YIJOM-3612; No of Pages 6

Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2017.02.1266, available online at http://www.sciencedirect.com

Clinical Paper
Oral Surgery

Dexamethasone injection into K. Boonsiriseth1, M. M. Latt1,2,

S. Kiattavorncharoen1,
V. Pairuchvej1, N. Wongsirichat1

the pterygomandibular space in

1
Department of Oral Maxillofacial Surgery,
Faculty of Dentistry, Mahidol University,
Bangkok, Thailand; 2Insein General Hospital,
Insein Township, Yangon, Myanmar

lower third molar surgery

K. Boonsiriseth, M.M. Latt, S. Kiattavorncharoen, V. Pairuchvej, N. Wongsirichat:
Dexamethasone injection into the pterygomandibular space in lower third molar
surgery. Int. J. Oral Maxillofac. Surg. 2017; xxx: xxx–xxx. ã 2017 International
Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights
reserved.

Abstract. The objective of this study was to evaluate the effects of 8 mg

dexamethasone injection into the pterygomandibular space on the postoperative
sequelae of lower third molar surgery. A prospective, randomized, controlled, split-
mouth study was designed involving 62 lower third molar extractions (31 patients).
Prior to surgery, the study group received 2 ml of 4 mg/ml (8 mg) dexamethasone
injection through the pterygomandibular space following local anaesthesia; the
control group received 2 ml normal saline injection. Facial swelling, mouth
opening, pain on a visual analogue scale (VAS), and the number of analgesics
consumed were assessed. Descriptive statistics and the independent-samples t-test
were used to compare the two groups at P < 0.05. There was a significant reduction
in swelling on day 2 postoperative in the dexamethasone group. Mouth opening was
also significantly greater on day 2 in the dexamethasone group. The VAS pain score
Key words: lower third molar surgery; dexa-
was significantly lower on the day of the operation and first postoperative day in the
methasone injection; pterygomandibular space;
dexamethasone group, but did not differ significantly between the groups on the postoperative sequelae; facial swelling; VAS
other postoperative days. The injection of 8 mg dexamethasone into the pain score.
pterygomandibular space was effective in reducing postoperative swelling, limited
mouth opening, and pain following impacted lower third molar extraction. Accepted for publication 15 February 2017

The surgical removal of impacted third
molars is the most common surgical pro-
cedure performed by oral and maxillofa-
cial surgeons1. It usually involves
surgical trauma in a highly vascularized
area, leading to inflammatory sequelae
such as pain, swelling, limited mouth
opening, and general oral dysfunction
during the immediate postoperative peri-
od2. The pterygomandibular space is one
of the important spaces related to the
lower third molar region and is where
the inferior alveolar nerve block is gen-
erally administered. It is also a potential
site for space infection, as it contains
mostly loose areolar tissues and numer-
ous blood vessels, with small fascia-lined
clefts. One of the signs and symptoms of
isolated pterygomandibular space infec-
tion is trismus or limited mouth open-
ing3,4. A good surgical technique and
gentle manipulation of the tissues can
only partly eliminate the pain and dis-
comfort associated with trismus1.
The administration of various drugs has
been considered to reduce the postsurgical
inflammatory response related to lower
third molar extraction, with many reports
published in the literature. In 1965, Linen-
berg employed a synthetic adrenocortical
steroid, dexamethasone, to control oede-
ma and to decrease limited mouth opening
and pain following oral surgery. Since

0901-5027/000001+06 ã 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Boonsiriseth K, et al. Dexamethasone injection into the pterygomandibular space in lower third molar
surgery, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.02.1266
YIJOM-3612; No of Pages 6
2 Boonsiriseth et al.
then, the use of synthetic steroids has
become increasingly popular in oral sur-
gical procedures due to its positive effects
in reducing post-inflammatory signs and
symptoms5–7.
Majid and Mahmood studied the effects
of submucosal and intramuscular dexa-
methasone following lower third molar
surgery8. They stated that submucosal
dexamethasone was an effective alterna-
tive to systemic dexamethasone, with
comparable results obtained for the two
routes of administration. Antunes et al.
studied the effects of 8 mg dexamethasone
injected through the masseter muscle or
taken orally and found that both adminis-
tration routes not only demonstrated simi-
lar effects in reducing pain, oedema, and
limited mouth opening following third
molar extraction, but also showed im-
proved effects compared to the control
group3. Moreover, many studies have
reported submucosal, intra-alveolar, intra-
venous, intramuscular, and oral uses of
dexamethasone6,7. In contrast, studies in-
volving the injection of dexamethasone
alone into the pterygomandibular space
have rarely been conducted.
Therefore, the aim of this study was to
evaluate the efficacy of a single dose of
8 mg dexamethasone injected preopera-
tively into the pterygomandibular space
in reducing postoperative pain, swelling,
and limited mouth opening following low-
er third molar surgery.
Materials and methods
The study sample consisted of 31 patients
(11 male, 20 female; mean age 22 years,
range 16–32 years) with similar bilaterally
impacted lower third molars.
This was a prospective, randomized,
controlled, split-mouth study involving
62 surgical extractions of lower third
molars in 31 patients. The study was per-
formed in the Department of Oral and
Maxillofacial Surgery, Faculty of Dentist-
ry, Mahidol University. Ethical approval
was obtained from The Mahidol Univer-
sity Institutional Review Board.
All of the third molar extractions were
performed under local anaesthesia. The
sample was divided randomly into two
sites: a study site and a control site (Table 1).
The positions and classes of the lower
third molars included in this study are
shown in Figs. 1 and 2, respectively9.
Evaluation of the longitudinal axis of
the third molars showed that 28 (45.2%)
impactions were mesioangular, 20
(32.2%) were horizontal, 12 (19.4%) were
vertical, and 2 (3.2%) were distoangular
(Fig. 3).
Please cite this article in press as: Boonsiriseth K, et al. Dexamethasone injection into the pterygomandibular space in lower third molar
surgery, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.02.1266
Table 1. Study and control sites for the administration of dexamethasone or normal saline in the
pterygomandibular space.
Study site Control site
Dexamethasone used No dexamethasone used
 2 ml of dexamethasone (concentration  2 ml of normal saline injected as a placebo
4 mg/ml, for a total of 8 mg) injected through the pterygomandibular space
through the pterygomandibular space  Preoperatively, after local anaesthesia
 Preoperatively, after local anaesthesia
The patients included in the sample access to the surgical field, followed by
were blinded to the use or not of dexa- bone removal and tooth sectioning. Fol-
methasone. All operations were performed lowing tooth removal, soft tissue curettage
by the same surgeon using standard tech- and socket irrigation were done. Finally,
niques. Local anaesthesia (4% articaine interrupted black silk sutures were placed
hydrochloride with 1:100,000 epineph- to re-approximate the flap. Postoperative-
rine) was delivered at each operation site ly, all patients received amoxicillin for
by inferior alveolar nerve block and buc- 5 days (500 mg four times daily before
cal nerve block. After the objective signs meals) and acetaminophen for use only
of anaesthesia were evident, 2 ml of 4 mg/ in the case of pain (500 mg every 6 h).
ml dexamethasone (total 8 mg) or 2 ml of Assessments of facial swelling and
normal saline (as a placebo) were injected mouth opening were done preoperatively
into the pterygomandibular space. For before the procedure and on the second
each patient, the contralateral third molar and seventh days postoperative6,7. Three
operation was performed 1 month later. measurements were taken to assess facial
The standard technique was followed in swelling: lateral canthus of the eye to the
each operation, which involved reflecting gonion angle, tragus to the commissure of
a mucoperiosteal flap to provide adequate the mouth, and tragus to pogonion. For the
Posion of Lower Third Molars each side
3 4
Posion of lower third
molars A
Posion of lower third
molars B
24 Posion of lower third
molars C
Fig. 1. Positions of the lower third molars in this study.
Classes of Lower Third Molars each side
19
20
12
15
10
5 0
0
I II III
Class of lower third molars
Fig. 2. Classes of the lower third molars in this study.
YIJOM-3612; No of Pages 6

Dexamethasone applied to pterygomandibular space 3

Percentage of type of impacons (P = 0.31), but the measurements between

tragus and pogonion and between the
3.2 lateral canthus of the eye and gonion were
significantly different (P = 0.04 and
19.4 P = 0.00, respectively) on days 2 and 7
45.2 mesioangular
postoperative. There was a significant re-
horizontal duction in the magnitude of swelling on
vercal the second postoperative day in the dexa-
32.2 methasone group compared with the con-
distoangular trol group. Moreover, the measurements
of swelling between the second postoper-
ative day and the preoperative value were
also significantly different between the
Fig. 3. Distribution of the types of impaction of the lower third molars in this study. control and study groups (Table 2).
Mouth opening measurements differed
was 22.8  8.3 min and in the control significantly (P = 0.04) in the control
group (non-dexamethasone) was 21.5  group, but the measurements in the
7.2 min. There was no significant differ- dexamethasone group did not differ
ence in the operation time between the two significantly (P = 0.27). There was a sig-
groups (P = 0.3). nificant difference in mouth opening
With regard to complications, no post- between the groups on day 2 postoperative
1 operative infections were observed. How- (P = 0.04). Furthermore, there was a
4 ever, lower lip paresthesia was reported in highly significant difference in the change
2 one of the patients in the dexamethasone in MIO from the preoperative measure-
group, which had resolved at 2 weeks ment to that obtained on day 2 postopera-
3 following the operation. No other compli- tive between the dexamethasone group
cations were observed in either of the and control group (P = 0.01) (Table 3).
groups. Table 4 and Fig. 5 show that the VAS
Fig. 4. Facial swelling and mouth opening There was a significant increase in pain scores differed significantly between
evaluation: (1) lateral canthus of the eye to the swelling compared with the preoperative the two groups on the day of the operation
gonion angle; (2) tragus to the commissure of values in the control group (non-dexa- and on the first postoperative day (P =
the mouth; (3) tragus to pogonion; (4) mouth methasone) (P < 0.05). In the dexameth- 0.00 and P = 0.00, respectively); however,
opening measurement.
asone group, the measurement of swelling the difference in scores between the con-
between the tragus and commissure of the trol and dexamethasone groups was not
mouth was not statistically significant significant on days 3 and 7 postoperative.
evaluation of mouth opening, the maxi-
mum inter-incisal opening was recorded
(MIO; distance between the upper and
Table 2. Measurements of swelling (millimetres): mean values and differences from preopera-
lower incisal edges of the central incisors) tive (baseline) values in the study groups.
(Fig. 4).
For the evaluation of pain, all patients Dexamethasone group Control group
Variable Evaluation Mean (SD) Mean (SD) P-value
were given a form on which to score pain
on a visual analogue scale (VAS) and to Tr–Com Preoperative 116.9 (5.6) 117.5 (6.5) 0.68
note the number of analgesics taken. VAS Day 2 120.8 (5.4) 124.5 (6.8) 0.04a
pain scores were collected on the day of Day 7 118.8 (4.9) 119.6 (6.7) 0.60
P-value 0.31 0.00a
the operation and on the first, third, and
Differences
seventh days postoperative. Similarly, da- Day 2 preoperative 3.9 (3.6) 6.6 (4.6) 0.01a
ta for the number of postoperative analge- Day 7 preoperative 1.9 (3.3) 2.0 (3.2) 0.87
sic tablets taken were collected on the first, Tr–Pog Preoperative 152.0 (10.3) 151.1 (12.6) 0.76
second, and third days postoperative. Day 2 155.8 (10.2) 159.0 (10.2) 0.22
Differences in the postoperative sequel- Day 7 153.3 (9.8) 153.9 (10.3) 0.81
ae between the two groups were calcula- P-value 0.04a 0.02a
ted using IBM SPSS Statistics version 22 Differences
software (IBM Corp., Armonk, NY, USA). Day 2 preoperative 3.8 (2.7) 7.9 (9.3) 0.02a
Descriptive statistics, including the mean Day 7 preoperative 1.2 (1.7) 2.7 (9.3) 0.39
Gn–Lc Preoperative 111.8 (6.3) 111.5 (7.9) 0.87
and standard deviation values, and the Day 2 115.3 (6.3) 119.5 (6.7) 0.01a
independent-samples t-test were used Day 7 112.7 (6.0) 114.8 (6.3) 0.2
to assess the differences. A probability of P-value 0.00a 0.00a
less than 0.05 was considered significant. Differences
Day 2 preoperative 3.5 (3.1) 8.0 (6.3) 0.00a
Day 7 preoperative 0.9 (1.6) 3.2 (4.5) 0.01a
Results
SD, standard deviation; Tr–Com, tragus to the commissure of the mouth; Tr–Pog, tragus to
The duration of surgery (mean  standard pogonion; Gn–Lc, gonion angle to lateral canthus of the eye.
deviation) in the dexamethasone group a
Significant, P < 0.05.

Please cite this article in press as: Boonsiriseth K, et al. Dexamethasone injection into the pterygomandibular space in lower third molar
surgery, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.02.1266
YIJOM-3612; No of Pages 6

4 Boonsiriseth et al.

Table 3. Measurements of maximum mouth opening (millimetres): mean values and differences approach for reducing swelling, trismus,
from preoperative (baseline) values in the study groups. and pain after the removal of impacted
Dexamethasone group Control group mandibular third molars11,12. Among the
Mean (SD) Mean (SD) P-value various types of injectable corticosteroid
Preoperative 43.9 (5.8) 43.3 (5.9) 0.7 available, only two are approved by the
Day 2 33.1 (8.9) 28.3 (9.3) 0.04a Food and Drug Administration of
Day 7 40.3 (8.0) 38.7 (8.5) 0.43 Thailand; one of these – dexamethasone
P-value 0.27 0.04a – was chosen for this study.
MIO differences The effectiveness of dexamethasone in
Preoperative – day 2 10.7 (6.6) 15.0 (7.2) 0.01a reducing postoperative swelling, pain, and
Preoperative – day 7 3.5 (5.4) 4.5 (4.8) 0.41 limited mouth opening is considered to be
SD, standard deviation; MIO, maximum inter-incisal opening. dose-dependent10. Alexander and Thrond-
a
Significant, P < 0.05. son studied different dosages of dexa-
methasone; they reported that 4 mg of
dexamethasone was sub-therapeutic and
Table 4. Measurements of pain VAS scores (millimetres) and the number of analgesics taken in suggested the use of 8–12 mg dexametha-
the two groups. sone to obtain the best results. Therefore,
Dexamethasone group Control group 8 mg dexamethasone injection was used in
Evaluation Mean (SD) Mean (SD) P-value this study12. Some previous studies have
Pain VAS scores stated that corticosteroids may not be nec-
Day of operation 25.2 (23.0) 51.5 (29.0) 0.00a essary for all lower third molar removals,
Day 1 postoperative 18.6 (17.1) 35.3 (24.8) 0.00a except in cases of technical difficulty13,14.
Day 3 postoperative 14.1 (17.2) 23.2 (24.6) 0.09 In this study, bone removal and tooth
Day 7 postoperative 4.7 (11.4) 11.4 (17.2) 0.07 sectioning were required in all cases;
P-value 0.00a 0.00a therefore, it was assumed that the cases
Day of reaching mild pain (20 mm) 1.8 (2.5) 3.8 (2.7) 0.00a overall were of moderate technical diffi-
Number of analgesic tablets taken
culty.
Day 1 postoperative 1.8 (1.2) 2.8 (1.6) 0.01a
Day 2 postoperative 2.0 (1.6) 3.4 (1.7) 0.00a The rate of absorption of drug largely
Day 3 postoperative 1.3 (1.4) 2.6 (2.1) 0.00a depends on the blood flow in the area of
P-value 0.92 0.00a administration15. The pterygomandibular
space was chosen as the site for dexameth-
VAS, visual analogue scale; SD, standard deviation.
a
Significant, P < 0.05. asone injection as it is adjacent to the
lower third molar surgical area. Further-
more, it contains mostly loose areolar
tissue with a rich vascular supply, which
The number of analgesics taken by Discussion helps in faster drug absorption. The injec-
the patients for pain reduction differed tion technique is similar to that for inferior
significantly between the control and dexa- Glucocorticoids suppress multiple signal- alveolar nerve block, which is familiar to
methasone groups on days 1, 2, and 3 ling pathways involved in the inflamma- dental practitioners.
postoperative. In this study, a pain VAS tory response, which results in decreased Swelling was evaluated by measuring
score cut-off of 20 mm was assumed as the inflammatory mediators at the site of in- three linear facial distances. This is a non-
point below which the pain was considered jury. Therefore, they are useful to reduce invasive, simple, cost-effective, and time-
mild. There was a significant difference the acute inflammatory conditions follow- saving method. It provides numerical data
between the dexamethasone group and con- ing oral surgeries10. Previous studies have that determine the soft tissue changes2. In
trol group regarding the day on which mild reported that the perioperative use of cor- this study, mean values for postoperative
pain (20 mm) was reached (P = 0.00). ticosteroids is a useful pharmacological swelling were significantly lower in the
dexamethasone group compared to the
control group on day 2 postoperative, with
60 the exception of the tragus to pogonion
51.5
measurement. The mean difference in
50 swelling on the second postoperative
day was also significantly lower in the
40
dexamethasone group. These results are
VAS (mm)

35.3871 dexamethasone
30 group consistent with those of Filho et al., who
25.2742 showed a decrease in facial swelling on
23.2581 control group
20 18.629
the second postoperative day when using
14.1452 4 mg and 8 mg dexamethasone preopera-
tively, the latter being more effective16.
11.4677
10
4.7097
Blackwell et al.17 and Hong and
0 Levine18 showed that glucocorticoids
Day 0 Day-1 Day-3 Day -7 can induce the release of antiphospholi-
Fig. 5. Differences in pain perception (VAS score) in the two groups; day 0 = immediately pase proteins, which presumably inhibit
postoperative; day 1 = postoperative day 1; day 3 = postoperative day 3; day 7 = postoperative the release of arachidonic acid and
day 7. its metabolism to prostaglandins and

Please cite this article in press as: Boonsiriseth K, et al. Dexamethasone injection into the pterygomandibular space in lower third molar
surgery, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.02.1266
YIJOM-3612; No of Pages 6
thromboxanes, which increase capillary
permeability. An important factor that
needs to be considered to reduce facial
swelling is the half-life of the drug. Dexa-
methasone has a half-life of 36–54 h and is
20–30 times more potent than cortisol.
Therefore, a single dose injection of dexa-
methasone is suitable for controlling sur-
gery-induced inflammation in the oral and
maxillofacial region19.
With regard to maximum mouth open-
ing, the dexamethasone group achieved
better results in comparison to the non-
dexamethasone group, especially on the
second postoperative day, and in the dif-
ferences between mean values of the pre-
operative and second postoperative day
(P = 0.04 and P = 0.01, respectively).
Limited mouth opening occurs as a direct
sequel to postoperative swelling, which
compresses the neural structures20. Limit-
ed mouth opening seemed to follow the
postoperative swelling. This study is con-
sistent with the study done by Antunes
et al., who concluded that both the in-
jectable and tablet forms of dexametha-
sone attained better results regarding
limited mouth opening compared to the
control3. Some authors have also reported
dexamethasone to be the most effective
therapeutic option for reducing limited
mouth opening after lower third molar
surgery20.
Postoperative pain depends on the de-
gree of surgical trauma induced during the
procedure. Bone removal and the exten-
sion of the periosteum affect postoperative
pain21. In this study, the mean VAS pain
scores were lower in the dexamethasone
group than in the control group at all
postoperative evaluation time points.
However, the role of corticosteroids in
the prevention of postoperative pain is
controversial. One previous study reported
that intense pain induced by swelling and
tissue tension was reduced when dexa-
methasone was used8. In the present study,
significantly lower VAS pain scores were
noted in the dexamethasone group com-
pared to the control group on the day of the
operation and the first postoperative day,
with P-values of 0.00 and 0.00, respec-
tively. In the dexamethasone group, a mild
pain score (20 mm) was attained earlier
and fewer analgesics were consumed than
in the control group. Some studies have
reported that corticosteroids alone do not
have significant analgesic effects12,14,22,23,
while others have stated that the use of
steroids is associated with a decreased
quantity of analgesics taken after the sur-
gical removal of third molars13,22. De
Oliveira Jr et al. suggested that the preop-
erative administration of steroids provides
Please cite this article in press as: Boonsiriseth K, et al. Dexamethasone injection into the pterygomandibular space in lower third molar
surgery, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.02.1266
Dexamethasone applied to pterygomandibular space
a greater effect on postoperative pain24. In
the present study, dexamethasone was
injected preoperatively but after the local
anaesthesia to acquire the maximum
advantages from the early onset of drug
action.
Blondeau and Daniel, in a study of 551
cases, reported that the postoperative com-
plication rate in lower third molar removal
was 6.9%, with complications including
infection, alveolitis, and lower lip pares-
thesia25. In this study, there was only one
case of lower lip paresthesia, which oc-
curred in the dexamethasone group. This
was due to a deeply positioned impacted
lower third molar and the associated sur-
gical trauma. However, the paresthesia
had resolved by the second week follow-
ing the operation.
This study utilized a bilateral split-
mouth design with impacted lower third
molars of similar types and in similar
positions. To reduce operator-based vari-
ability, a single surgeon performed all of
the extractions. Moreover, the duration of
the operations did not differ significantly
between the groups.
In conclusion, 8 mg dexamethasone in-
jection into the pterygomandibular space
was effective in reducing the postopera-
tive swelling, limited mouth opening, and
pain following lower third molar surgery.
The pterygomandibular space, due to its
close proximity to the surgical site and
composition of loose areolar tissue along
with a rich vascular supply, provides an
excellent location for better drug absorp-
tion. The preoperative steroid injection
was painless to the patients because the
injection was administered into a previ-
ously anaesthetized region. The preopera-
tive injection of steroid provides better
results than postoperative injection due
to the early onset of drug action. Addi-
tionally, the technique involved in inject-
ing the anaesthetic agent into the
pterygomandibular space is similar to an
inferior alveolar nerve block and is con-
venient and familiar to dental practi-
tioners. Hence, dexamethasone injection,
if not contraindicated, can be considered
as the drug of choice for controlling post-
operative swelling, trismus, and pain after
the surgical removal of lower third molars.
Funding
None.
Competing interests
None.
5
Ethical approval
This study was approved by The Mahidol
University Institutional Review Board
(MU-IRB) with COA No. MU-DT/PY-
IRB 2016/021.2303.
Patient consent
Not required.
Acknowledgements. The authors would
like to thank the staff and dental assistants,
including their colleagues, in the Depart-
ment of Oral and Maxillofacial Surgery,
Faculty of Dentistry, Mahidol University.
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Please cite this article in press as: Boonsiriseth K, et al. Dexamethasone injection into the pterygomandibular space in lower third molar
surgery, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.ijom.2017.02.1266
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Address:
Natthamet Wongsirichat
Department of Oral Maxillofacial Surgery
Faculty of Dentistry
Mahidol University
6 Yothi Street
Rachathewee District
Bangkok 10400
Thailand
E-mail: natthamet.won@mahidol.ac.th