Are Impacted Third Molars Always Necessary to be Removed? Part I - A Literature Review- Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF DENTISTRY & ORAL HEALTH
The third molar is the last tooth to erupt in the
oral cavity and it is also the most retained/impacted tooth of the jaws.
Even though this tooth can remain asymptomatic causing no problems
whatsoever to the patient, a series of disorders can be directly related
with its presence. Throughout Dentistry history there have always been
some doubts concerning the real need for asymptomatic impacted third
molar removal and the best time to do it if indicated. This present
article, Part I, has the objective to review the literature on the
topic. A future to be published article, Part II, will discuss the still
controversial issue and propose a conclusion. There is unanimity among
oral and maxillofacial surgeons for impacted third molars removal when
involved with pathological conditions. The concept of prophylactic
extraction of third molars when the indications are not obvious,
surgical extraction recommendation must be based on clinical experience
and in adequate professional judgment, always taking into account the
relation cost/benefits and if patient´s systemic condition is adequate
for totally recover from surgical trauma.
Keywords:Impacted tooth; Retained third molar; Impacted third molar; Third molar removalIntroduction
Among the alterations of the development of the face,
dental inclusion or retention presents nowadays as a very important
chapter inside Modern Dentistry specifically in the areas of Oral
Pathology and Oral and Maxillofacial surgery.
It is understood by retained tooth a dental organ
that even completely developed did not erupted in the normal time being
so totally involved by bone (in other words, in his interior) or by both
bone and mucous membrane.
The term inclusion is commonly used by Frenchmen, impaction more by North Americans, while retention by Hispanics and Germans.
Shafer [1] defined retained teeth those, separately
or in groups, which for any reason did not manage to overcome
mucous-bone structure because of absence of an eruptive force or for any
mechanical impediment.
Nordenram et al. [2] quoted that impacted is any
tooth that is totally immersed in tissue and has already passed its
right time for eruption while tooth not erupted for a tooth immersed in
tissue still in its normal development period with great probability for
eruption.
Marzola [3] preferred the term retained classifying
as such any tooth when its normal time for eruption has approached is
partially or totally maintained in the interior of alveolar bone,
preserving or not the entirety of the dental follicular sac.
For the few above reasons it will be used along this
literature review article the term dental inclusion or impaction. And
for those teeth found in normal eruption phase it will be used the
expression physiologic inclusion or impaction.
The inclusion can be observed in both dentitions
however it is predominant in the permanent one since during the
formation and eruption of teeth the child is subject to several local or
systemic factors which can determine the eruption or the inclusion of
one or more teeth.
Dental inclusion is a frequent condition found in
patients in dental offices. In spite of an impacted tooth to be able to
remain asymptomatic without causing any problems to a patient a series
of troubles can be straightly connected with its presence. In
statistical terms the highest number of these dental inclusions is on
account of the third molars, being lower molars in higher incidence than
upper ones.
Many factors corroborate for this to happen such as: a) growth
of the cranium to the detriment of the jaws, b) diet every day now
less demanding of the stomatognathic system, c) coincidence of
a preventive Dentistry in which patients suffer less mutilations,
d) fluoridated water resulting in very important teeth decay
reduction during infancy and adolescence, e) less teeth decay
associated with less severe periodontal diseases when entering
adulthood with patients maintaining all teeth in their dental
arches producing lack of spacing and dental crowding.
Literature Review
It is possible to logically understand that impacted third
molars associated to pathological processes have formal
indication for removal. However the questioning still remains
about preventive removal or not for retained teeth that are
not locally causing any alteration. In the literature we can find
advocates for both arguments as shown below.
Not surgical removal
Amler [4] studied the factor age in bone repair after dental
extractions. The repair time in patients in the second decade of
life was histologically compared with individuals with 50 years
or more. During the period up to 10 days of post-operative there
were no significant differences between two groups of patients.
From the tenth day on the tissues of the youngest individuals
accelerated the remodeling whereas that only took place to
the twentieth day in the old individuals. Approximately to the
thirtieth day bone repair was the same in both groups. Also the
author affirmed that there are few evidences that extraction of
third molars will minimize the present or future crowding of
the lower anterior teeth for patients in orthodontic treatment
as well for those not receiving the same type of treatment.
Dental crowding is not a situation that indicates the extraction
of third molars because it has no relation with the impaction
of those teeth. So it was recommended that the third molars in
total inclusion must be moved only when there is evidence of
pathological conditions.
Accordingly with Lytle [5] counter-indications for dental
extraction of retained molars can be summarized by the relation
cost/benefit evaluated before indicating the removal. In the side
of the risks the important factors are: a) age of the patient, b) his/
her physical and psychological status. On behalf of the benefits it
is necessary to find what are the problems related to the retained
tooth which could be but not limited to: a) infection, b) pain, c)
edema, or d) discomfort. The symptomatic impacted teeth must
always be extracted even in patients with terminal diseases,
if the patient tolerates the proceeding and it can make more
comfortable his/her remaining period of life. Summarizing it can
be said that the indications and counter-indications must guide
the professional for choosing surgical or conservative treatment
for third molars. Each patient must be considered individually.
The majority of young people will benefit with the extraction of
impacted third molars. With aging buccal diseases can determine the necessity of the extraction. The asymptomatic impactions
with small potential risk for development of pathologies must
be periodically followed up. However the author agreed that
most of impacted teeth associated with a pathological condition
must be surgically extracted to prevent future and more severe
problems. Some impacted teeth can be maintained in position if
the professional judges that surgery might cause more problems
than the disease itself.
Nitzan et al. [6] studied the incidence of root resorption
associated with impacted third molars through periapical X-rays.
A total of one hundred ninety nine impacted third molars were
evaluated. Of this total only 7.5% presented root resorption
of adjacent tooth. Most of the cases affected patients between
twenty one and thirty years of age and the frequency doubled for
males. They came to the conclusion that from the clinical point
of view indicating surgery with the intention of root resorption
prevention in the adjacent tooth it is doubtful in those cases
where the extraction should be a choice for impacted third
molars, especially after thirty years of age.
The work of Lysell & Rohlin [7] carried out in Sweden with
eight hundred and seventy patients with age of twenty seven
years affirmed that the frequency of pathological entities as
follicular cyst, tumors, second molars root resorptions and
periodontal problems was low when compared to the impact
of the extraction of asymptomatic third molars and the possible
sequels derived from the surgical act. For the authors third
molars deeply impacted without pathological evidences must
be maintained until they cause some symptom that indicates
the extraction. Third molars with roots completely formed and
covered by bone must not be extracted simply because of being
retained.
Stanley et al. [8] evaluated eleven thousand, five hundred
ninety eight cases of impacted third of patients with twenty years
of age, in the State of Florida - USA, through Panoramic X-rays.
There was observed a total of 0.25% of cases of developments
of cysts; 0.13% of internal resorption; 0.72% of damages to
periodontal tissues and 0.72% of decays and resorptions in
the second molars. In spite of the literature to affirm that an
impacted third molar can cause serious pathological conditions
in the future and that so being this tooth should be prophylactic
extracted this single study did not agree with this philosophy
due to the very low of pathological complications presented.
Eliasson et al. [9] affirmed that the risks of complications
related to the impacted third molars do not increase in spite
of patient aging. Fully impacted third molars can turn in a
complicated surgery with risk of injury to the inferior alveolar
nerve. So, they affirmed that it is not recommended the
extraction of impacted third molars in the absence of clinical and
radiographic indications.
The study of Von Wonwern & Nielsen [10] affirmed
that
the indication for surgical extraction of a retained third molar is
clear if the tooth causes pain or if there are clinical and/or
radiographic signs of existing pathology. If the third molar is
asymptomatic the relation cost/benefit must be evaluated, i.e.
all complications which the patient will be subjected to. As a
benefit the surgical extraction can remove the development of
inflammation, pathological injuries such as cyst, root resorption,
tumors, decays, and periodontitis.
The work of Stephens et al. [11] concluded that there was
an existing preoccupation of teaching that extraction of not
erupted third molar, even asymptomatic and free of pathologies
was not a proved preventive procedure. They then proposed that
surgical extraction of those types of teeth must be limited to
when present pathological indications are defined as: infection,
cyst, tumor, resorption or decays not restorable. The study also
emphasized the necessity of the professional to inform his/her
patient the possibility of the post-operative complications.
Bricley et al. [12] also affirmed that there was a real concern
to teach in School-hospitals an alternative treatment for
asymptomatic third molars free of pathologies and that was the
surgical removal of those teeth. This vision gained great support
in the last years and reflected in a preoccupation about the
validity of the preventive surgery. Meantime this study presented
that the number of prophylactic extracted impacted teeth did
not change in the decade of 90´s. Worried with the legitimacy of
the preventive surgery the authors affirmed that if there were
a reduction in at least 10% of not indicated lower third molars
extraction this alone would reduce the morbidity of thousands of
persons in England annually, providing an economy of millions
of pounds to the Public and Private services. They ended up
confirming that as in any area of surgery unless the intervention
promotes profit in any patient´s health it is difficult to justify the
necessity of a preventive surgery.
Venta et al. [13] affirmed that from a practical point of view
it is not possible to prophylactic remove all inferior third molars
in a patient´s young age. It would be more reasonable to surgical
remove lower third molars partially erupted, with presence of
follicular space extended between the tooth and the adjacent
molar and third molars in distoangular position which were
presenting great risks of acute diseases. So they came to the
conclusion that the extraction of asymptomatic impacted third
molars is indicated if there is high probability of development of
future pathologies.
Brickley & Shepherd [14] determined that the option for
impacted third molars without associate pathologies is not
intervention; soon, in a cost/benefit analysis the preventive
surgical extraction is probably unjustified. The study also
reports that the predominance of future pathologies associated
to impacted third molars which remain in the oral cavity is small
with aging.
Accordingly with Koerner [15] the decision of an impacted
third molar surgical extraction is based on countless factors being the most important the patient´s signs and symptoms.
When the indications are not obvious, the recommendation for
extraction of these teeth is based more on the clinical experience
and in the professional judgment, always taking into account
that the age of the patient interferes not only with the surgery
difficulty but also with postoperative.
The objective of the study done by Chiapasco et al. [16] was
to compare incidences of complications in three age groups:
from nine to sixteen, from seventeen to twenty four and above
twenty five years of age in order to obtain more information on
the choice of the best moment for surgical extraction of impacted
third molar. The study concluded that the germectomy must only
be carried out when: 1) In the presence of morphostructural
alterations or ectopic impactions; 2) Dental eruption is hindered
by dysplastic alterations of the dental germ or pathological
processes of the mandible; 3) Is desired to gain space in the
posterior segment of the mandible when distalization of the first
and second molars are necessary; 4) Excessive anteroposterior
mandibular growth or severe dentoalveolar discrepancy
present. If there is none of the quoted indications the preventive
removal of impacted third molar must be carefully evaluated and
preferably postponed up to the age group between seventeen
and twenty four years when it is easier to correctly establish the
real necessities for the surgery.
Basile & Gregori [17] affirmed that the fact of the tooth be
impacted does not demand any treatment since the find means
an abnormal condition which suggests only periodic clinical
and radiographic control each ten or twelve months. Being so it
does not represent pathological picture to which it is necessary
to apply surgical therapeutics. The surgical or conservative
treatments must be chosen by the professional weighing all the
benefits and risks involved for each patient, determining case
necessity and opportunity.
Song et al. [18] evaluated articles found in the literature on
preventive extraction of impacted third molars. The authors
concluded that there are few reliable evidences on the validity
of such procedure. In the absence of good evidences that support
the anticipated surgical extraction it seems certain to affirm that
there is no justification for this attitude towards impacted third
molars free of associated pathologies.
The study of Kostopoulou et al. [19] was carried evaluating
impacted third molars with different degrees of eruption and
angulations in patients of both sexes, in groups with age from
nineteen to twenty five, from twenty six to forty, and from forty
one to sixty years old. It was summarized that there is no way
to predict the development of local pathologies in asymptomatic
impacted third molars.
One year later Kostopoulou et al. [20] declared that
the
decision of indicating or not for surgical extraction of an impacted
third molar is based on the experience of the professional,
in his daily practice. Since there are no clear evidences in the
literature in order to predict if a pathology will be installed in
a symptomatic third molar, the decision making is extremely
subjective.
Haddok & Flower [21] affirmed that the use of general
anesthesia for the extraction of impacted asymptomatic third
molars is not a sufficient justification for the extraction of
other impacted third molars without pathologies in the same
surgical time. An evaluation of clinical strategies also concluded
that the preventive extraction is not recommendable since it is
supposed that the patient must always return for routine clinical
and radiographic consultations, and that the diagnosis of any
pathology associated to the third molar would be done in the
beginning and so to indicate or not the extraction. Indications
well defined for preventive impacted third molar removal must
be studied.
Prophylactic surgical removal
Laskin [22] evaluated the indications and counter-indications
for impacted third molars surgical extractions. He mentioned
that in spite of an impacted third molar be able to remain
asymptomatic for the whole life of an individual frequently this
tooth can be involved in pathological process and because of
that is his opinion that a preventive extraction has much less
transoperative complications when the impacted third molar is
not associated with pathologies. So he recommended that this
tooth be extracted as soon as it insufficient space is detected
for its eruption. Since the mandibular and maxillary growth,
accompanied by resorption of the anterior edge of the ramus, are
completed between sixteen/seventeen years of age, the decision
of preventive extraction can be done during this phase.
Lytle [5] categorically affirmed that an extraction of impacted
third molars would have a higher benefit than not extracting
based on the great number of problems connected with its
retention. Any tooth that has not assumed the appropriate
position and function in dental arch is a not erupted tooth which
probably will become impacted if not reaching the position and
desirable function after the period of time considered normal for
eruption which is two years on average.
Hinds & Frey [23] affirmed that as Dentistry always aimed
oral health, regarding impacted third molars, any tooth that is
not assuming its own position and function in the arch should
be removed; or when not possible of transplanting this tooth, or
using it as an orthodontic anchor, or for a prosthesis support, or
still in the absence of counter-indications because of systemic
complications which the patient might present. The difficulty,
complications, and inherent risks of the surgery in old patients
indicate that the impacted third molars should to be carried out
in young age when most of the dental problems have already
been manifested.
Stephens et al. [11] determined that the fundamental reason
for a prophylactic surgical is the prevention of lesions such as
but not limited to: a) dentigerous cyst, b) ameloblastoma, c) epidermoid carcinoma, d) infection, and e) root resorption of
adjacent tooth. However the incidence of dentigerous cyst is less
than 1%. Rarer still is the formation of ameloblastoma. There are
no clear conclusions about the incidence of root resorption of
adjacent teeth. There are few scientific studies on the incidence
and recurrence of pericoronaritis in spite of existing available
information on the relation to dental position and the probability
of infection incidence. Concluding, the author confirms that there
are no scientific data on which the impacted third molars would
cause crowding of the lower anterior teeth.
For Brokaw [24] if the extraction of an impacted third molar
is indicated it is not advisable to wait until the referred tooth
becomes symptomatic because post-operative pain, infection,
edema, and other possible consequences appear with much
less frequency in adult patients. It was demonstrated that third
molar does not assume a functional and healthy position in 95%
of cases. They reported that is responsibility of the professional
to inform his/her patients the potential problems associated to
impacted third molars and explain the recommendations for
surgical extraction as early as possible.
Accordingly to Mercier & Precious [25] the best treatment
adopted by an oral surgeon is the extraction of a not erupted
third molar in developing patients, generally between fourteen
and twenty two years of age when the eruption chances are
minimal.
Samsudim & Madson [26] related that recurrent pain
resulted from pericoronaritis, pulpitis or periodontitis, edema
and trismus associated to a third molar eruption frequently
demand use of antibiotics and results in loss of days of work. A
great number of patients who had surgical extraction of their
third molars experienced all these symptoms which could have
been avoided with a prophylactic extraction conduct.
For Koerner [15] the indications for impacted third
molar removal are: a) abnormal positions such as vestibular,
lingual or palatal, mesial and distal inclinations, b) specially
when accompanied by pathologies, c) pain resulted from
pericoronaritis, periodontitis, periapical abscess, neoplasms, d)
resorption of second molar, e) third molar caries or in the distal
face of second molar, and f) inflammation caused by compression
of soft tissue by an antagonist tooth.
Boer et al. [27] reported that dental arches needed to have
an anteroposterior growth to accommodate all permanent
molars. Due to the fact that mandibular third molars tend to
erupt relatively late and slowly, disturbances related to position,
for example, pericoronaritis and impaction easily appear in
the second and third decades of life. The prevention of these
disturbances is the main reason for preventive removal of lower
third molars.
From the clinical point of view, accordingly with Flick [28] the
use of the term asymptomatic is incorrect when used to designate
the absence of pathological condition because the majority of them develop in association with a third molar which initially is
asymptomatic. Conditions such as cysts, caries and periodontal
diseases give clinical symptoms only after a significant damage
to adjacent tissues. Then the use of the term asymptomatic for
absence of a pathological condition can produce doubts but it
would be correctly used if was designating absence of symptoms
even in the presence of any pathological condition.
Godfrey & Dent [29] determined that the term asymptomatic
is used to describe when patient did not suffer pain or discomfort
attributed to a third molar. However asymptomatic does not
mean that third molar does not take risks of presenting any future
pathologies. The term would best define a tooth that erupted in
a satisfactory functional position without periodontal pathology
or that remained deeply retained in bone tissue without sign
of pathologies or eruptive movement during a long period.
According to the authors the prophylactic surgical extraction
is indicated in the following situations: a) prevention of lower
anterior teeth crowding attributed to third molar eruptive
forces; b) avoid risks of pathological sequels expected with the
presence of partially erupted third molar, c) superior impacted
third molar simultaneously extracted by the preventive reason
to avoid resultant problems from the lack of contact between
this tooth and the impacted mandibular third molar already
extracted.
Kaminishi [30] determined that when there is doubt for
treatment choice whether surgical or conservative for an
impacted third molar there are two points to be evaluated:
a) cost, and b) risk. What seems to be forgotten is the cost
for maintaining an impacted third molar in oral cavity which
requires periodic clinical and X-rays evaluations every two
years for the entire patient´s life. Today it is common to observe
pathologies in old patients with impacted third molars. If the
cost of a Panoramic X-ray for any life of the patient is estimated
or four periapical X-rays to every two years, in approximately
50 and 60 years it would exceed the costs for extraction of four
impacted third molars today. The author conclusion is that it is
not possible to hope that impacted third molars remain free of
pathologies for the whole life. More prudent is the extraction
of impacted third molars and the risk is much less if surgery is
carried out in young age while the patient is in good health and
his/her repairing capacity is at maximum.
Risks and benefits of surgical removal and not intervention
Mercier & Precious [25] determined risks and benefits of
surgical removal and not intervention.
Risks of surgical removal:A. Transitory: 1) alteration
of sensory nerve, 2) alveolitis, 3) trismus, 4) infection, 5)
hemorrhage, 6) dentoalveolar fracture, 7) tooth dislocation; B.
Permanent: 1) infection of vital organ, 2) mandibular fracture
and/or maxillary tuberosity, 3) total parestesia of inferior
alveolar or lingual nerves.
Risks of not intervention: 11) dental crowding based on the
predicted growth; 2) resorption of adjacent tooth; 3) destruction
of periodontium; 4) development of pathological conditions
such as infection, cyst and tumor.
Benefits of surgical removal:A) Regarding the age: 1)
the newer is the patient the lesser morbidity of an impacted
third molar extraction; B) Regarding the different therapeutic
measures: 1) ample alveolus lavage with clorexidine after
extraction to avoid alveolitis; 2) anti-inflammatory steroidal or no
steroidal medication which reduce post-operative complications
such as pain and edema.
Benefits of not intervention:1) avoid transoperative risks
during surgery; 2) preservation of function with future eruption;
3) transplant in case of premature teeth loss in the arch; 4)
preservation of alveolar crest as support for future prosthesis.
For Koerner [15] surgical extraction of impacted third molar
must not be carried out if: a) there is sufficient space for normal
eruption, b) third molar will be useful as a prosthesis support,
c) patient refuses to be subjected to surgery, and d) potential
trauma to exceed the benefits of the extraction.
Postoperative complications
After surgical removal of impacted third molars there are
several complications that patient can present with. It is certain
to say that all pre and postoperative recommendations as well
as transoperative measures have the purpose of minimizing or
avoiding such complications. However, it is known that there are
few not explained factors that cause appearance of complication
or even the surgical trauma itself imposed on the patient and his/
her body response to it. Since complications were exhaustively
studied it is the professional obligation to evaluate all of them
the patient will be subjected to, connect them with the beneficial
aspects surgery will bring to his/her health and then take the
decision to extract or not. The risks which the patient will
undergo must be lesser than the impacted third molar extraction
benefits. It is of general agreement that for any surgical
procedure, including surgical removal of impacted third molar,
patient be informed of all the risks and complications which he/
she will be subjected to. Patient´s opinion is decisive in choosing
the type of treatment, whether surgical or conservative.
Authors such as Van Gool et al. [31], Bruce et al. [32], Osborn
et al. [33], Sisk et al. [34], Sands et al. [35], Koener [15], Chiapasco
et al. [16], Boer et al. [27], and Lopes et al. [36] presented the
commonest complications after third molar removal such as: a)
pain, b) edema, c) trismus; d) dysfagia, e) incapacity for working,
f) alveolitis, g) trauma to nervous tissue, mainly inferior alveolar
nerve paresthesia, h) secondary infection, i) abscess, j) halitosis,
k) hemorrhage, l) ecchymosis, m) late bone repair, n) oro-antral
fistula (for upper impacted molars), o) periodontal packet
formation in the distal aspect of second molar.
Van Gool et al. [31] carried out a study in order to compare
different surgical techniques and their resultant postoperative
complications. Among the complications these ones were
presented:
1) Pain:the antibiotic usage, preoperative preventive
medications, exaggerated force when using elevators, not
intentional damages to periosteum, quantity of local anesthetics,
odontosection with drill and osteotomies had not significant
influence in pain level. The presence of acute inflammation such
as pericoronaritis, periodontitis, submucous or pericoronal
abscesses in the moment of the surgery resulted in significant
increase postoperative pain. Great amount of bone covering
the distal portion of the third molar crown and necessity of
mucoperiosteal flap incisions resulted in more pain because of
surgical time increase and more handling of soft tissues.
2) Trismus:type of incision and suture did not interfere
in the presence of trismus. Position of tooth, presence of great
quantity of alveolar bone to be removed in the distal portion
of impacted lower third molar and necessity of odontosection
influenced the presence of trismus probably because of the
increase of surgical time.
3) Edema:caused by mucoperiosteal incision and flap
reflection manipulation. The edema is straightly related to
surgical time increase (osteotomy and odontosection) and
damages to periosteum.
4) Dysfagia:it was more frequent in cases with flap incisions
and increase in periosteum handling.
5) Incapacity for working:this is related to the surgery
technique when flaps were performed. In the first days fever and
malaise were the most important reasons and in the following
days, edema and trismus more than the pain itself were the main
reasons of missing work.
6) Alveolitis:with a percentage of 3.5% there was no
relation of alveolitis with suture, type of incision, flap design,
acute inflammation present, preoperative antibioticotherapy,
surgery damage itself, oral hygiene, surgeon’s skills, quantity
of local anesthetics (vasoconstrictor) and alveolus filling out
with blood in the moment of suture. On the other side usage
of elevator exaggerated force increased frequency of alveolitis
possibly for the damages in alveolar walls.
7) Abscesses:less of the half of the abscesses that took
place were resultant of bone fragments and enamel present
under periosteum, characteristics of late abscesses (from three
to eleven weeks later).
8) Trauma to nervous tissue:paresthesia of inferior
alveolar nerve is the most frequent complication. There is a
narrow correlation to the roots positioning of lower impacted
third molars with the nerve proximity and its respective injury
and consequent expected paresthesia.
Bruce et al. [32] studied trans and postoperative
complications after impacted third molars removal in three
different groups of age. First group composed of individual up
to twenty four years, second group, from twenty five to thirty
four years and third group, above thirty five years of age). The
main transoperative complications in nine hundred and ninety
extracted molars were: a) hemorrhage, b) inferior alveolar
nerve injury, c) fractured root, d) injury to adjacent tooth, and
e) fracture of lingual bone plate. All trans and postoperative
complications were in larger scale in the third group composed
of most advanced age persons. Damages to the inferior alveolar
and lingual nerves occurred in 1.5 to 3% of the cases. Alveolitis
occurred in 3 to 30% of the cases. Infection with abscess
formation occurred in 3% and secondary hemorrhage in 0.5%
of the cases, respectively. Pain, trismus, edema, dysfagia reports
were common in 50% of patients in the first four days. Damages
to adjacent tooth and periodontium occurred in 3% of all cases.
Handelman et al. [37] compared the methodology of
procedures and complications after surgical removal of impacted
superior and inferior third molars by oral and maxillofacial
surgeons and general practitioner dentists. The commonest
postoperative complication was alveolitis. This complication
occurred in 25.9% of all lower extractions and frequency was
similar between the two groups of studied professionals. The
diagnosis criterion for alveolitis was the postoperative patient
return with constant pain and relief of this pain after placement
of an anodyne medication inside the alveolus. The postoperative
hemorrhage occurred in 2% of superior molars and 1.1% of
inferiors. The middle number of postoperative visits was 1.56.
Paresthesia occurred in 8.1% of the cases for both professionals
and trismus in 9.5% for oral and maxillofacial surgeons and in
5.6 % for general clinicians. The authors were able to conclude
that, statistically, there were no differences in the frequency of
postoperative complications and in the factors for complications
of both groups of professionals.
Berge and Boe [38] presented a correlation between pre and
transoperative variables and inflammation factors, including
patient sex, eruption stage, saggital angulation, presence of
pericoronaritis, surgery duration and difficulty, hour of the day
in which the surgery was carried out, use of oral contraceptives,
tobacco and alcohol. However, after to consider all these factors
it was believed that there are still unknown factors which
considerably influence the postoperative response. In daily
clinic it would be useful to predict when there would be a patient
exacerbated response to begin preventive measures. The study
concluded that the use of oral contraceptives showed to have no
relation with postoperative reaction. And complications such as
edema, pain and trismus were straightly connected with impacted
teeth covered with bone and longer surgeries, horizontal
angulation, and in higher frequency in female smoking patients.
Depth, third molar angulation and surgery time can predict in a
limited way postoperative morbidity. This study indicated that
the influence of pre and transoperative variables, individually
or simultaneously, is very small. The most commonly studied
variables explained only from 8 to 17% in patient pain variation,
edema, trismus, and days of incapacity for working. With the
current knowledge it is not possible to exactly predict which
patients will experience an exacerbated inflammatory reaction
after surgery.
The study of Boer et al. [27] evaluated postoperative
complications of one thousand, seven hundred and ninety seven
patients who had their impacted third molars surgically extracted.
The total of postoperative complications was 10.6%. These were
the conclusions of this long study: 1) Patients above thirty years
of age present high risk of postoperative complications after
lower impacted third molars removal, independently of patient
sex. This is due to the fact that bone tissue of an older person
is denser than of a young one. Another explanation can be that
erupted third molars in an advanced age person already suffered
masticatory forces and those teeth are more stuck to alveolar
bone by less periodontal ligament. 2) The more abnormal the
position of a third molar the higher the risks for patients to
have postoperative symptoms. This is due to the fact the need
for odontosection and osteotomy was increased in a wider
surface. 3) There were no statistically significant difference for
postoperative complication rates between beginners and more
experienced professionals.
In 1995 Lopes et al. [36] studied five hundred and twenty
two patients in Eastman Dental and University College Hospitals,
London - England, in one year period. Of this total of patients
23.2% presented postoperative complications. During the
postoperative period 76.2% of the patients imagined that the
original problems they had were reduced or solved through
surgery. The middle number of missing days of working was 3
while 19% of operated patients did not missed work.
Armstrong et al. [39] emphasized that the risks associated
to third molar surgery are already quite well established. The
philosophy used by the authors emphasizes that treatment
plan must be done in partnership with patient who needs
to understand possible surgery complications and risks for
example as: edema, trismus, pain, nervous tissue injury, which
can be permanent. Besides complications relative to general
anesthesia if that is the case. The information must be given to
the patient in writing since very often he/she will absorb them
and better reflect upon in a more familiar environment and not
in a stressful environment as a doctor’s office or hospital. The
report of possible risks and complications of a surgery serves
either to protect the professional of possible forensic risks and/
or to reduce levels of patient anxiety.
Armstrong et al. [39] emphasized that the risks
associated
In 1996 Shugars et al. [40] evaluated third molar surgery
interference in patient´s skills for chewing, sleeping, having
daily routine activities, speaking and working. According to this
work most of the adults, young and healthy, experienced some symptoms
and limitations in their activities for five days after the
surgery. Interferences in daily activities, work or school, occurred
in the first three days after the surgery with pain symptom
mitigating up to the fifth day. Bleeding, edema, and nausea were
relatively minimum and limited to the first two postoperative
days. Hematomas were rare. Problems with food impaction in
spite of initially be minimal were gradually increased during
postoperative days and disappeared up to two weeks after. This
is due to the diet change then returning to normal food habits.
The objective of Blomqvist et al. [41] study was to evaluated
when it is possible to recognize patient´s contribution to signalize
when it was really pain or simply a discomfort sensation during
impacted inferior third molar removal procedures under local
anesthesia. The most frequent pain was reported during the
injection of local anesthetics and women complained more
about pain during the procedures that men. The preoperative
factors such as smoke and pericoronaritis and the transoperative
one such as surgery time were negative important factors for
prognoses. The results of this study indicated that third molar
surgery effects can influence several aspects related to the
quality of patient´s life during the first postoperative week.
Patients must be orientated as for the possibility of a difficulty of
mouth opening and mastication even after a week. However, skill
for swallowing must have returned to normal during this period.
Some patients can have difficulties while speaking and changes
in the taste even after the seventh day postoperatively and
approximately 50% of patients will feel pain even with analgesic
therapy until the same period of days. After a week almost half
of patients thought that it wasted considerable time of work
and 20% of all patients would not recommend the surgery for
third molar extraction. The reasons would be related to pain,
missing of work and fear of the procedure. The interferences in
food intake were considered an adverse effect of higher impact
in patient´s quality of life followed by pain. Probably pain was
not put in first place because all patients naturally expect pain
to be present in the postoperative days. Meanwhile professionals
established pain as the worst adverse effect and on the contrary
of what patients realized the interferences in daily activities were
the least. The study concluded that patients are not routinely
informed about pain, edema, trismus, and possible parestesia of
lower lip or tongue. Patients would express less dissatisfaction
with surgery effects if they were informed of all possible adverse
effects related to the maintenance of quality of life.
Irvine & Hapangama [42] aimed to reduce the number
of postoperative visits for patients undergone third molars
extractions. A total of a hundred and thirty patients were
studied who undergone third molar extractions under general
anesthesia and sutured with resorbable suture. The cost spent
with postoperative visits is always a reason to be quoted in order
to routine scheduling be avoided. Not scheduling a patient for
a postoperative consultation not only economizes expenses as
it releases time-table for other consultations for new patients.
From the point of view of public health, it was detected that the
postoperative consultations were causing great expense. This
study concluded that there is no need for routinely schedule
postoperative consultations for patients who had their impacted
third molars surgically removed without transoperative
complications. However, the authors affirmed that a good
postoperative analgesia is necessary, that the professional
must go over again to give patients clear recommendations and
postoperative cares, and explain that they should have to contact
the professional if and when necessary
Conrad et al. [43] affirmed that before accepting surgery
patients must be informed of risks and benefits of having their
third molars surgically extracted. At present patients demand
more information and more options for decision of their health
treatment.
Yuasa et al. [44] determined that difficulty of impacted third
molar extraction is associated with the depth in which the tooth
is immersed in the interior of bone tissue, the space between
second molar and the available mandibular ramus, the biggest
root diameter or the combination of these factors. Difficult
surgeries result in more tissue handling, increased surgical time,
and increase in postoperative complications.
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