Antimicrobial Resistance in Pediatric Dentistry: Rational Antibiotic Use in Childhood Infections

Antimicrobial resistance (AMR) has emerged as a critical global public health challenge, directly affecting dental practice. In pediatric dentistry, inappropriate or excessive antibiotic prescribing contributes significantly to the development of resistant microbial strains.

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Since most odontogenic infections in children can be managed through local operative measures, antibiotics should be prescribed only when clinically justified. This article reviews the mechanisms, clinical implications, and principles of rational antibiotic use in pediatric dental infections, emphasizing prevention of antimicrobial resistance.

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✅ Antimicrobial Resistance: Mechanisms and Clinical Impact
Antimicrobial resistance occurs when microorganisms survive exposure to antibiotics through adaptive mechanisms such as:
▪️ Enzymatic inactivation of antibiotics
▪️ Alteration of bacterial target sites
▪️ Reduced membrane permeability
▪️ Efflux pump activation
In pediatric patients, AMR may result in treatment failure, prolonged infections, increased hospitalization, and limited therapeutic options. Resistant oral pathogens may also disseminate systemically, posing serious health risks.

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✅ Common Pediatric Odontogenic Infections
Most dental infections in children originate from:

▪️ Dental caries progressing to pulpal necrosis
▪️ Periapical and periodontal infections
▪️ Acute dentoalveolar abscesses
▪️ Cellulitis of odontogenic origin
Importantly, antibiotics alone do not eliminate the source of infection. Definitive treatment involves pulp therapy, drainage, or extraction.

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✅ Principles of Rational Antibiotic Use in Pediatric Dentistry
Rational antibiotic prescribing is based on the following principles:

▪️ Accurate diagnosis
▪️ Assessment of systemic involvement
▪️ Use of narrow-spectrum antibiotics when possible
▪️ Correct dosage based on body weight
▪️ Appropriate duration of therapy
▪️ Avoidance of antibiotics for localized infections without systemic signs
Antibiotics are indicated only in cases presenting with fever, facial swelling, lymphadenopathy, malaise, or risk of systemic spread.

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✅ Most Commonly Used Antibiotics in Pediatric Dentistry
First-line antibiotics typically include penicillin derivatives, due to their efficacy and safety profile. Alternatives are reserved for patients with allergies or specific clinical conditions.

✅ Prevention of Antimicrobial Resistance
Preventive strategies include:

▪️ Emphasizing early caries management
▪️ Educating parents on the limited role of antibiotics
▪️ Following evidence-based clinical guidelines
▪️ Avoiding prophylactic antibiotic misuse
▪️ Promoting oral hygiene and preventive programs
Dentists play a crucial role in antimicrobial stewardship within the pediatric population.

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💬 Discussion
Despite well-established guidelines, antibiotics continue to be overprescribed in pediatric dental care. Misconceptions among caregivers and fear of complications often contribute to unnecessary prescriptions. Integrating clinical judgment, updated guidelines, and patient education is essential to curb antimicrobial resistance. Pediatric dentists must act as stewards of responsible antibiotic use.

🎯 Recommendations
▪️ Prescribe antibiotics only when systemic involvement is present
▪️ Prioritize local operative treatment over pharmacological management
▪️ Use weight-based dosing and shortest effective duration
▪️ Document antibiotic indication clearly in clinical records
▪️ Educate caregivers about antibiotic resistance and adherence

✍️ Conclusion
Antimicrobial resistance in pediatric dentistry is preventable through rational antibiotic use and adherence to evidence-based protocols. Dentists must prioritize definitive dental treatment, reserve antibiotics for clearly indicated cases, and actively participate in antimicrobial stewardship to protect pediatric patients and public health.

📊 Comparative Table: Commonly Used Antibiotics in Pediatric Dentistry

Antibiotic	Clinical Indications	Limitations and Risks
Amoxicillin	First-line treatment for acute odontogenic infections with systemic involvement	Increasing resistance; ineffective without source control
Amoxicillin–Clavulanic Acid	Infections caused by beta-lactamase–producing bacteria	Higher risk of gastrointestinal adverse effects
Clindamycin	Alternative for penicillin-allergic patients	Risk of Clostridioides difficile infection
Azithromycin	Selected cases with penicillin allergy	Limited anaerobic coverage; resistance concerns

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Guideline on antibiotic therapy for pediatric dental patients. Pediatric Dentistry, 45(6), 357–364.
✔ World Health Organization. (2023). Global antimicrobial resistance and use surveillance system (GLASS) report. WHO.
✔ Robertson, D., & Smith, A. J. (2009). The microbiology of the acute dental abscess. Journal of Medical Microbiology, 58(2), 155–162. https://doi.org/10.1099/jmm.0.003517-0
✔ Sweeney, L. C., Dave, J., Chambers, P. A., & Heritage, J. (2004). Antibiotic resistance in general dental practice—a cause for concern? Journal of Antimicrobial Chemotherapy, 53(4), 567–576. https://doi.org/10.1093/jac/dkh137

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Tongue Cancer: Early Warning Signs, Prevention, and the Role of Self-Examination

Tongue cancer is one of the most common malignancies of the oral cavity and represents a significant global health concern. Early detection remains a decisive factor for patient survival and quality of life.

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Dentists play a critical role in identifying early warning signs, promoting preventive strategies, and educating patients about oral self-examination. This article reviews the clinical features, risk factors, prevention measures, and pre- and post-treatment care related to tongue cancer.

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✅ Etiology and Risk Factors
Tongue cancer is predominantly classified as oral squamous cell carcinoma (OSCC). Its development is multifactorial and strongly associated with:

▪️ Tobacco use (smoked and smokeless)
▪️ Excessive alcohol consumption
▪️ Human papillomavirus (HPV), especially HPV-16
▪️ Chronic mechanical irritation
▪️ Poor oral hygiene
▪️ Immunosuppression
▪️ Nutritional deficiencies (iron, folate, vitamin B12)
The synergistic effect of tobacco and alcohol significantly increases carcinogenic risk.

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✅ Early Warning Signs and Clinical Manifestations
Early recognition is essential for improving prognosis. Warning signs of tongue cancer include:

▪️ Persistent ulceration lasting more than two weeks
▪️ Indurated or non-healing lesions
▪️ Red (erythroplakia) or white (leukoplakia) patches
▪️ Pain or burning sensation
▪️ Difficulty chewing, swallowing, or speaking
▪️ Unexplained bleeding
▪️ Palpable cervical lymphadenopathy
Lesions often appear on the lateral borders and ventral surface of the tongue, areas that require meticulous clinical examination.

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✅ Importance of Oral Self-Examination
Oral self-examination is a simple and cost-effective strategy that empowers patients to identify suspicious changes at an early stage. Patients should be instructed to:

▪️ Inspect the tongue under good lighting
▪️ Palpate both lateral borders
▪️ Observe color changes, ulcers, or masses
▪️ Seek professional evaluation if abnormalities persist beyond 14 days
Self-examination complements professional screening but does not replace routine dental examinations.

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✅ Pre-Treatment Care
Before initiating oncologic treatment, dental management aims to minimize complications:

▪️ Comprehensive oral examination
▪️ Elimination of active infections
▪️ Extraction of non-restorable teeth
▪️ Oral hygiene instruction
▪️ Fluoride therapy to reduce post-treatment caries risk
Pre-treatment dental care is essential in patients scheduled for surgery, radiotherapy, or chemotherapy.

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✅ Post-Treatment Care and Oral Management
Post-treatment complications may significantly affect oral function and quality of life. Dental professionals should monitor and manage:

▪️ Xerostomia
▪️ Mucositis
▪️ Dysgeusia
▪️ Trismus
▪️ Osteoradionecrosis
Long-term follow-up includes regular oral examinations, salivary substitutes, topical fluoride use, and reinforcement of oral hygiene practices.

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✅ Prevention Strategies
Primary prevention focuses on reducing exposure to known risk factors:

▪️ Smoking cessation and alcohol moderation
▪️ HPV vaccination
▪️ Nutritional counseling
▪️ Regular dental check-ups
▪️ Public education on early signs of oral cancer
Secondary prevention emphasizes early diagnosis through routine screening and self-examination.

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💬 Discussion
Despite advances in oncologic therapies, tongue cancer continues to present diagnostic challenges due to late patient presentation. Dentists are strategically positioned to detect early lesions and initiate timely referral. Integrating patient education, preventive counseling, and systematic oral examination significantly improves outcomes.

🎯 Recommendations
▪️ Perform systematic tongue examination during every dental visit
▪️ Educate patients on oral self-examination techniques
▪️ Refer suspicious lesions promptly for biopsy
▪️ Collaborate with oncologists in pre- and post-treatment dental care
▪️ Promote preventive public health strategies

✍️ Conclusion
Tongue cancer remains a potentially life-threatening condition, yet it is highly curable when detected early. Dentists play a fundamental role in prevention, early diagnosis, and long-term oral management. Emphasizing self-examination, risk factor control, and regular dental screening is essential to reducing morbidity and mortality associated with this disease.

📚 References

✔ Warnakulasuriya, S. (2020). Oral potentially malignant disorders: A comprehensive review. Oral Oncology, 102, 104550. https://doi.org/10.1016/j.oraloncology.2019.104550
✔ World Health Organization. (2023). WHO classification of head and neck tumours (5th ed.). IARC Press.
✔ National Comprehensive Cancer Network. (2024). NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers. NCCN.
✔ Rivera, C. (2015). Essentials of oral cancer. International Journal of Clinical and Experimental Pathology, 8(9), 11884–11894.

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Recurrent Oral Ulcers in Children: Etiology and Management (Recurrent Aphthous Stomatitis)

Recurrent aphthous stomatitis (RAS) is the most common cause of recurrent oral ulcers in children, characterized by painful ulcerations affecting oral mucosa without systemic disease.

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This article reviews etiology, clinical characteristics, treatment strategies, and differential diagnosis relevant to pediatric dental practice.

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✅ Introduction
Recurrent oral ulcers in children, clinically known as recurrent aphthous stomatitis (RAS), represent a frequent complaint in pediatric dentistry. Although benign and self-limiting, RAS significantly affects oral function, nutrition, and quality of life. Early recognition and accurate diagnosis are essential to distinguish RAS from systemic or infectious diseases presenting with similar lesions.

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✅ Etiology of Recurrent Aphthous Stomatitis
The exact etiology of RAS remains multifactorial and incompletely understood. Proposed contributing factors include:
▪️ Genetic predisposition, particularly a positive family history
▪️ Immune dysregulation, involving T-cell–mediated responses
▪️ Nutritional deficiencies, especially iron, folate, vitamin B12, and zinc
▪️ Local trauma to the oral mucosa
▪️ Psychological stress
▪️ Food hypersensitivity and sodium lauryl sulfate exposure
RAS is not considered infectious and is not associated with viral replication.

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✅ Clinical Characteristics
Recurrent aphthous ulcers typically present on non-keratinized oral mucosa, including the labial mucosa, buccal mucosa, floor of the mouth, and ventral tongue.
Clinical Types
▪️ Minor RAS: Small (less than 10 mm), shallow ulcers healing within 7–14 days without scarring
▪️ Major RAS: Larger, deeper ulcers with prolonged healing and possible scarring
▪️ Herpetiform RAS: Multiple small ulcers occurring in clusters
Common symptoms include pain, burning sensation, and difficulty eating or speaking.

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✅ Treatment and Management
There is no definitive cure for RAS; treatment focuses on symptom control, lesion duration reduction, and recurrence prevention.

Local Therapies
▪️ Topical corticosteroids (e.g., triamcinolone acetonide)
▪️ Topical anesthetics for pain relief
▪️ Antimicrobial mouth rinses (chlorhexidine) to prevent secondary infection

Systemic and Adjunctive Approaches
▪️ Nutritional supplementation when deficiencies are identified
▪️ Avoidance of known triggers
▪️ Maintenance of optimal oral hygiene
Systemic therapy is rarely indicated in children and should be reserved for severe cases.

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💬 Discussion
Despite its benign nature, recurrent aphthous stomatitis may indicate underlying systemic or nutritional disorders. Accurate diagnosis is essential to prevent overtreatment and to differentiate RAS from viral, autoimmune, or hematologic diseases. Pediatric dentists play a critical role in early identification and appropriate referral when systemic involvement is suspected.

🎯 Recommendations for Pediatric Dental Practice
▪️ Perform thorough medical and dietary history assessments
▪️ Educate caregivers on trigger avoidance and oral hygiene practices
▪️ Use topical therapy as first-line treatment
▪️ Refer patients with atypical or severe lesions for medical evaluation

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✍️ Conclusion
Recurrent aphthous stomatitis is the leading cause of recurrent oral ulcers in children, with multifactorial etiology and characteristic clinical presentation. Evidence-based diagnosis and conservative management allow effective symptom control while minimizing unnecessary interventions.

📊 Comparative Table: Differential Diagnosis of Recurrent Oral Ulcers in Children

Condition	Key Clinical Features	Distinguishing Factors
Recurrent Aphthous Stomatitis	Painful, shallow ulcers on non-keratinized mucosa	No systemic symptoms, recurrent pattern
Primary Herpetic Gingivostomatitis	Multiple vesicles progressing to ulcers	Fever, lymphadenopathy, viral etiology
Behçet Disease	Recurrent oral and genital ulcers	Systemic involvement, ocular lesions
Traumatic Ulcers	Single ulcer at trauma site	History of mechanical injury

📚 References

✔ Edgar, N. R., Saleh, D., & Miller, R. A. (2017). Recurrent aphthous stomatitis: A review. Journal of Clinical and Aesthetic Dermatology, 10(3), 26–36.
✔ Preeti, L., Magesh, K. T., Rajkumar, K., & Karthik, R. (2011). Recurrent aphthous stomatitis. Journal of Oral and Maxillofacial Pathology, 15(3), 252–256.
✔ Scully, C., & Porter, S. (2008). Oral mucosal disease: Recurrent aphthous stomatitis. British Journal of Oral and Maxillofacial Surgery, 46(3), 198–206.
✔ Shulman, J. D. (2004). An epidemiologic study of recurrent aphthous ulceration in U.S. children. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 98(4), 405–410.

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Fluoride Varnish vs. Silver Diamine Fluoride: Clinical Roles in Caries Prevention and Arrest

Dental caries remains one of the most prevalent chronic diseases worldwide, affecting both pediatric and adult populations. Contemporary minimally invasive dentistry emphasizes caries prevention, early intervention, and lesion arrest, rather than operative treatment alone.

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Among non-invasive strategies, fluoride varnish (FV) and silver diamine fluoride (SDF) have emerged as key agents with distinct clinical roles. Although both are fluoride-based therapies, their mechanisms of action, indications, and outcomes differ significantly, making their correct clinical selection essential.

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✅ Mechanism of Action

Fluoride Varnish
Fluoride varnish typically contains 5% sodium fluoride (22,600 ppm fluoride). Its primary mechanism includes:
▪️ Promotion of enamel remineralization
▪️ Formation of fluorapatite, increasing acid resistance
▪️ Inhibition of bacterial metabolism at low levels
▪️ Sustained fluoride release due to prolonged contact with enamel
Fluoride varnish is most effective in non-cavitated lesions and for caries prevention.

Silver Diamine Fluoride
Silver diamine fluoride contains 38% SDF, composed of silver ions, fluoride ions, and ammonia. Its mechanisms include:
▪️ Antibacterial action through silver-induced protein denaturation
▪️ Arrest of dentinal caries by inhibiting collagen degradation
▪️ Fluoride-driven remineralization of affected dentin
▪️ Increased dentin hardness and resistance to further demineralization
SDF is uniquely effective for active cavitated lesions, particularly in dentin.

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✅ Clinical Characteristics
▪️ Fluoride varnish is colorless to yellowish, well tolerated, and esthetically acceptable.
▪️ Silver diamine fluoride causes permanent black staining of carious dentin, which is a known and expected outcome.
▪️ FV requires multiple applications over time for optimal preventive effect.
▪️ SDF can arrest caries with fewer applications, even in high-risk patients.

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✅ Clinical Use and Indications

Indications for Fluoride Varnish
▪️ Caries prevention in high-risk patients
▪️ Early enamel lesions (white spot lesions)
▪️ Patients with orthodontic appliances
▪️ Xerostomia or reduced salivary flow
▪️ Community and school-based preventive programs

Indications for Silver Diamine Fluoride
▪️ Arrest of cavitated carious lesions
▪️ Young children with limited cooperation
▪️ Patients with special health care needs
▪️ Elderly or medically compromised patients
▪️ Situations where conventional restorative care is delayed or contraindicated

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✅ Limitations and Considerations

Fluoride Varnish
▪️ Limited effect on established dentinal caries
▪️ Requires repeated applications
▪️ Preventive rather than therapeutic in advanced lesions

Silver Diamine Fluoride
▪️ Unesthetic black staining of treated lesions
▪️ Metallic taste reported by some patients
▪️ Not intended for teeth requiring immediate esthetic restoration
▪️ Informed consent is essential due to visible discoloration

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💬 Discussion
Comparing fluoride varnish and silver diamine fluoride is clinically appropriate, provided their different therapeutic objectives are clearly defined. Fluoride varnish is a preventive agent, designed to strengthen enamel and reduce future caries risk. In contrast, SDF is a therapeutic agent, capable of arresting active dentinal caries. Rather than competing interventions, they represent complementary tools within a risk-based caries management approach.

✍️ Conclusion
Fluoride varnish and silver diamine fluoride play distinct yet complementary roles in modern caries management. Fluoride varnish is ideal for prevention and early intervention, while SDF is uniquely effective for arresting cavitated lesions, especially in vulnerable populations. Proper case selection, patient education, and informed consent are critical to maximize clinical success.

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🎯 Clinical Recommendations
▪️ Use fluoride varnish for routine preventive care and early lesions.
▪️ Reserve silver diamine fluoride for active cavitated caries when conventional treatment is not feasible.
▪️ Clearly explain esthetic outcomes when using SDF.
▪️ Integrate both agents into a minimally invasive, evidence-based caries management protocol.

📊 Comparative Table: Additional Caries Preventive Products

Preventive Product	Primary Benefits	Clinical Limitations
Pit and Fissure Sealants	Physical barrier against plaque accumulation in occlusal surfaces	Technique-sensitive; requires moisture control
Fluoridated Toothpaste	Daily low-dose fluoride exposure for enamel remineralization	Effectiveness depends on patient compliance
Fluoride Mouthrinses	Adjunctive caries prevention in high-risk individuals	Not recommended for very young children due to ingestion risk
CPP-ACP Products	Enhances calcium and phosphate availability for remineralization	Limited evidence compared to fluoride-based therapies

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Policy on the use of silver diamine fluoride for pediatric dental patients. Pediatric Dentistry, 45(6), 66–70.
✔ Crystal, Y. O., & Niederman, R. (2019). Evidence-based dentistry update on silver diamine fluoride. Dental Clinics of North America, 63(1), 45–68.
✔ Gao, S. S., Zhao, I. S., Hiraishi, N., Duangthip, D., Mei, M. L., Lo, E. C. M., & Chu, C. H. (2016). Clinical trials of silver diamine fluoride in arresting caries. Journal of Dentistry, 48, 1–7.
✔ Marinho, V. C. C., Worthington, H. V., Walsh, T., & Clarkson, J. E. (2013). Fluoride varnishes for preventing dental caries. Cochrane Database of Systematic Reviews, (7), CD002279.
✔ Chu, C. H., Mei, L., Seneviratne, C. J., & Lo, E. C. M. (2012). Effects of silver diamine fluoride on dentine caries lesions. Journal of Dentistry, 40(11), 1024–1031.

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Surgical Techniques for Third Molar Extraction: Definitions, Indications, and Clinical Advantages

The extraction of third molars is one of the most frequently performed oral surgical procedures worldwide. Due to their variable position, eruption pattern, and anatomical relationship with vital structures, third molars often require specific surgical techniques rather than simple exodontia.

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A comprehensive understanding of these techniques allows clinicians to reduce complications, improve healing, and optimize patient outcomes. This article reviews the most commonly used surgical techniques for third molar extraction, focusing on their definitions, clinical characteristics, and advantages.

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✅ Main Surgical Techniques for Third Molar Extraction

1. Simple Surgical Extraction
This technique is indicated for fully erupted third molars with favorable angulation and minimal bone resistance. It involves the use of elevators and forceps without flap elevation or bone removal.
Advantages:
▪️ Short surgical time
▪️ Minimal postoperative morbidity
Characteristics:
▪️ Limited to erupted teeth
▪️ Requires adequate crown exposure

2. Surgical Extraction with Mucoperiosteal Flap
A mucoperiosteal flap is raised to gain adequate access to partially erupted or impacted third molars.
Advantages:
▪️ Improved visibility and access
▪️ Better control of surgical field
Characteristics:
▪️ Requires suturing
▪️ Moderate postoperative discomfort

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3. Osteotomy-Assisted Extraction
Osteotomy involves controlled removal of surrounding alveolar bone using rotary instruments or piezoelectric devices.
Advantages:
▪️ Reduces excessive force during extraction
▪️ Allows safer removal of deeply impacted teeth
Characteristics:
▪️ Increased surgical complexity
▪️ Requires precise anatomical knowledge

4. Odontosection
Odontosection consists of sectioning the crown and/or roots to facilitate removal in segments.
Advantages:
▪️ Minimizes bone removal
▪️ Decreases risk of mandibular fracture
Characteristics:
▪️ Commonly combined with osteotomy
▪️ Particularly useful in mesioangular or horizontal impactions

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5. Piezoelectric Surgery
This technique uses ultrasonic vibrations to perform selective bone cutting while preserving soft tissues.
Advantages:
▪️ Reduced risk of nerve injury
▪️ Improved postoperative healing
Characteristics:
▪️ Longer operative time
▪️ Requires specialized equipment

6. Coronectomy
Coronectomy involves removal of the crown while intentionally leaving the roots in situ.
Advantages:
▪️ Significantly reduces risk of inferior alveolar nerve injury
Characteristics:
▪️ Strict case selection required
▪️ Requires long-term radiographic follow-up

📊 Comparative Table: Clinical Characteristics of Third Molars

Clinical Feature	Surgical Relevance	Potential Complications
Impaction depth	Determines need for osteotomy or flap	Increased surgical difficulty
Angulation	Affects choice of odontosection	Risk of adjacent tooth damage
Root morphology	Influences extraction strategy	Root fracture
Proximity to inferior alveolar nerve	Indication for coronectomy	Nerve injury or paresthesia

💬 Discussion
The selection of an appropriate surgical technique for third molar extraction is directly related to anatomical, radiographic, and patient-specific factors. Modern approaches, such as piezoelectric surgery and coronectomy, emphasize tissue preservation and risk reduction, particularly in cases involving neural proximity. However, these techniques require advanced training and careful case selection to ensure predictable outcomes.

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✍️ Conclusion
Surgical extraction of third molars is a procedure that demands precise diagnosis and technique selection. Understanding the definitions, advantages, and characteristics of each surgical approach allows clinicians to tailor treatment plans, minimize complications, and enhance postoperative recovery.

🎯 Clinical Recommendations
▪️ Perform thorough radiographic assessment before surgery
▪️ Select the least invasive technique that ensures complete tooth removal
▪️ Consider coronectomy when nerve injury risk is high
▪️ Provide adequate postoperative monitoring and follow-up

📚 References

✔ Renton, T., Hankins, M., Sproate, C., & McGurk, M. (2005). A randomised controlled clinical trial to compare the incidence of injury to the inferior alveolar nerve after coronectomy and removal of mandibular third molars. British Journal of Oral and Maxillofacial Surgery, 43(1), 7–12. https://doi.org/10.1016/j.bjoms.2004.09.002
✔ Peterson, L. J., Ellis, E., Hupp, J. R., & Tucker, M. R. (2014). Contemporary Oral and Maxillofacial Surgery (6th ed.). Elsevier Mosby.
✔ Monaco, G., De Santis, G., Gatto, M. R., & Corinaldesi, G. (2014). Coronectomy: A surgical option for impacted third molars in close proximity to the inferior alveolar nerve. Journal of the American Dental Association, 145(5), 463–469. https://doi.org/10.14219/jada.2014.13

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