Original Article

Jamahiriya Medical Journal

Published by the Libyan Board of Medical Specialities

Surgical Extraction of Impacted Mandibular Third Molars: Postoperative Complications and their Risk Factors
Abulwefa Ahmed1, Fadel Mohamed2 and Kamel Hattab3 1- Department of Pedodontic, Orthodontic, and Preventive Dentistry 2- Department of Oral Biology 3-Department of Prosthodontics, Faculty of Dental Medicine and Oral Surgery, Al-Fateh University Tripoli, Libya.

ABSTRACT: The purpose of this study was to evaluate the incidence of various complications, including alveolitis, infection and paresthesia of the inferior alveolar and lingual nerves, associated with surgical extraction of impacted mandibular third molars. The relation between these complications and several clinical variables (age, sex, degree of impaction, and surgical difficulty) was also examined. Data were collected for all patients who underwent surgical extraction of an impacted lower third molar in the oral Surgery Department, Central Dental Clinic, Tripoli, Libya , over a period of four years. A total of 1921 impacted mandibular third molars were surgically removed from 888 male and 1033 female patients. After surgery, patients were seen at three days, one week and four weeks after surgery to establish the occurrence of complications. Those with complications were treated, and those with paraesthesia were followed for at least three years. The complication rate was 7.7%, consisting of 93 cases of alveolitis, 26 cases of infection, and 11cases of paresthesia of the inferior alveolar nerve, and 17 cases of lingual nerve dysfunction. The risk factors with permanent neurosensory deficit of inferior alveolar and lingual nerves were female sex, Pell and Gregory IC or IIC classification of impaction, and age greater than 25 years. Surgical extraction of the impacted mandibular third molars should be carried out well before the age of 25 years, especially for female patients. Older patients are at a greater risk of postoperative complications and permanent sequelae. A surgeon's lack of experience could also be a major factor in the development of postoperative complications. KEY WORDS: -Lower third molar ,Complications,Oral surgery. INTRODUCTION: Surgical extraction of impacted mandibular third molars is a common procedure in oral surgery. The most common reasons for removal of these teeth include: recurrent pericoronitis, periodontal problems, unrestorable carious lesion on the second or third mandibular molar, presence of a cyst or a tumour, and to prevent future complications(1). Before any surgical procedure, the patient must be informed of the reason for the surgery and the associated risks. Several complications are associated with surgical extraction of impacted mandibular third molars, the most common being alveolitis, infection and paresthesia of the inferior alveolar and lingual nerves (2,3).
Received 16-04-2009 ; Accepted 15-06-2009 . Correspondence and reprint request: Abulwefa Ahmed Department of Pedodontic, Orthodontic, and Preventive Dentistry E- mail : abulwefa2009@yahoo.com PO Pox: 4540 Tripoli,Libya

Haemorrhage and fracture of the mandible during or after surgery, prolonged trismus, damage to an adjacent tooth, and lingual nerve paresthesia are relatively rare(3,4). Surgical technique seems to play a major role in the occurrence of the latter problems. Most of these complications are temporary, but in some cases, paraesthesia may become permanent and lead to functional deficit(5,6,7). Several factors have been associated with these complications, including age and health of the patient, degree of impaction, and the surgeon's experience (7,8). From previous studies, these factors appear to be associated with the occurrence and rates of these complications, The purpose of this study was to evaluate the incidence and management of complications associated with the surgical extraction of impacted mandibular third molars. PATIENTS AND METHODS: 1921 patients, had a surgical extraction for impacted lower third molar tooth; the procedures were performed in the Department of Oral Surgery at the Central Dental Clinic; Tripoli. All these cases were Libyan nationls. A variety of data were collected for each patient, including

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Surgical Extraction of Impacted Mandibular Third Molars

age, gender and medical status at the time of the procedure, and together with their case sheet number were recorded with the site and type of procedure performed. All patients in the present study were given full information and counseled regarding the postoperative complications that might arise, prior to giving their consent. Drugs prescribed preoperatively varied according to individual policies. Patients were encouraged to maintain oral hygiene and motivated to gain better result of the planned surgery. The Pell and Gregory(9) and Winter(10) classifications were used to document the position of the impacted mandibular third molars, to predict surgical difficulty and to evaluate the risk of postoperative complications, in particular neurosensory deficits, but also the other complications of interest such as; alveolitis and infection. The procedures were made under local anaesthesia with or without sedation, (given orally or intravenously). Extraction through an intraoral approach was performed using ostectomy and/or an odontectomy surgical technique lingual splits were not used (8). Following extraction of the impacted tooth debridment of the wound was done and the flap was sutured. When the procedure was performed under antibiotic cover, the wound was left open with dressing for drainage. No postoperative antibiotic was given, except to patients with previously existing medical conditions, or acute infection of the impacted mandibular third molar. In all cases, adequate education for post-treatment care and followup were advised. Patients were told to return earlier if any problems arose. Postoperative educational advice to the patient, included the importance of the application of cold compresses on the affected side during the first 24 hours and hot compresses to fermentation, and the use of an antiseptic mouth rinse was recommended after the second day of surgery. Most patients received voltaren, and/or other analgesic tablets, with the dosage adjusted according to usual guidelines. Postoperative complications were seen by one of the authors. Patients were seen after three days and were asked about their initial postoperative condition. After one week, the suture was removed and the patient checked for whether any problems had arisen. All patients who had doubts about their postoperative condition or who experienced complications (i.e., alveolitis, infection or paresthesia) were seen, and appropriate treatment was initiated. Alveolitis was defined as the presence of severe pain with bad taste and unpleasant odour requiring treatment at two to five days after surgery. The diagnosis was confirmed by passing a small curette into the surgical wound. The presence of infection was defined by purulent discharge at the extraction site and/or painful induration. Paresthesia was defined as any postoperative change in sensitivity of the tissues innervated by the trigeminal nerve; and was evaluated both subjectively and objectively, using light touch and a needle. Cases of alveolitis were treated by irrigating the site with sterile saline and application of sedative dressings (Alvogyl paste -Septodont). Cases of infection were
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examined, and antibiotic therapy was prescribed. In some cases, depending on the clinical judgment of the operator and the severity of the problem, curettage and surgical drainage was carried out and the patient was seen through four or more postoperative appointments before complete resolution of the symptoms. Patients with paresthesia were followed regularly for at least 36 months. Paraesthesia that persisted for more than 12 months was considered permanent. No cases of paresthesia showed recovery beyond this 12-month period. RESULTS: A total of 1921 impacted mandibular third molars were surgically extracted from 888 (46.3%) male and 1033 (53.7%) female patients. The patients' ages were between 16 and 55 years. The complication rate was 7.7% (Table1). The overall complication rate differed highly between males and females (4.6% and 10.3%). This difference was also evident for the individual complications reported: 2.9% and 6.5%, respectively, for alveolitis; 0.5% and 2.1%, respectively, for postoperative infection the difference between males and females regarding paresthesia of inferior alveolar and lingual nerves was 0.5% and 0.7%, respectively, for inferior alveolar nerve; and 0.8% and1.0%, respectively for paraesthesia of the lingual nerve. The total incidence of paresthesia of the inferior alveolar nerve was 0.6% (11cases), and the total incidence of lingual nerve paraesthesia was 0.9% (17 cases). The patients with paresthesia were between the ages of 20 and 35 years, and 9 of these patients were older than 25 years (Table 2). Of the 28 cases encountered, 23(1.2% of the whole cohort), involved temporary paresthesia that disappeared within one year after surgery. The five patients with permanent paresthesia (0.3% of the whole cohort) were at least 23 years of age (23, 25,28, 36 and 40 years, respectively). There were no cases of bilateral paresthesia. There appeared to be a direct relation between the degree of impaction of the extracted tooth and the incidence of postoperative complications (Table 3). Most of the complications were associated with a greater degree of impaction. Teeth classified as having IC, IIC and IIIC impaction had more complications than teeth classified as having B or A impaction. The position of impacted mandibular third molars seemed to influence the incidence of postoperative complications (Table 4). The rate of complications was far higher with vertical impaction (60/612 or 10%) and mesioangular (MA) impaction (40/459 or 9%) than with other positions. Together, these two positions were associated with a total of 103 complications (out of 1071 interventions), whereas the other tooth positions (including distoangular (DA) and horizontal), were associated with a total of foutyfour complications (out of 850 interventions). Furthermore, among the twenty eight cases of paraesthesia, nine of the teeth were in a mesioangular position and fifteen had a vertical position. The horizontal position had the lowest complication rate (14/277 or 5%).
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(Table 1) Complications According to Patients' Gender .

Complication Males n = 888 teeth (%) 26 (2.9) 4 (0.5) 7 (0.8) 847 (95.4) 41(4.6) Total Females n = 1033teeth (%) n = 1921 teeth (%) 67 (6.5) 22 (2.1) 7(0.7) 10 (1.0) 927 (89.7) 106 (10.3) 93 (4.8) 26 (2.4) 11 (0.6) 17 (0.9) 1774 (92.3) 147 (7.7)

Alveolitis Infection Paresthesia of the IAN Lingual paresthesia None Total

(Table 2) Incidence of Paraesthesia Aaccording to Patients' Age.

Type of paraesthesia 16 < 20 20 < 25 25 < 30 Temporary Permanent Total 0 0 0 1 0 1 7 2 9 > 30 15 3 18 Total 23 5 28

(Table 3) Complications According to Degree of Impaction.

IC IIA IIB IIC IIIA IIIB IIIC IA IB (47) (65) (173) (320) (575) (450) (13) (98) (180)o Complication Alveolitis Infection Paresthesia No. of complications (% for category) 1 2 0 3 (6) 2 1 1 4 (6) 6 4 5 15 (9) 13 2 0 14 (4) 21 3 3 24 (4) 30 9 14 53 0 1 0 1 5 2 1 8 15 2 4 21 (12)

(12) (8) (8)

(Table 4) Complications According to Position of Impacted Mandibular Third molar. Position of Molar (Winter Classification). MA= mesioangular, DA= distoangular
Complication Alveolitis Infection Paraesthesia No. of complications (% for category) Other Horizontal DA MA Vertical (612 teeth) (459 teeth) (277 teeth) (124 teeth) (449 teeth) 34 10 15 59 (10) 29 6 9 44 (10) 9 4 1 14 (5) 7 2 1 10 (8) 14 4 2 20 (5)

DISCUSSION: In this study of surgical extraction of impacted mandibular third molars, the total complication rate (7.7%) compared favourably with previously reported rates, which have ranged from 2.6% to 30.9% (11,12). Most of the complications occurred in females, which conforms with the results of other studies, especially for alveolitis (13,14). Several prospective studies recorded a wide range incidence of this complication 1% to
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35%(12,13). However; most studies indicated a rate between 5% and 10% (13). Generally the hypothetical rate of alveolitis was between 1% and 5% (11). The incidence of alveolitis in the current study was 4.8% ; this result is still within the range of that which was published by earlier authors. Indeed; diagnostic criteria, which vary from author to author, might partly explain this variation. We found a major difference in the rate of development of this complication between sexes; the incidence of alveolitis was 2.2 times greater among females than among males. This finding was in agreement with those of previous studies (13,14). The postoperative infection rate reported in the literature varies between 1.5% and 5.8%,(1,13) or between 0.9% and 4.3% (2,15,16) depending on the articles consulted. In the current study, the infection rate was 2.4%. Chiapasco and others (15) reported an incidence of 1.5% in a study of extraction of 1.500 teeth, in which all patients received antibiotics after surgery. Bui and others (2), reported an infection rate of 0.8%; most of the patients, (94%), had received postoperative antibiotics. In this study, antibiotics were not used and the infection rate was relatively low, however; it appears that the prophylactic use of postoperative antibiotics is unnecessary, as suggested by Poeschl and others (17). Moreover, the irrational use of antibiotics, (locally or systematically), carries its own risks. In this study, the incidence of paraesthesia of the inferior alveolar nerve was 0.6%, whereas the incidence rate of lingual nerve paraesthesia was found to be 0.9%. The early reported rates in the literature vary between 0.4% and 8.4% (1,14,18). In some previous reports, there has been no distinction between permanent and temporary paraesthesia. In this study, the rate of permanent paraesthesia was 1.8%. All of these paraesthesia were followed up for more than three years. The neurosensory deficit of the lingual nerve is often due to neuropraxia and were transient in nature; recovery of normal sensation appears within 3 to 6 months, and no permanent paraesthesia was observed. The relationship between the degree of impaction and the appearance of paraesthesia was constant. In 14 of the patients with paraesthesia, the affected tooth was classified as having a vertical position IIC impaction. In 9 patients, the impaction was classified as having a mesio-angular position IC impaction, and in only five patient of the horizontal, disto-angular, and other position IIIC impactions. These findings indicate that initial impaction position and depth are factors in the risk of paraesthesia. For patients who experienced permanent paraesthesia, the impacted teeth were classified as having vertical impaction position (2 patients), mesioangular position (1patient), and other positions (2 patients); or IIC impaction (3patients), IC impaction (1patient) and IIIC impaction (1patient). At the time of the intervention, the first two and the last one of these procedures were considered surgically difficult, the cases of mesio-angular impaction and distoangular impaction were considered easy. There was also a relationship between tooth position based on the Winter classification (10) and the appearance
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Surgical Extraction of Impacted Mandibular Third Molars

of post-operative complications. Vertical and mesioangular impaction were associated with nearly twice as many complications as the other tooth positions: [103/1071(9.6%)], for horizontal, [24/401(6%)] distoangular position, and [20/449 (5%)]for other affected tooth . In the cases of permanent paraesthesia, the important factors were the patient's sex and age. In this study, 3 cases (2.7%) of permanent neurosensory disturbances occurred in females and 2 cases (1.8%) in males;cases from both gender were over 25 years of age. The agerelated trend has been noted by most other authors. The factors that have been suggested to explain this situation are increased bone density, surgical difficulty, complete formation of the root, and reduced capacity for subsequent healing (2, 19). Brann and others (5) did not support age as a risk factor, but rather believed that the experience of the surgeon is a determining factor. More recently, Bataineh (20) attributed a higher incidence of paraesthesia to lack of experience, and the complication rates reported here tend to support this observation. CONCLUSIONS: The incidence of postoperative complications associated with surgical extraction of impacted mandibular third molars is notably significant in females. No specific factor was identified to explain this difference between the sexes in the examined complications (alveolitis, infections and paraesthesia of inferior alveolar and lingual nerves). For paraesthesia, age at the time of extraction appeared to be a major factor. The rate of postoperative complications and the risks of permanent sequelae increase with age. Therefore, it is recommended that, once a decision has been made to extract an impacted mandibular third molar, the surgery should be carried out as soon as possible and well before the age of 25 years, especially for females. A surgeon's experience or inexperience could also be a major factor in the development of postoperative complications. Acknowledgment : We would like to acknowledge the contribution of dental surgeons and sisters in the Oral Surgery Department without their assistance this study could not have been completed. REFERENCES: 1-Chiapasco M, De Cicco L, Marrone G. Side effects and complications associated with third molar surgery. Oral Surg Oral Med Oral Pathol 1993; 76(4):412-20. 2-Bui CH, Seldin EB, Dodson TB. Types, frequencies, and risk factors for complications after third molar extraction. J Oral Maxillofac Surg 2003; 61(12):137989. 3-Sisk AL, Hammer WB, Shelton DW, Joy ED Jr. Complications following removal of impacted third molars: the role of the experience of the surgeon. J Oral Maxillofac Surg 1986; 44(11):855-9. 4-Muhonen A, Venta I, Ylipaavalniemi P. Factors predisposing to postopera-tive complications related to wisdom tooth surgery among university stu-dents. J Am Coll Health 1997; 46(1):39-42.
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