, 4, 6 and 12 hours after surgery,
and on each of the 7 postoperative days.

Suture removal after 7 days

Check for postoperative complications


such as hematoma, wound opening,
infection or postoperative neuropathy

Success was determined by panoramic radiographic


study using a digital orthopantomograph OP100.
The resulting image was calibrated using the
CliniView program Version and introduced into an
image analyzer,

Evolution evaluated at 6 and 12 months of surgery

according to the criteria of von Arx and Kurt


classified as:

1 failure; 2 improvement; 3 success.

It was also noted if the tooth remained in the mouth,


being classified as either a functional or nonfunctional
tooth (if the tooth had been extracted)

Results

Table of patients, lesions, teeth and size by


ostectomy and osteotomy.

No of
patient

No of
lesions

No of
teeth

Size
<1c
m

Ostectomy

66

Osteotomy

1-2cm >2cm

98

78

49

44

5
-

Overall evolution at 6 and 12 months following the criteria


of von Arx and Kurt (9) in %.
6 months
Succes Improve
s
ment

Ostecto
my

12 months
Failure

No of
functio
nal
tooth

succes Improve
s
ment

Failur
e

27.9
( n = 22)

13.1
73
(n=10
)

34.6
(n =
27)

46.1
19.3
(n = 36) (n =
15)

59.0

Osteoto
my

33.3
(n=
3)

55.6
(n = 5)

55.6
(n =
5)

33.3
(n = 3)

11.1
( n=1
)

Over all

34.5
(n
=30)

46.0
19.5
(n = 40) (n=17)

58.4
(n
=51)

29.0
(n = 25)

12.6
(n
=11)

82

11.1
(n =1)

(n=46
)

Postoperative complications
5 patient with hematoma (all in G1),
3 patients with suture dehiscence (2 in G1 and 1
inG2).
1 patient had a postoperative infection(in G1)
1 patient had a transitory mental neuropathy (In
G1).
There was no relationship between postoperative
complications and prognosis in PS (p>0.05).

Patient undergoing osteotomy had a more


distinct peak of pain and swelling. Patients in
G1 perceived maximum pain during the first 48
hours, while in G2 pain increased to a
maximum on day 2
Swelling evolved similarly in G1 and G2;
increasing progressively until reaching a
maximum on the second day.
There was no statistically significant
relationship between the size of the ostectomy
and osteotomy with either pain or swelling

patients subjected to ostectomy (G1)


presented greater postoperative swelling
than patients with osteotomy (G2) (p=0.02).

Regarding prognosis, at 6 months follow-up


the success rate was higher in patients
undergoing osteotomy with repositioning of
the vestibular cortical (G2) against
ostectomy (G1)

Discussion

In the osteotomy group, pain peaked at a maximum


on the second day, while in the ostectomy group
pain remained level during the first 48 hours.

Regarding perceived swelling, a maximum peak


was found on the 2nd postoperative day;

Patients undergoing ostectomy presented greater


swelling during the postoperative period than the
patients with osteotomy and repositioning of the
vestibular cortical.

Although the success rate of PS on mandibular


molars was 58.4% after 12 months follow-up, a high

Ostectomy was used to access the tooth


roots in the majority of the lesions
(91.6%).
Osteotomy allows the repositioning of
the vestibular cortical after surgery, but
brought no benefits in the few cases of
this preliminary study.

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Thank
you