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COMPARATIVE OF PIEZOELECTRIC AND CONVENTIONAL OSTEOTOMY FOR

LOWER THIRD MOLAR IMPACTION EXTRACTION WITH SUBMUCOSAL
DEXAMETHASONE INJECTION

Article in Universal Journal of Pharmaceutical Research · November 2024

DOI: 10.22270/ujpr.v9i5.1193

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Universal Journal of Pharmaceutical Research
An International Peer Reviewed Journal
ISSN: 2831-5235 (Print); 2456-8058 (Electronic)
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RESEARCH ARTICLE

COMPARATIVE OF PIEZOELECTRIC AND CONVENTIONAL OSTEOTOMY

FOR LOWER THIRD MOLAR IMPACTION EXTRACTION WITH
SUBMUCOSAL DEXAMETHASONE INJECTION
Sohaib Ezzi Dhaif Allah Senan1 , Abdullah HT Farhan1 , Ala،a Ahmed M Shareef1 ,
Hassan Abdulwahab Al-Shamahy2,3
1
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Sana'a University, Republic of Yemen.
2
Departement of Basic Sciences, Faculty of Dentistry, Sana’a University, Republic of Yemen.
3
Medical Microbiology and Clinical Immunology Department, Faculty of Medicine and Health Sciences, Sana’a University,
Republic of Yemen.

Article Info: Abstract

_______________________________________________ ____________________________________________________________________________________________________

Article History: Background and aim: The most common procedure performed in the outpatient
Received: 11 July 2024 setting in maxillofacial surgery practices is the extraction of impacted third molars.
Reviewed: 17 September 2024 This technique often requires incision, flap reflection, and bone removal, which
Accepted: 23 October 2024 causes tissue stress and involves large amounts of connective tissue and blood
Published: 15 November 2024 vessels in the third molar area. The aim of this study was to examine
_______________________________________________ decompression surgery and the rotary technique alone and to evaluate the
Cite this article: combined effect of decompression surgery and conventional osteotomy with
Senan SEDA, Farhan AHT, Shareef AAM, Al- submucosal dexamethasone injection on the sequelae after surgical extraction of
Shamahy HA. Comparative of piezoelectric and impacted mandibular third molars.
conventional osteotomy for lower third molar Methodology: With a sample of sixty individuals, a randomized controlled clinical
impaction extraction with submucosal trial was carried out. Four groups of fifteen participants each were created: Group 1
dexamethasone injection. Universal Journal of was for conventional rotatory therapy; Group 2 was for conventional rotatory
Pharmaceutical Research 2024; 9(5): 15-23.
therapy plus a 4 mg dose of dexamethasone following surgery; Group 3 was for
http://doi.org/10.22270/ujpr.v9i5.1193
piezosurgery; and Group 4 was for piezosurgery plus a 4 mg dose of
______________________________________________
dexamethasone following surgery. The surgical working time was determined in
*Address for Correspondence: minutes, the maximum mouth opening was measured in millimeters at baseline and
Dr. Hassan A. Al-Shamahy, Faculty of on the second, fifth, and seventh day using a Vernier Caliper, and the postoperative
Medicine and Heath Sciences, Sana'a University, pain was quantified using a Visual Analog Scale (VAS) every day for the first
Yemen. Tel: +967-1-239551; week.
E-mail: shmahe@yemen.net.ye Result: A study involving 36 women and 24 men aged 21-32 years performed a
procedure involving impacted lower third molars, with a 100% success rate. All
patients showed soft tissue healing without serious events or infection. Pain levels
were greater in group 3 (3.7 degrees) and lower in group 2 (2.6 degrees). No
significant differences were found in pain levels of dexamethasone injection among
the four groups.
Conclusion: The use of submucosal dexamethasone injection with conventional
and electrosurgical osteotomy is beneficial for alleviating post operative
complication after removal of impacted third molar surgery.
Keywords: Conventional osteotomy, dexamethasone, extraction, piezoelectric
osteotomy, third molar impaction.

INTRODUCTION biological reactions in the tissues, including edema,

trismus, and discomfort1,2. Following surgery, these
The most frequent outpatient operation performed in post-operative sequelae cause discomfort for the
maxillofacial surgery practices is the extraction of patient, which lowers their quality of life3. Several
impacted third molars. Incision, flap reflection, and treatment plans have been put forth in an effort to
bone removal are frequently required for this surgery, avoid or reduce third molar surgery-related post-
which might result in tissue trauma because the third operative complications. Among these, corticosteroids
molar region contains a large quantity of connective are regarded as a well-researched and generally
tissue and blood arteries. Trauma related to surgery sets acknowledged pharmaceutical adjunct therapy regimen
off an inflammatory chain reaction that causes for averting problems following third molar surgery.

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Senan et al., Universal Journal of Pharmaceutical Research 2024; 9(5): 15-23

Their mode of action relies on reducing edema, extraction of a bilateral lower third molar between
trismus, and post-operative discomfort while inhibiting 2023 and 2024 were eligible to participate. These
inflammation 1,4. Dextamethasone (dex), a synthetic patients were divided into four groups at random:
analogue of prednisolone with strong anti- Group 1 (Control): Osteotomy performed surgically
inflammatory properties 20–30 times stronger than without the use of dexamethasone injection, with
natural corticosteroids, is the most widely utilized standard rotatory devices.
corticosteroid type in oral surgery5,6. Several literature Group 2: Post-operative submucosal dexamethasone
studies have examined the delivery of dex using injection after surgical extraction utilizing traditional
various techniques in third molar surgery, with positive rotatory instruments to accomplish osteotomy.
results reported. Over the best clinical outcomes, there Group 3: Piezosurgery-based surgical extraction
is still disagreement over the time, methods, and performed without a dexamethasone injection.
dosages of dex3,7,8. High-speed surgical hand parts are Group 4: Post-surgery 4 mg submucosal
frequently utilized in third molar surgical operations dexamethasone injection after surgical extraction
since the procedure requires the removal of bone. utilizing Piezosurgery technology; it was found that the
Nevertheless, these tools invariably produce heat and sample needed a minimum of 30 individuals, 15 in
uneven bone surfaces, which exacerbate post-operative each group.
discomfort9. Ultrasonic devices have surfaced as a Sample size: The sample size was 30 patients,
substitute for traditional surgical instruments in order calculated was similar to a previous study conducted
to address these drawbacks10. Micro vibration by Arakji et al.22.
piezosurgery devices offer a less invasive, more Inclusion criteria:1: individuals in the age range of
accurate method of cutting bones while causing 20 to 35. 2: The existence in every participant of
minimum bleeding and injury to the surrounding impacted lower third molars that are bilateral and
tissues. Therefore, if this approach was chosen as the symmetrically directed and require extraction for
surgical option, the likelihood of problems would be orthodontic or preventive purposes. 3: A minimum of
significantly decreased9,11. one third molar, completely or partially impacted,
The topic of the current study has not been studied requiring surgical extraction (or at the very least,
before in Yemen, but there have been studies on requiring an osteotomy and flap incision); 2 mm. 4:
surgical site infection 12, mandibular canal anatomy and The patient who consents to take part in the research. 5:
the location of its holes in a sample of Yemeni Patients with decent oral hygiene.
patients13, the prevalence of temporomandibular joint Exclusion criteria: Patient with sever pericoronities,
disorders14, dystonia of the mandibular musculature15, individual who is older than 40 years old, individual
interleukin-1 beta levels in the human gingival sulcus16, who has a sever periodontal diseases, individual with a
the impact of dental implants on the colonization of medically compromised condition that makes surgery
aerobic bacteria in the oral cavity17, deep bite not an option, and smoker patients.
malocclusion18, resolving factors and the extraction Data collection: Every patient had a clinical
pattern of permanent teeth in dental clinics19, evaluation, and all data was gathered and entered into a
Porphyromonas gingivalis20, and the antimicrobial data collection sheet, also known as a case sheet, which
activity of sodium hypochlorite, nanosilver, and was intended to have a methodological recording.
chlorhexidine against monospecific biofilms of specific Before the procedure, the inter-incisal distance was
oral microorganisms21. measured using a caliper. From the first day of the
The current retrospective clinical study aimed to procedure to the seventh, each patient was monitored.
compare the effectiveness of piezo surgery devices The inter-incisal distance was measured and the
versus conventional surgical instruments in terms of swelling was assessed on the second, fifth, and seventh
post-operative discomfort and to examine the effects of day. From the first day of surgery until the seventh,
sub-mucosal dex injections on post-operative each patient was asked to report the level of pain.
discomfort among patients who had undergone Every side was removed at a separate visit.
mandibular third molar surgery. Surgical management:
Preoperative assessment: The medical history was
MATERIALS AND METHODS reviewed for previously undiscovered systemic issues.
The operator measured the maximum mouth opening
Study design: It was a split-mouth, prospective, (mm) with a Vernier caliper as the distance between
randomized research. Every patient was divided into the upper and lower incisors.
four groups at random (1:1). The assignment of the Surgical technique: The same trained surgeon
interventions was hidden from the participants. The extracted the impacted mandibular third molar teeth
allocation concealment of the researcher delivering the from each patient, and the length of each procedure
interventions was not used because of the variations was also noted (from the point of incision to the final
across the four approaches. suture). In order to prepare the surgical site of the
Study Area: The study was carried out in the oral and impacted third molar for the treatment, regular saline
maxillofacial surgery clinic in the Faculty of dentistry irrigation was applied. Under local anesthetic, the
Sana’a university. inferior alveolar, lingual, and buccal nerves were
Study population : Patients who met the inclusion and blocked using 1.8 ml cartridges containing 2%
exclusion criteria and visited the dental clinic at the lidocaine and 1:100.000 epinephrine for the surgical
Faculty of Dentistry Sana'a University for surgical procedure. The flap was created by making an incision

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using a number 15 scalpel blade. Using a periosteal Every response had one of the following numbers:
elevator, the full-thickness fap exposes the affected 0 indicates no pain; 1=very little discomfort; 2=little
tooth and surrounding bone. With generous amounts of discomfort during eating; 3=excruciating pain that
normal saline irrigation, bone was removed from the keeps you from sleeping.
occlusal and buccal portions of the teeth for groups 1 Swelling: Swelling was examined in the 2nd day, 5th
and 2 using a straight handpiece with sufficient speed day, and 7th day after the surgery, in which each
and torque. Extraction for groups three and four: OT7 category had a number as follows: 0=no swelling, 1=
inserts were utilized in conjunction with a piezosurgery mild swelling, 2=moderate swelling, and 3=severe
instrument (PIEZOSURGERY® touch, MECTRON swelling.
Medical Technology, Italy) to remove bone Statistical method: Information provided with suitable
surrounding the impacted teeth. The micro-vibration descriptive statistics (P-value, mean, frequency, and
amplitude was tuned between 35 and 55 μm/s, while standard deviation). Excel 2010 and the Statistical
the frequency was modified between 25 and 35 kHz. In Package for Social Science (SPSS) version 26 were
order to remove the impacted tooth with the least used for all statistical analysis of the data. wherein they
amount of bone stress, the least amount of tooth were recorded and added to SPSS for analysis
separation and bone guttering was performed. A following data collection.
thorough debridement was completed following the Ethical Approval: Ethical approval was obtained from
extraction of impacted teeth. Any jagged edges of bone the Medical Ethics Committee of the Faculty of
were smoothed with a bone file. Next, regular saline Dentistry, Sana'a University, No.: 24-2023, dated 1-1-
was used to clean the socket. After that, a 3-0 black silk 2023, and the confidentiality of all data, including the
interrupted suture was used to seal the flap. Seven days patient's identity, was maintained.
following surgery, the suture was removed. A
disposable syringe was used to inject 4 mg of RESULTS
submucosal dexamethazone into groups 2 and 4.
Variables of the study: The total sample included 36 women (60%) and 24
The inter-incisal distance: Every patient checks for men (40%). The age of the study patients ranged from
any limitations on their ability to open their mouths, 21 to 32 years, with the mean age being 23.9±3.09 in
but none of them have any. On the second, fourth, and group 1, 24.3±3.31 in group 2, 23.9±3.09 in group 3,
seventh days following the procedure, the inter-incisal and 24.3±3.31 in group 4 (Table 1). The duration of
distance was measured and recorded in centimeters surgical operations ranged from 23 to 55 minutes, and
(cm). the mean operating time was 27.5±2.36 minutes in
Pain level: By responding to questions over the course group 1, 29.3±2.57 minutes in group 2, 35.2±5.92
of the seven postoperative days, the patient's level of minutes in group 3, and 36.2±7.38 minutes in group 4
discomfort was ascertained using a visual analog scale. (Table 3).

Table 1: Age and gender distribution of patients participated on the study.

Group 1 Group 2 Group 3 Group 4
n=15 n=15 n=15 n=15
Age (Mean±SD) 23.9±3.09 24.3±3.31 23.9±3.09 24.3±3.31
Gender n (%)
Male 6 (40%) 6 (40%) 6 (40%) 6 (40%)
Female 9 (60%) 9 (60%) 9 (60%) 9 (60%)

Table 2: Distribution of participated patients by type of impaction.

Group 1 Group 2 Group 3 Group 4
p value
n=15 n=15 n=15 n=15
Type of impaction n (%)
Mesioangular 7 (46.7%) 7 (46.7%) 7 (46.7%) 4 (26.7%)
Horizontal 6 (40.0%) 7 (46.7%) 5 (33.3%) 6 (40.0%) 0.597
Vertical 2 (13.3%) 1 (6.7%) 3 (20.0%) 5 (33.3%)

Table 3: Surgical working times by minute for the 4 different techniques.

Group 1 Group 2 Group 3 Group 4
p value
n=15 n=15 n=15 n=15
Working time in minutes
27.5±2.36 29.3±4.57 35.2±5.92 36.2±7.38 0.000*
(Mean±SD)

With the effective extraction of every affected lower Differences in pain levels by group on different
third molar, the procedure's success rate was 100%. postoperative days (Figure 1). Pain levels were greater
Between the first postoperative day and the seventh in group 3 than the other groups, with the mean pain
postoperative day, every patient underwent a thorough levels in group 3 being (3.7 degrees). While pain levels
clinical evaluation. Every patient exhibited soft tissue were lower in group 2 with a mean of (2.6). There were
healing without any significant complications or statistically significant differences in pain levels on day
infections. 4 among the four groups, with a probability value (p)

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of (0.001). Pain levels were greater in group 3 than the Pain levels without dexamethasone were greater (3.4
other groups, with the mean pain levels in group 3 degrees), while pain levels with dexamethasone were
being (2.7 degrees). Group 4's pain threshold was (1.6 lower on average (2.9 degrees). There were statistically
degrees), however. For the approach on days 1, 2, 4, 5, significant differences in pain level of dexamethasone
6, and 7, there were no statistically significant injection on day 4 among the four groups (p<0.0001).
differences in pain levels across the four groups. Pain levels without dexamethasone were greater (2.6
degrees), while pain levels with dexamethasone were
lower on average (1.7 degrees) (Figure 3). The first
group experienced a decrease in pain from (3.9
degrees) on the first day to (0.3 degrees) on the seventh
day, with statistically significant differences in pain
levels (p<0.0001). As the pain dropped from (4.3
degrees) on the first day to (0.3 degrees) on the
seventh, there were statistically significant differences
in the second group's pain level (p<0.0001).

Figure 1: The pain scores by groups.

On day three, however, there were differences between

the four groups that were statistically significant
(p=0.008). Pain levels in the piezo surgery technique
were significant (3.4 degrees). While pain levels in the
conventional technique were lower with an average
(2.8 degrees) (Figure 2).

Figure 3: The pain scores by dexamethasone

injection.

As the pain decreased from (4.2 degrees) on the first

day to (0.5 degrees) on the seventh, there were
statistically significant differences in the third group's
pain level (p<0.0001) (Table 4). Pain decreased from
(4.1) on day 1 to (0.3) on day 7 for the conventional
technique (p<0.0001). There were statistically
significant differences in pain level in the piezo surgery
technique (p<0.0001). Pain decreased from (3.9) on
day 1 to (0.4) on day 7 (Table 5). There were
Figure 2: The pain scores by technique. statistically significant differences in pain level with
the use of dexamethasone (p<0.000), as pain decreased
There were no statistically significant differences in the from (3.9) on the first day to (0.3) on the seventh day,
pain level of dexamethasone injection on day 1, day 2, and pain decreased in patients who did not use
day 5, day 6, and day 7 among the four groups, while dexamethasone from (4.0) on the first day to (0.4) on
there were statistically significant differences on day 3 the seventh day (p<0.0001).
among the four groups with a p value of (0.049).

Table 4: The pain scores by groups at different post-operative days

Pain scores by group
Days Group 1 Group 2 Group 3 Group 4
p valueb
n=15 n=15 n=15 n=15
Day 1 3.9 ±1.3 4.3±1.5 4.2±1.6 3.5±1.1 0.423
Day 2 3.7±1.1 3.7±1.1 3.5±0.9 3.1±1.2 0.467
Day 3 3.1±0.3 2.6±1.1 3.7±1.0 3.2±0.6 0.012*
Day 4 2.5±0.8 1.7±1.0 2.7±0.5 1.6±1.1 0.001*
Day 5 1.4±1.6 1.6±1.6 2.2±1.4 1.5±1.5 0.450
Day 6 0.5±1.2 0.8±1.2 0.7±1.2 0.7 ±1.1 0.902
Day 7 0.3±0.9 0.3±0.7 0.5±1.2 0.3±0.8 0.915
p value b < 0.001 < 0.001 < 0.001 < 0.001
a Mann-Whitney Test, b Kruskal Wallis test; p value less than 0.05 was considered
significant

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Table 5: The effect of techniques on the pain scores.

Technique
Days
Conventional Piezosurgery p valuea
Day 1 4.1±1.4 3.9±1.4 0.495
Day 2 3.7±1.1 3.3±1.1 0.200
Day 3 2.8±0.8 3.4±0.8 0.008*
Day 4 2.1±1.0 2.1±1.0 0.833
Day 5 1.5±1.5 1.9±1.5 0.371
Day 6 0.7±1.1 0.7±1.1 0.866
Day 7 0.3±0.8 0.4±1.0 0.686
p valueb < 0.001 < 0.001
a Mann-Whitney Test, b Kruskal Wallis test; p value less than 0.05 was considered significant

Table 6: The effect of dexamethasone injection in pain score.

Days Dexamethasone Injection
With Without
p valuea
Dexamethasone Dexamethasone
Day 1 3.9±1.3 4.0±1.5 0.780
Day 2 3.4±1.2 3.6±1.0 0.465
Day 3 2.9±0.8 3.4±0.8 0.049*
Day 4 1.7±1.0 2.6±0.7 0.000*
Day 5 1.6±1.5 1.8±1.5 0.506
Day 6 0.8±1.1 0.6±1.1 0.507
Day 7 0.3±0.7 0.4±1.0 0.642
p valueb < 0.001 < 0.001
a Mann-Whitney Test, b Kruskal Wallis test; p value less than 0.05 was considered significant

Group 1 saw higher amounts of swelling than the other

groups, with group 3 having the highest mean of (1.9).
Group 4 had reduced swelling, with a mean of (1.3)
The p-value for the technique was above the
significance level of 0.05, indicating that there were no
changes in swelling levels between the four groups that
were statistically significant on all days (Figure 4).

Figure 5: The swelling scores by technique.

There were no statistically significant differences in the

level of humeral spasm for the technique on all days
among the four groups (p<0.05) (Figure 8). There
were no statistically significant differences in the level
of muscle spasm after injection with dexamethasone
compared to injection without dexamethasone on all
days for the four groups (p>0.05), but there was a
significant decrease in muscle spasm over the days
Figure 4: The swelling scores by groups. (lowest level on day 7 for both techniques) (Figure 9).

On the first, third, fourth, fifth, sixth, and seventh days

following a dexamethasone injection, there were no
statistically significant differences between the four
groups; however, on the second day, there were
statistically significant differences between the four
groups, with a probability value (p) of (0.004) (Figure
5). Swelling levels without dexamethasone were
greater (1.8), while swelling levels with dexametha-
sone were lower on average (1.4) (Figure 6). Figure 7
shows the differences in muscle spasm levels (trismus)
by group on different postoperative days. There were
no statistically significant differences in muscle spasm Figure 6: The swelling scores by dexamethasone
levels on all days among the four groups (p>0.05). injection.

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the other groups, with a mean of 3.7 degrees. These

findings are similar to the result of Nehme et al.25.
while Nehme et al.25, found the route of administration
of dexamethasone was by muscular administration. Our
results show the advantage of submucosal
dexamethasone injection in reducing postoperative pain
following third molar surgical extraction.

Figure 7: The trismus scores by groups.

DISCUSSION

This topic was chosen due to the lack of previous

research in Yemen on the application of piezo versus
motor injections after lower third molar surgery,
common complications in Yemeni society due to Qat Figure 9: The trismus scores by dexamethasone
chewing habits, and the high prevalence of impacted injection.
third molar surgery in dental clinics. In the current
study, the mean time for piezo surgery was 35.7 min, There are no statistically significant differences in the
while the mean time for conventional rotary surgery level of pain for technique on day 1, day 2, day 4, day
was 28.4 min (p<0.0001). 5, day 6, and day 7 between the four groups. While
statistically significant differences were found on day 3
between the four groups (p=0.008). The pain levels in
piezosurgery technique were larger at 3.4 degrees, and
this may be returning to the long duration of surgery, as
reported by Rullo et al.23. Another clinical study
published by Goyal et al.26, suggested patients in the
piezotome group had significantly less pain than those
in the conventional group. Between the four groups,
there are no statistically significant variations in the
degree of pain experienced following a dexamethasone
injection on days 1, 2, 5, 6, and 7. On day three,
however, there were differences between the four
groups that were statistically significant (p=0.049).
Without dexamethasone, pain levels in the current trial
Figure 8: The trismus scores by technique. were higher than those with it (3.4 degrees). This
outcome is comparable to that of Mojsa et al.27, s
These results are similar to those reported by Jiang et study, which found that patients who got
al., where the time was shorter with the conventional dexamethasone following surgery felt much less pain
rotary method versus longer with piezo surgery23. The overall compared to those who received the medication
same results were also reported by Arakji et al., in before to the procedure and those who were given a
2016 (28.5±3.57 min for piezo surgery versus placebo. The variation of pains in the different studies
17.6±2.95 min for the rotary group (p=0.0001)24. The might be explained by the fact that ways to measure
greater time consumption of piezo surgery is due to the pain are subjective because they are related to patient
lower effectiveness of piezo in cutting the bone and the pain thresholds, tolerance levels, emotional states, and
lower hand power and speed in cutting. cultural backgrounds28.
While there are statistically significant differences on The degree of swelling on days 1, 3, 4, 5, 6, and 7 does
day 3 (p=0.012) between the four groups, there are no not differ statistically significantly among the four
statistically significant differences in pain levels groups in the present investigation. Day 2 revealed
between the groups on days 1, 2, 5, 6, and 7 of the statistically significant differences (p=0.009)
current study. Group 2 (surgical extraction using throughout the four groups. While Group 4 in the
conventional rotatory tools to perform osteotomy with current study had a mean swelling level of 1.3, this
4 mg submucosal dexamethasone injection post result is similar to that reported previously, where the
surgery) had lower pain levels than the other groups, conventional technique resulted in more swelling,
with a mean of 2.6 degrees. Group 3 (surgical particularly on day23. This highlights the benefit of
extraction using the Piezosurgery technique without submucosal dexamethasone injection in reducing the
dexamethasone injection) had higher pain levels than

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swelling postoperatively, as reported by Markovic and CONCLUSIONS

Todorovic29 and Aurora et al.30.
In the current study, there are no statistically significant Longer piezo surgery time increases the degree of
differences in the level of swelling for the different complications, and the use of submucosal
techniques on all days between the four groups. This dexamethasone with two techniques of conventional
result is similar to that reported by Menziletoglu et al., osteotomy and piezo surgery reduces postoperative
in which piezo surgery did not provide a superiority complications for bilateral impacted lower third molar
over conventional methods31. In the current study, there extraction. Further studies with larger sample size and
were statistically significant differences found on day 2 more details are needed. Also, the use of a digital
between the four groups in the level of swelling for swelling scale could provide more accurate data.
dexamethasone injection (p=0.004). The swelling
levels without dexamethasone were larger (1.8). While ACKNOWLEDGEMENTS
swelling levels with dexamethasone were less with a
mean of 1.4. This result is similar to that of several The authors would like to thank Yemen and the Faculty
studies32-35. This result emphasizes the benefit of of Dentistry at Sana'a University for their kind
submucosal dexamethasone injection on postoperative cooperation.
sequale, and all patients who received dexamethasone
submucosally post-extraction feel more comfort than AUTHOR’S CONTRIBUTION
the other control group.
In the current study, there were no statistically Senan SEDA: writing original draft, methodology,
significant differences in the level of muscle spasm of investigation. Al-Shamahy HA: formal analysis, data
the technique on all days among the four groups. This curation, conceptualization. Farhan AHT: writing,
is similar to the three findings of Piersanti et al.36, review and editing, methodology. Shareef AAM:
Barone et al.37, and Mantovani et al.38, who evaluated formal analysis, data curation, conceptualization. All
mouth opening in both the conventional rotary authors reviewed the article and approved the final
instrument group and the compression surgery group at version of the article.
1 week postoperatively, indicating that mouth opening
was significantly better in the compression surgery DATA AVAILABILITY
group on the first postoperative day with no
discrepancy and no statistically significant differences The accompanying author can provide the empirical
between the two groups at 5 and 7 days data that were utilized to support the study's
postoperatively. Similar to studies by Graziani et al.39, conclusions upon request.
and Grossi et al.40, which both reported a significant
reduction in edema in the immediate postoperative CONFLICT OF INTEREST
period compared to controls but only a limited effect
on muscle spasm, the current study found no There are no conflicts of interest in regard to this
statistically significant differences in the level of project.
muscle spasm following dexamethasone injection on
all days between the four groups. It's possible that REFERENCES
because dexamethasone was injected submucosally at
the site of injury, there was no discernible decrease in 1. Saravanan K, Kannan R, John RR, Nantha Kumar C. A
muscle spasm as a result of this observation. Steroids, Single Pre Operative Dose of Sub Mucosal
Dexamethasone is Effective in Improving Post Operative
however, do not directly affect muscular contraction 41. Quality of Life in the Surgical Management of Impacted
According to other research, submucosal injection of Third Molars: A Comparative Randomised Prospective
dexamethasone (4 mg) significantly reduced jaw spasm Study. J Maxillofac Oral Surg. 2016 Mar;15(1):67-71.
on the second postoperative day when compared to the https://doi.org/10.1007/s12663-015-0795-0
control group, but no significant reduction was 2. Schmelzeisen R, Frölich JC. Prevention of postoperative
observed on the other postoperative days35,42. All swelling and pain by dexamethasone after operative
removal of impacted third molar teeth. Eur J Clin
studies showed a significant reduction in swelling and Pharmacol. 1993; 44(3):275-7.
discomfort following third molar operations when https://doi.org/10.1007/BF00271371 PMID: 8491244
submucosal dexamethasone was given, but no 3. Moraschini V, Hidalgo R, Porto Barboza Ed. Effect of
improvement in jaw spasm43. The anterior fibers of the submucosal injection of dexamethasone after third molar
temporalis muscle, which attach to the anterior border surgery: a meta-analysis of randomized controlled trials.
of the ramus and extend to the posterior molar region, Int J Oral Maxillofac Surg 2016 Feb;45(2):232-40.
https://doi.org/10.1016/j.ijom.2015.09.008
may have been injured as a result of jaw spasm 4. Nandini GD. Eventuality of dexamethasone injected intra-
following third molar surgery. massetrically on post operative sequel following the
Limitation of the study surgical extraction of impacted mandibular third molars: A
The main limiting factors of this study were the small Prospective Study. J Maxillofac Oral Surg 2016 Dec;
sample size and lack of details about the operations and 15(4):456-460.
https://doi.org/10.1007/s12663-015-0847-5
post-operative complications. A digital swelling scale 5. Bortoluzzi MC, Capella DL, Barbieri T, et al. A single
was not used, which might provide more accurate data. dose of amoxicillin and dexamethasone for prevention of
postoperative complications in third molar surgery: A

ISSN: 2456-8058 21 CODEN (USA): UJPRA3

Senan et al., Universal Journal of Pharmaceutical Research 2024; 9(5): 15-23

randomized, double-blind, placebo controlled clinical trial. 20. Al-Deen HMS, Al-Ankoshy AAM, Al-Shamahy HA, et al.
J Clin Med Res 2013 Feb; 5(1):26-33. Porphyromonas gingivalis: Biofilm formation,
https://doi.org/10.4021/jocmr1160w antimicrobial susceptibility of isolates from cases of
6. Boonsiriseth K, Klongnoi B, Sirintawat N, et al. localized aggressive periodontitis (LAP). Universal J
Comparative study of the effect of dexamethasone Pharm Res 2021; 6 (4):1-6.
injection and consumption in lower third molar surgery. Int https://doi.org/10.22270/ujpr.v6i4.633
J Oral Maxillofac Surg 2012 Feb;41(2):244-7. 21. Alsamhari MMA, AlKhawlani MML, Al-Shamahy HA,
https://doi.org/10.1016/j.ijom.2011.12.011 et al. Antimicrobial activity of sodium hypochlorite, nano
7. Deo SP. Single- dose of submucosal injection of silver and chlorhexidine against mono-species biofilms of
dexamethasone affects the post operative quality of life selected microorganisms of oral sources. Universal J
after third molar surgery. J Maxillofac Oral Surg 2016 Pharm Res 2022; 7 (1):1-6.
Sep;15(3):367-375. https://doi.org/10.22270/ujpr.v7i1.716
https://doi.org/10.1007/s12663-015-0846-6 22. Arakji H, Shokry M, Aboelsaad N. Comparison of
8. Graziani F, D’Aiuto F, Arduino PG, Tonelli M, Gabriela piezosurgery and conventional rotary instruments for
M. Perioperative dexamethasone reduces post-surgical removal of impacted mandibular third molars: A
sequelae of wisdom tooth removal. A splitmouth randomized controlled clinical and radiographic trial. Int J
randomized double-masked clinical trial. Int J Oral Dent 2016;2016:8169356.
Maxillofac Surg 2006; 35:241–6. https://doi.org/10.1155/2016/8169356
9. Basheer SA, Govind RJ, Daniel A, Sam G, Adarsh VJ, 23. Jiang Q, Qiu Y, Yang C, Yang J, Chen M, Zhang Z.
Rao A. Comparative study of piezoelectric and rotary Piezoelectric versus conventional rotary techniques for
osteotomy technique for third molar impaction. J Contemp impacted third molar extraction: A meta-analysis of
Dent Pract 2017 Jan 1;18(1):60-64. randomized controlled trials. Medicine (Baltimore) 2015
https://doi.org/10.5005/jp-journals-10024-1990 Oct;94(41):e1685.
10. Horton JE, Tarpley TM, Jacoway JR. Clinical applications https://doi.org/10.1097/MD.0000000000001685
of ultrasonic instrumentation in the surgical removal of 24. Arakji H, Shokry M, Aboelsaad N. Comparison of
bone. Oral Surg Oral Med Oral Pathol 1981; 51:236–42. piezosurgery and conventional rotary instruments for
11. Al-Moraissi EA, Elmansi YA, Al-Sharaee YA, Alrmali removal of impacted mandibular third molars: A
AE, Alkhutari AS. Does the piezoelectric surgical randomized controlled clinical and radiographic trial. Int J
technique produce fewer post-operative sequelae after Dent 2016; 2016:8169356.
lower third molar surgery than conventional rotary https://doi.org/10.1155/2016/8169356
instruments? A systematic review and meta analysis. Int J 25. Nehme W, Fares Y, Abou-Abbas L. Piezo-surgery
Oral Maxillofac Surg 2016; 45:383–91. technique and intramuscular dexamethasone injection to
12. Alhadi YAA, Al-Kibsi TAM, Al-Shamahy HA, Aldeen reduce postoperative pain after impacted mandibular third
YAAS. Surgical site infections: Prevalence, associated molar surgery: A randomized clinical trial. BMC Oral
factors and antimicrobial susceptibility patterns of the Health. 2021 Aug 11;21(1):393.
bacterial isolates among postoperative patients in Sana’a, https://doi.org/10.1186/s12903-021-01759-x
Yemen. Universal J Pharm Res 2022; 7(3):1-6. 26. Goyal M, Marya K, Jhamb A, Chawla S, Sonoo PR, Singh
https://doi.org/10.22270/ujpr.v7i3.777 V, Aggarwal A. Comparative evaluation of surgical
13. Alhadi YAA, Alasbahi AA, Al-Shamahy HA. Anatomical outcome after removal of impacted mandibular third
pattern course of mandibular canal and its foramina molars using a Piezotome or a conventional handpiece: A
location on sample of Yemeni patients using cone beam prospective study. Br J Oral Maxillofac Surg 2012 Sep;
computed tomography. Universal J Pharm Res 2023; 50(6):556-61. https://doi.org/10.1016/j.bjoms.2011.10.010
8(1):35-41. https://doi.org/10.22270/ujpr.v8i1.895 27. Mojsa IM, Pokrowiecki R, Lipczynski K, Czerwonka D,
14. Al-Khorasani MAM, Al-Kebsi AM, Al-Shamahy HA, et Szczeklik K, Zaleska M. Effect of submucosal
al. Prevalence of signs of temporomandibular disorders in dexamethasone injection on postoperative pain, oedema,
healthy asymptomatic completely edentulous individuals and trismus following mandibular third molar surgery: A
and the effect of denture on temporomandibular prospective, randomized, double-blind clinical trial. Int J
disorders. Universal J Pharm Res 2023; 8(1): 28-34. Oral Maxillofac Surg 2017 Apr;46(4):524-530.
https://doi.org/10.22270/ujpr.v8i1.894 https://doi.org/10.1016/j.ijom.2016.11.006
15. Aldeen HMAS, Abbas AK, Al-Shamahy HA, Jahaf SHA, 28. Chen Q, Chen J, Hu B, Feng G, Song J. Submucosal
et al. Oromandibular dystonia: Prevalence, clinical and injection of dexamethasone reduces postoperative
demographic data, therapeutic strategies out-come for discomfort after third-molar extraction: A systematic
hundred patients in Sana’a city, Yemen. Universal J Pharm review and meta-analysis. J Am Dent Assoc 2017
Res 2023;8 (2): 1-8. Feb;148(2):81-91.
https://doi.org/10.22270/ujpr.v8i2.925 https://doi.org/10.1016/j.adaj.2016.09.014
16. Al-dossary O A, Al-Kholani AIM, Al-Shamahy HA, et 29. Markovic A, Todorovic Lj. Effectiveness of
al. Interleukin-1β levels in the human gingival sulcus: dexamethasone and low-power laser in minimizing
Rates and factors affecting its levels in healthy oedema after third molar surgery: a clinical trial. Int J Oral
subjects. Universal J Pharm Res 2022; 7(5):1-6. Maxillofac Surg 2007 Mar;36(3):226-9.
https://doi.org/10.22270/ujpr.v7i5.838 https://doi.org/10.1016/j.ijom.2006.10.006
17. Al-Hamzi MA, Sharafuddin AH, Al-Shamahy HA, et al. 30. Arora SS, Phull T, Kumar I, Kumar A, Kumar N, Singh H.
The effect of dental implants on aerobic bacteria A comparative study of the effect of two dosages of
colonization in the oral cavity and the antibiotic profile of submucosal injection of dexamethasone on postoperative
common isolated aerobic bacteria. Universal J Pharm Res discomfort after third molar surgery: A prospective
2023; 8(4): 1-6. https://doi.org/10.22270/ujpr.v8i4.969 randomized study. Oral Maxillofac Surg 2018
18. Alaklany BAGA, Almotareb FL, Al-Shamahy HA, et al. Jun;22(2):225-230.
Deep bite malocclusion: exploration of the skeletal and https://doi.org/10.1007/s10006-018-0699-5
dental factors. Universal J Pharm Res 2023; 8(2):1-6. 31. Menziletoglu D, Basturk F, Isik BK, Esen A. A
https://doi.org/10.22270/ujpr.v8i2.919 prospective split-mouth clinical study: Comparison of
19. Zabara AQ, Al-Kholani AIM, Al-Shamahy, et al. piezosurgery and conventional rotary instruments in
Resolution of factors and pattern of permanent dental impacted third molar surgery. Oral Maxillofac Surg 2020
extraction in selected dental clinics in Sana’a city, Mar;24(1):51-55.
Yemen. Universal J Pharm Res 2022; 7 (4):1-6. https://doi.org/10.1007/s10006-019-00817-7
https://doi.org/10.22270/ujpr.v7i4.813

ISSN: 2456-8058 22 CODEN (USA): UJPRA3

 Senan et al., Universal Journal of Pharmaceutical Research 2024; 9(5): 15-23

32. Deo SP. Effect of submucosal injection of dexamethasone

on post-operative sequelae of third molar surgery. JNMA J 38. Mantovani E, Arduino PG, Schierano G, et al. A split-
Nepal Med Assoc. 2011 Apr-Jun;51(182):72-8. PMID: mouth randomized clinical trial to evaluate the
22916516. performance of piezosurgery compared with traditional
33. Bhargava D, Sreekumar K, Deshpande A. Effects of intra- technique in lower wisdom tooth removal. J Oral
space injection of twin mix versus intraoral-submucosal, Maxillofac Surg 2014 Oct; 72(10):1890-7.
intramuscular, intravenous and per-oral administration of https://doi.org/10.1016/j.joms.2014.05.002
dexamethasone on post-operative sequelae after 39. Graziani F, D'Aiuto F, Arduino PG, Tonelli M, Gabriele
mandibular impacted third molar surgery: A preliminary M. Perioperative dexamethasone reduces post-surgical
clinical comparative study. Oral Maxillofac Surg 2014 sequelae of wisdom tooth removal. A split-mouth
Sep;18(3):293-6. randomized double-masked clinical trial. Int J Oral
https://doi.org/10.1007/s10006-013-0412-7 Maxillofac Surg. 2006 Mar;35(3):241-6.
34. Saravanan K, Kannan R, John RR, Nantha Kumar C. A https://doi.org/10.1016/j.ijom.2005.07.010
single pre operative dose of sub mucosal dexamethasone is 40. Grossi GB, Maiorana C, Garramone RA, et al. Effect of
effective in improving post operative quality of life in the submucosal injection of dexamethasone on postoperative
surgical management of impacted third molars: A discomfort after third molar surgery: a prospective study. J
comparative randomised prospective study. J Maxillofac Oral Maxillofac Surg 2007 Nov;65(11):2218-26.
Oral Surg 2016 Mar; 15(1):67-71. https://doi.org/10.1016/j.joms.2006.11.036
https://doi.org/10.1007/s12663-015-0795-0 41. Warraich R, Faisal M, Rana M, Shaheen A, Gellrich NC,
35. Ehsan A, Ali Bukhari SG, Ashar, Manzoor A, Junaid M. Rana M. Evaluation of postoperative discomfort following
Effects of pre-operative submucosal dexamethasone third molar surgery using submucosal dexamethasone - a
injection on the postoperative swelling and trismus randomized observer blind prospective study. Oral Surg
following surgical extraction of mandibular third molar. J Oral Med Oral Pathol Oral Radiol. 2013 Jul;116(1):16-22.
Coll Physicians Surg Pak 2014 Jul; 24(7):489-92. PMID: https://doi.org/10.1016/j.oooo.2012.12.007
25052972. 42. Gümrükçü Z. The effects of piezosurgery and submucosal
36. Piersanti L, Dilorenzo M, Monaco G, Marchetti C. dexamethasone injection on post-operative complications
Piezosurgery or conventional rotatory instruments for after third molar surgery. J Stomatol Oral Maxillofac Surg.
inferior third molar extractions? J Oral Maxillofac Surg 2019 Jun;120(3):182-187.
2014 Sep;72(9):1647-52. https://doi.org/10.1016/j.jormas.2018.10.012
https://doi.org/10.1016/j.joms.2014.04.032 43. Moraschini V, Hidalgo R, Porto Barboza Ed. Effect of
37. Barone A, Marconcini S, Giacomelli L, Rispoli L, Calvo submucosal injection of dexamethasone after third molar
JL, Covani U. A randomized clinical evaluation of surgery: a meta-analysis of randomized controlled trials.
ultrasound bone surgery versus traditional rotary Int J Oral Maxillofac Surg 2016 Feb; 45(2):232-40.
instruments in lower third molar extraction. J Oral https://doi.org/10.1016/j.ijom.2015.09.008
Maxillofac Surg 2010 Feb;68(2):330-6.
https://doi.org/10.1016/j.joms.2009.03.053

ISSN: 2456-8058 23 CODEN (USA): UJPRA3

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