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Third molar surgery is the most common procedure performed by oral and maxillofacial surgeons. A thorough understanding of the complications associated with this procedure will enable the practitioner to identify and counsel high-risk patients, appropriately manage more common complications, and be cognizant of less common sequelae and the most effective methods of management. Surgical extraction of third molars is often accompanied by pain, swelling, trismus, and general oral dysfunction during the healing phase. Careful surgical technique and scrupulous perioperative care can minimize the frequency of complications and limit their severity. Although this article discusses complications and management, it is by no means an exhaustive appraisal of the current body of literature.
Mild bleeding, surgical edema, trismus, and postoperative pain Complications such as pain, swelling, and trismus are anticipated after the removal of third molars. Although transitory, these conditions can be a source of anxiety for the patient. Much of this anxiety can be alleviated if there is a preoperative discussion of the expected perioperative course. Mild bleeding can be managed effectively with local measures. Most bleeding can be managed by applying gauze packing over the extraction site with
* Corresponding author. North Shore Medical and Dental Center, Salem Peabody Oral Surgery Inc., 6 Essex Center Drive, Peabody, MA 01960.
direct focused pressure. Persistent intraoperative bleeding commonly can be controlled with additional sutures to the wound. Other surgical adjuncts include the application of topical thrombin to the wound or the use of a packing medium, such as Gelfoam or Surgicel. Arterial bleeding, if identified, is best treated with vessel identification and subsequent ligation or cautery. Surgical edema is an expected sequela of removal of impacted teeth. Swelling usually reaches a maximum level 2 to 3 days postoperatively and should subside by 4 days and be completely resolved by 7 days [1]. The use of ice and head elevation in the perioperative period may limit postoperative swelling and improve patient comfort [1]. The preoperative use of systemic corticosteroids has been advocated to reduce immediate swelling, but debate still exists as to their efficacy [2,3]. Trismus is often the result of surgical trauma and is secondary to masticatory muscle and fascial inflammation. As with surgical edema, there is evidence to support the preoperative use of steroids in reducing postoperative trismus [2]. No current agreement exists as to the most beneficial dose, type, or timing of its administration, however. Measurement of interincisal opening preoperatively and at followup ensures that the patient returns to the preoperative level of function. Pain caused by third molar surgery usually begins after the anesthesia from the procedure subsides and reaches peak levels 6 to 12 hours postoperatively. Pain is anticipated, and the use of numerous analgesics, including nonsteroidal antiinflammatory drugs and narcotics, has been advocated for management. Selected studies have suggested a role for the pre-
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Common complications and their management Alveolar osteitis Alveolar osteitis is one of the most common complications associated with third molar surgery [5,6]. It is characterized by a severe throbbing pain that usually begins 3 to 5 days postoperatively [5]. By this time, most of the pain and swelling associated with surgical trauma should disappear, and residual radiating pain to the ear is a common complaint in patients with alveolar osteitis. The causes of this painful condition, commonly known as dry socket, are not completely known but are considered to be related to malformation or disruption of blood clots in a newly vacated third molar socket [7]. Although data support the rationale that alveolar osteitis can be caused independent of fibrinolysis, destruction of a formed thrombus by invading oral bacteria is generally accepted as a more important etiologic factor [8,9]. This conclusion is supported by data that indicate that the use of antifibrinolytic agents decreases the incidence of alveolar osteitis and that saliva with a high bacterial count is associated with an increased incidence [5]. Overall rates of alveolar osteitis vary in the literature from 1% to 30% [5,10]. The variability of reported percentages can be attributed largely to ambiguous diagnostic criteria. Multiple authors have shown that factors such as age, sex, surgical experience, type of extraction, tobacco use, oral contraceptive use, and use of irrigation intraoperatively affect the incidence of alveolar osteitis, but the mechanism of their effects is not clear. Mandibular third molar surgery is more commonly associated with alveolar osteitis than maxillary third molar surgery [11,12]. Incidence also increases with patient age. Patients under the age of 20 are considered a low-risk population for this problem, which may be because the bone in these patients has more elasticity, circulation, and greater healing capacity [6,13,14]. Patients who take oral contraceptives [6] and patients who are habitual tobacco users [5] seem to be at a greater risk for development of alveolar osteitis. The onset of alveolitis has been found to be higher in women than in men, possibly skewed by the use of oral contraceptives [5,6]. Surgical experience seems to be inversely related to the incidence of alveolar osteitis [5,15]. Patients with preexisting pericoronitis and patients with poor oral hygiene are at increased risk
for development of osteitis, which suggests the role of bacteria in fibrinolysis [5]. Methods for reducing the incidence of alveolar osteitis have been recommended. Depending on the risk level of the patient, different courses of action may be indicated. Some researchers have advocated the routine use of prophylactic agents for inexperienced surgeons [5]. Various measures can be taken to reduce the incidence of alveolar osteitis, including evacuation of the vacant socket via saline irrigation [12], the use of topical antibiotics, such as tetracycline powder, within the socket [16], placement of Gelfoam packing soaked in antibiotic media [17], and the perioperative use of chlorhexidine rinses [18]. Early postoperative infections Because of the large variety of indigenous oral flora, postoperative infection is of concern. Although the use of aseptic technique, hemostasis, meticulous tissue management, and complete and thorough lavage of extraction sites can decrease the likelihood of postoperative infection, the routine use of antibiotic therapy to prevent infection is still debated [18 20]. The overall incidence of infection from third molar extraction has been reported to be in the range of 3% to 5% [14,21]. It has been suggested that the rates of postoperative infection are higher for mandibular bony impactions than for any other type of extractions, reflective of the increased surgical trauma [13 15]. Surgical experience also can influence the rate of secondary infection [14,15]. Systemic antibiotics have been of suggested value for infection prevention in patients with gingivitis, pericoronitis, or general debilitating diseases, but their effectiveness in reducing postoperative infections overall remains controversial [19,20,22]. The incidence of deep fascial space infection is low [6,23,24]. Management of these more severe infections depends on the severity. Treatment should include proper assessment and management of the airway, adequate imaging, dependent drainage with culture and sensitivity testing, and appropriate use of antibiotics. Excessive postoperative bleeding Excessive bleeding is defined as bleeding beyond that expected from the extraction or continued bleeding beyond the postoperative window for clot formation (6 12 hours). Various risk factors for excessive postoperative bleeding related to third molar surgery have been identified, and methods for management have been studied [6,15,25 28].
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Excessive bleeding and hemorrhage have been reported to occur in the range of 1% to 6% of third molar surgery [25,26]. Preoperative assessment of intrinsic coagulation disorders and the use of anticoagulant and antiplatelet medications (ASA, Coumadin, Plavix) are essential. Of the predisposing risk factors reported, the most important is the level of the impaction and its proximity to the neurovascular bundle [15,27,28]. Excessive bleeding has been reported to occur more frequently with the extraction of mandibular third molars versus their maxillary counterparts. Excessive bleeding is more frequent, regardless of the type of impaction, for inexperienced surgeons [15,27]. It is also more commonly reported in older patients, probably because of vascular fragility and less effective coagulation mechanisms [26,27]. It is reported that men are as much as 60% more likely to suffer from excessive bleeding than women, possibly because of the higher incidence of contraceptive use in women and the positive effect of oral contraceptives on coagulation [6,27]. Identification of patients at risk is a critical first step in appraising the likelihood of bleeding complications after third molar surgery. During the preoperative consultation, it is imperative that the surgeon inquire about any past surgeries and the occurrence of associated bleeding complications. Any family history of bleeding abnormalities should be elicited. Excessive bleeding with loss of deciduous teeth and, in women, a history of menorrhagia, can be suggestive of an underlying coagulopathy. Intraoperatively, careful soft tissue management and local measures can control and prevent most bleeding problems. Hemorrhage that cannot be controlled with local measures is rare. In such isolated cases, interventional radiology with selective embolization or proximal vessel identification and ligation may be required [29]. Wound healing problems Risk factors for poor wound healing have been identified. A 1993 workshop of the American Association of Oral and Maxillofacial Surgeons (AAOMS) identified the following patient risk factors: pathogenic accumulation and periodontal compromise adjacent to the wound site, tobacco use, and increasing age over 25 years [30]. The report of the workshop also stated that wound healing is more rapid and complications less frequent when third molars are removed before complete root development and that various factors affect wound healing independent of age. Patients who display at least three of the following factors were defined to have an increased risk of wound compromise: bony defects distal to the
second molar, increased mesioangular positioning of the third molar, close proximity and contact of second and third molar roots, and resorption of the second molar root [30]. Identification of high-risk patients preoperatively and case-specific intervention are the best courses of action to minimize this problem.
Less common complications and their management Fractures Although they occur infrequently (0.00049%) during the extraction of third molars, fractures of the mandible (Fig. 1) are of serious consequence, particularly if associated with nerve injury [31]. Fractures usually occur when excessive force is used to extract a tooth, although even small forces can cause fractures for deeply impacted teeth. Because of extremely small numbers, specific risk factors are difficult to identify. Some studies have shown older age as a risk factor [32]. Fracture also can occur in delayed fashion, sometimes weeks after tooth removal. Treatment should include a standard approach of reduction and stabilization using intermaxillary fixation or rigid internal fixation (Fig. 2). Damage to adjacent teeth Because of the force required to remove third molars, it is possible to damage adjacent teeth during the procedure [33]. Inadvertent fracture of adjacent teeth can be minimized if care is taken to visualize the entire operating field rather than the tooth or teeth being extracted. A surgeon who is aware of the periphery of the operating field often is able to anticipate possible damage and take action to prevent its occurrence. Even with adequate awareness and careful surgical technique, however, fractures of carious or heavily restored teeth are sometimes unavoidable. Preoperative discussion regarding fractures is the best measure. When carious teeth or restorations exist, the practitioner should advise the patient of the possibility that these structures may sustain damage and explain what is done if such a situation occurs. If an adjacent tooth is luxated or avulsed inadvertently, the most common course of action is repositioning of the tooth followed by fixation, if needed [33]. Fixation often can be obtained using additional sutures placed laterally across the occlusal surface, thereby holding the tooth in place. Use of other means of fixation, including dental wires, arch bars, and composite splints, also has been effective [33].
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Fig. 1. Postoperative panoramic radiograph displaying a displaced right mandibular angle fracture in the line of a recently removed lower third molar.
Fig. 2. Panoramic radiograph after reduction and rigid internal fixation of the mandible fracture.
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Periodontal defects Periodontal defects after third molar surgery often can be anticipated before surgery based on the patients age and preoperative periodontal health. Although there is controversy regarding the removal of asymptomatic third molars, it is generally accepted that prophylactic removal of deeply impacted third molars is contraindicated in older patients with good periodontal health [34 38]. Of general concern is the effect of removal of third molars on the periodontal health of the second molars, specifically bone height and pocket depth [39,40]. In most cases, there is negligible difference between the preoperative and postoperative height of bone on the distal aspect of the second molar [41,42]. With this in mind, it is generally accepted that bone healing is more predictable if the third molar is removed before the presence of bone loss along the distal aspect of the second molar [42 44]. In general, periodontal defects after third molar surgery are most likely to occur in older patients ( > 35 years), especially if there is existing bone loss along the distal aspect of the second molar and if periodontal lesions, which are commonly associated with partially erupted third molars, exist. For these patients, it is not advisable to perform the extractions unless pathologic indications necessitate such surgery [45]. Oroantral communication and fistula formation Occasionally, the removal of maxillary third molars results in a communication between the oral cavity and the maxillary sinus [33]. For deeply impacted maxillary molars and teeth that have roots with large surface area, it is possible that the antral floor will be violated during tooth removal. Two common sequelae associated with this complication are maxillary sinusitis and chronic oroantral fistula formation. The degree of severity of these conditions is dictated largely by the size of the communication and the preoperative sinus status. Preoperative imaging is helpful but not entirely predictive of sinus involvement. Treatment of oroantral fistulae depends on the size of the opening between the maxillary sinus and the oral cavity [33]. If the opening is small ( < 2 mm in diameter), surgical intervention is seldom required and closure usually follows effective medical management. Patients should be instructed not to engage in activities that rapidly change the pressure equilibrium of the sinuses, including nose blowing, sucking on straws, smoking, and forceful sneezing. For larger openings (2 6 mm in diameter), additional suturing
may be required to contain the blood clot and facilitate healing, along with a course of antibiotics and the continued use of commercial oral or nasal decongestants. For larger fistulae ( 7 mm in diameter) and for patients with a history of secondary chronic sinusitis, bridement and surgical intervention, including sinus de drainage, polypectomy, and closure by flap development, are recommended. Antibiotic and decongestant therapies also should be prescribed. Displacement of teeth Displacement of teeth or tooth fragments into either fascial spaces or the maxillary sinus, although not a common occurrence, is one that demands attention. Anecdotal descriptions of such occurrences are common. Decisions to remove teeth after displacement should be planned using three-dimensional analysis from radiographs or tomographic cuts.
Nerve injuries after third molar removal Among the most serious and often discussed postoperative complications that arise from third molar surgery is trigeminal nerve injury, specifically, involvement of either the inferior alveolar or lingual nerve. These nerves can be damaged as the result of direct or indirect forces. Direct injuries include those that result from anesthetic injections, crush injuries, injuries sustained during the extraction process or soft tissue management, and damage caused by the use of instruments. Indirect injuries to nerves can be the result of physiologic phenomena, including root infections, pressure from hematomas, and postsurgical edema [46]. The overall risk of inferior alveolar nerve injury associated with third molar removal ranges from 0.5% to 5% [47,48]. In most cases, the injured nerve recovers spontaneously. The reported rate of permanent inferior alveolar nerve injury is considerably less than 1% [49 55]. The proximity of the mandibular third molar root and the inferior alveolar nerve may be suspected from panoramic or periapical radiographs. Statistically significant high-risk radiologic signs include a narrowing or deviation of the canal, a loss of the canal cortical outline, and increased radiolucency over the root [52]. Although these features provide preliminary evidence that the nerve may be encountered during extraction, injuries may occur independent of the presence of any of these factors. The incidence of lingual nerve injury is considerably lower than for inferior alveolar nerve injury
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Fig. 3. Close-up image of an impacted mandibular third molar. Note the associated pericoronal lucency and clear evidence of high-risk findings: divergence of the inferior alveolar canal, loss of the cortical white line, and darkening of the root. This patient was symptomatic with one previous episode of infection.
and ranges from 0.02% to 0.06%. In the presence of injury, however, spontaneous recovery is less common [56 60]. The anatomic position of the lingual nerve varies considerably. Although the nerve itself is commonly located near the lingual cortex of the mandibular third molar, it can be located anywhere within the space between the mylohyoid muscle and the gingival crevice [61]. Soft tissue manipulation that involves elevation and protection of the lingual periosteum (as routinely performed during the lingual split technique) has been discussed as an etiologic factor for transitory lingual nerve injury. Descriptive nomenclature exists for categorizing nerve injury. A commonly accepted classification separates neural trauma into three categories: neuropraxia, axonotmesis, and neurotmesis [62]. Inhibition of conduction signals caused by damage of the myelin sheath is known as neuropraxia. Disruption of the axonal system without accompanying injury to the nerve trunk is known as axonotmesis. Neurotmesis involves damage to nerve fibers, usually the result of severing a nerve and destroying the adjacent connective tissue. Aside from direct recognition of nerve injuries intraoperatively, postoperative subjective neural dysfunction (dysesthesia, paresthesia, anesthesia) war-
rants careful investigation into the possibility of nerve injury. Complete and thorough neurosensory testing and documentation are imperative. Accepted methods include examination of fine touch and direction proprioception, two-point discrimination, use of sequential von Freys hairs, temperature sensation, and detection of sharp and dull objects. A subjective evaluation of taste also should be documented. Diagram and chart use is recommended [63]. Although the incidence of permanent nerve dysfunction is rare, early consultation with a microsurgical specialist is encouraged because early surgical repair has been shown to be associated with the most favorable outcome [64,65]. Factors that predispose patients to specific nerve injuries have been investigated and identified thoroughly [66]. Dental, radiologic, and patient variables can affect the incidence of nerve injuries. Root proximity to the inferior alveolar canal, as ascertained from radiographs, has been shown to be predictive of injury. Surgical removal of horizontal and mesioangular impacted teeth also is more likely to result in nerve injuries, probably because of the increased surgical manipulation and exposure required to remove such teeth. Postoperative hemorrhage from the extraction site also has been implicated in the
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Fig. 4. Selected formatted coronal CT images. Note the presence of the inferior alveolar canal traversing the substance of the roots of the third molar.
onset of dysesthesias. There is no conclusive evidence currently regarding the relationship with age, sex, and race and the incidence of nerve injuries. Various investigators have attempted to study the effects of modified surgical techniques on nerve
injury incidence, with no conclusive results [66]. The most effective method of managing nerve injuries remains a combination of preoperative assessment of radiographs, discussion with patients about the possibility of injury, and a cautious approach to
Fig. 5. Close-up image of intentionally retained roots after crown sectioning and enucleation of pericoronal dentigerous cyst.
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S.M. Susarla et al. / Oral Maxillofacial Surg Clin N Am 15 (2003) 177186 lae of third molar removal. J Oral Maxillofac Surg 1992;50:1177 82. Hyrkas T. Effect of preoperative single doses of diclofenac and methylprednisolone on wound healing. Scand J Plast Reconstr Surg 1994;28:275 8. Larsen PE. Alveolar osteitis after surgical removal of impacted mandibular third molars: identification of the patient at risk. Oral Surg Oral Med Oral Pathol 1992; 73:393 7. Muhonen A, Venta I, Ylipaavalniemi P. Factors predisposing to postoperative complications related to wisdom tooth surgery among university students. J Am Coll Health 1997;46:39 42. Heasman PA, Jacobs DJ. A clinical investigation into the incidence of dry socket. Br J Oral Maxillofac Surg 1984;22:115 22. Mercier P, Precious D. Risks and benefits of removal of impacted third molars: a critical review of the literature. Int J Oral Maxillofac Surg 1992;21:17 27. Nitzan DW. On the genesis of dry socket. J Oral Maxillofac Surg 1983;41:706 10. Catellani JE, Harvey S, Erickson S, et al. Effect of oral contraceptive cycle on dry socket (localized alveolar osteitis). J Am Dent Assoc 1980;101:777 80. Awang MN. The aetiology of dry socket: a review. Int Dent J 1989;39:236 40. Berwick JE, Lessin ME. Effects of a chlorhexidine gluconate oral rinse on the incidence of alveolar osteitis in mandibular third molar surgery. J Oral Maxillofac Surg 1990;48:444 8. Herpy AK, Goupil MT. A monitoring and evaluating study of third molar surgery complications at a major medical center. Mil Med 1991;156:10 2. Osborn TP, Frederickson G, Small I, et al. A prospective study of complications related to mandibular third molar surgery. J Oral Maxillofac Surg 1985;43:767 9. Sisk AL, Hammer WB, Shelton DW, et al. Complications following removal of impacted third molars: the role of the experience of the surgeon. J Oral Maxillofac Surg 1986;44:855 9. Sorensen DC, Preisch JW. The effect of tetracycline on the incidence of postextraction alveolar osteitis. J Oral Maxillofac Surg 1987;45:1029 33. Bloomer CR. Alveolar osteitis prevention by immediate placement of medicated packing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:282 4. Hermesch CB, Hilton TJ, Biesbrock AR, et al. Perioperative use of 0.12% chlorhexidine gluconate for the prevention of alveolar osteitis: efficacy and risk factor analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:381 7. Bulut E, Bulut S, Etikan I, et al. The value of routine antibiotic prophylaxis in mandibular third molar surgery: acute-phase protein levels as indicators of infection. J Oral Sci 2001;43:117 22. Sekhar CH, Narayanan V, Baig MF. Role of antimicrobials in third molar surgery: prospective, double blind, randomized, placebo-controlled clinical study. Br J Oral Maxillofac Surg 2001;39:134 7.
high-risk patients (or patients whose radiographic signs suggest a close anatomic relationship between the tooth root and the inferior alveolar nerve (IAN) canal). Recent advances in CT and reformatting of images have been helpful in visualizing the threedimensional position of the inferior alveolar nerve relative to the roots of the third molar [67,68]. With this additional information, alteration in surgical approaches can be attempted to minimize the potential for nerve injury (Figs. 3 5). Despite technologic advances, informed consent regarding the incidence of nerve injury is imperative. Thorough explanation of the potential for nerve injury, the associated symptoms, and the methods for treatment of such injuries can help prevent considerable unnecessary hardship on the part of the patient and the practitioner. An open dialogue between the patient and clinician before surgery, during which all possible complications and treatment options are explained, may help prevent subsequent legal action.
[4]
[5]
[6]
[7]
[8]
[9] [10]
Summary Recent literature and long-term experience have improved the understanding of the origin and treatment of complications related to third molar surgery. The armamentarium available to the clinician in preventing and managing these problems continues to evolve. As the body of literature related to third molar surgery and its complications expands, more techniques and predisposing factors will be elucidated. Until such a time when there is a concrete and unambiguous literature regarding such complications, however, the strongest asset at the surgeons disposal remains open lines of communication and the timely transfer of information to patients. Early recognition and appropriate management of complications as they arise hopefully will minimize permanent and disabling consequences.
[11] [12]
[13]
[14]
[15]
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[18]
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