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Today AEEDC Dubai 2014

science & practice10 AEEDC Dubai 2014 The term “surgery” is derived from the Greek words “chir” (hand) and “ergos” (work). Accord- ing to this etymology, surgery should include any clinical work implemented with our hands. In daily clinical practice, however, the use of this word is often lim- ited to practical therapeutic acts, such as those involving cutting soft tissue (incisions), flap raising, osteotomies and reconstruction, as well as repairing and dressing living tissue. The term “oral” per- tains to the mouth (or oral cavity), and oral surgery would conse- quently encompass maxillary si- nus membrane lifts, onlay and in- lay bone grafts, the placement of dental osseointegrated implants, exodontia (including surgical ex- traction of impacted teeth and tooth-like structures), as well as the incision and drainage of cel- lulitis, just to name a few. Despite these different fields of use, the limits of oral surgery are not yet well defined and may reach max- illofacial surgery, a term that im- plies a greater scope of surgical interest, such as temporomandi- bular joint surgery, orthognathic surgery,thetreatmentofheadand necktrauma,aswellascancersur- gery. General dental practitioners are only required to undertake surgical treatment of teeth, tooth- likestructures,andsofttissuesur- rounding teeth. In this regard, the UK General Dental Council de- fines “surgical dentistry” as “those surgical procedures within the mouth which would normally be accomplished for a cooperative patient under local anaesthe- sia, with or without sedation, in a tolerably short operating time.” In the past 30 years, oral surgery has progressed signif- icantly in the diagnosis and treatment of dental and jaw pathology. Dentistry, particu- larly surgical dentistry, is rap- idly changing and evolving, and dentists worldwide are at- tempting to adapt to the revo- lutionary changes and new opportunities resulting from globalisation of dental and medical surgical specialties. New insights and discoveries related to oral surgery are in- deed astonishing and many of them have already been ap- pliedineverydaypractice,and addressed in textbooks and at international conventions. The near future will probably witness Er:YAG laser bone abla- tion replacing surgical drill os- teotomy in oral surgical practice. Indeed, scanning electron micro- scope observations have deter- mined that Er:YAG laser treat- ment produces well-defined edges. Melting and carbonisation associated with carbon dioxide lasers could not be observed on sites irradiated with Er:YAG lasers. In addition, Fourier trans- form infrared spectroscopy re- vealed that the chemical composi- tion of bony surfaces after abla- tion with an Er:YAG laser was al- most the same as that after conventional drilling with a bur, proving that the use of Er:YAG laser ablation can be an alterna- tive to traditional bur ablation in oral and periodontal osseous sur- geries, particularly in mandibular ramus onlay block harvesting, apicectomy, cysts and benign jaw tumour surgery, or the irradiation of bisphosphonate-associated jaw osteonecrosis. Dental pulp stem cells (DPSCs) can nowadays be cryopreserved and stored for years, while still re- taining their multipotency and bone-producing capacity. These highlyspecialisedcellsshowvery low morbidity and are easy to col- lect from extracted wisdom teeth or buds, for example. They also in- teract with bone biomaterials and substitutes, which makes them an ideal cell population for jaw re- construction. In addition, stromal bone-producing DPSCs, a multipo- tent stem cell subpopulation of DPSCs, are capable of differentiat- ing into osteoblasts, and they are claimed to possess immune privi- lege and exert anti-inflammatory abilities like many other mes- enchymal stem cells. CBCT, which was introduced in the late 1990s, is becoming the main imaging armamentarium of oral surgeries, as it provides more and comprehensive anatomical information and data that help to improve preoperative and perop- erativeclinicalimplementationof the extraction of impacted teeth, cystectomies, removal of benign jaw tumours, and placement of dental implants. Whileoralsurgerycontinuesto develop further with new technologies and visions, the assessment and diagnosis of patients will still form the cor- nerstone of any surgical spe- cialty. Decision-making, a complex cognitive process that involves consideration of surgical patients’ complaints andpreferences,theavailabil- ity of evidence-based data, as wellaspractitioners’case-spe- cific clinical judgement, con- sequently remains an ongoing challenge for oral surgeons and dental general practition- ers alike. Inter-clinician variability anddisparityindecision-mak- ing are very well known in dentistry and medicine.1–5 In oralsurgery,treatmentrecom- mendations, options and deci- sions can vary widely among practising dentists. In many cases, they are based more on per- sonal values and expertise than onobjective,rigorousorevidence- based analysis of treatment alter- natives, risks, prognosis and ben- efits. There are treatment guide- lines for the management of im- pacted teeth but none for aggressive and relapsing jaw cysts and odontogenic tumours, for which documented long-term treatment success has not yet been achieved. Owing to this lack, the treatment planning process in oral surgery remains a dilemma and warrants further interest and research. As a matter of fact, regional dif- ferences in training, education, and dental school treatment phi- losophy, the “schools effect”, may significantly influence decision- making processes.6,7 It seems likely that specialists are much more confident in their ability to manage surgical cases success- fully.Abetterunderstandingofin- ter-clinicianvariabilityincollabo- rative decision-making will defi- nitelyhelptheoralhealthcommu- nity in improving consistency and implementation of oral surgical treatment recommendations and options. One of the most promising ap- proaches is probably the non-sur- gical medical treatment of tu- mours and lesions of the jaws, as reported by Marx and Stern in 2003.8 They found a 65per cent rate of complete resolution of central giant cell granulomas (CGCGs) in the jaws through intra- lesional corticosteroid injections. Dexamethasone and triamci- nolonearecurrentlythemostpop- ular intra-lesional steroids, and weekly injections with these are common practice not only for CGCGs, but also for solitary jaw- bone lesions of Langerhans cell histiocytosis, a proliferative dis- ease of the macrophage/dendritic cell lineage. CGCGs, considered trouble- some pathologies, are also cur- rently medically managed by cal- citonin, a polypeptide hormone produced in humans primarily by parafollicular cells of the thyroid gland, C cells. Calcitonin is known to counteract parathyroid hor- mone, inhibit osteoclast activity and increase calcium influx in bones.Inthisregard,salmoncalci- tonin, which is used in post- menopausal osteoporosis, hyper- calcaemia, Paget’s disease and bone metastases, is considered to be more active than human calci- tonin and to be an important tool inthemedicaltreatmentofjawtu- moursandlesions.Themainques- tion is whether intranasal salmon calcitonin is as effective as subcu- taneous human calcitonin in the medicaltreatmentofCGCGsofthe jaws. Finally yet importantly, many clinicians and clinical investiga- tors believe in the radical treat- ment of ameloblastomas, odonto- genic tumours well known for their aggressiveness and high re- currence after conservative treat- ment.Forthesereasons,enblocre- section is often implemented, which includes a resection of at least 1–2 cm of normal sound jaw- bone beyond the tumour’s mar- gins. Such a radical surgical proce- dure is unacceptable in children with growing jaws though be- cause segmental resection often leads to jaw deformity and dys- function, which in turn may ham- per physical growth and the men- tal well-being of the child/adoles- cent. At the very least, conservative treatment of an ameloblastoma, if indicated, will gain time until growth of the jaw is finally com- plete.9 Consideringthatthemajor- ity of ameloblastomas in children are unicystic and have a very low rate of recurrence,10 they can be managedbyenucleation,aconser- vative form of surgical treat- ment.11–14 ThisFriday,DrZiadNoujeimwillbe giving a presentation on oral and maxillofacial surgery as part of the scientific programme of AEEDC Dubai 2014. He is a currently Direc- tor of the Oral Pathology Postgradu- ateProgrammeattheLebaneseUni- versity’s School of Dentistry in Beirut in Lebanon. Current perspectives on oral surgery How to improve consistency and implementation of contemporary treatment recommendations and options in general dental practice By Dr Ziad Noujeim,Lebanon Dr Ziad Noujeim, Lebanon AD

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