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Complications After Extraction of Impacted Third Molars- Literature Review

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Complications After Extraction of Impacted Third Molars- Literature Review http://dx.doi.org/10.5272/jimab.2016223.1202 Journal of IMAB Journal of IMAB - Annual Proceeding (Scientific Papers) 2016, vol. 22, issue 3 ISSN: 1312-773X http://www.journal-imab-bg.org COMPLICATIONS AFTER EXTRACTION OF IMPACTED THIRD MOLARS- LITERATURE REVIEW Elitsa G. Deliverska, Milena Petkova. Department of Oral and Maxillofacial surgery, Faculty of Dental medicine, Medical University –Sofia, Bulgaria ABSTRACT cations. Most of the complications are associated with a Third molar surgery is the most common procedure greater degree of impaction. Teeth classified as having IC, performed by oral and maxillofacial surgeons worldwide. IIC and IIIC impaction have more complications than teeth This article addresses the incidence of specific complications classified as having B or A impaction [3]. There is also a and, where possible, offers a preventive or management strat- relation between tooth position based on the Winter classi- egy. Complications, such as pain, dry socket, swelling, fication and the appearance of postoperative complications. paresthesia of the lingual or inferior alveolar nerve, bleed- Mesioangular and distoangular impaction are associated ing, and infection are most common. Factors thought to in- with nearly twice as many complications as the other tooth fluence the incidence of complications after third molar re- positions [3]. Other authors state that horizontal and moval include age, gender, medical history, oral contracep- distoangular impactions are inclined to develop more com- tives, presence of pericoronitis, poor oral hygiene, smoking, plications [4]. Deep impacted third molar surgery needs a type of impaction, relationship of third molar to the inferior bigger flap design. Tissues in the neighborhood and mus- alveolar nerve, surgical time, surgical technique, surgeon cles can receive more damage because of this wide and large experience, use of perioperative antibiotics, use of topical access flap [5]. antiseptics, use of intra-socket medications, and anaesthetic There is a distinctive association between age and technique. observed postoperative complications. These associations For the general dental practitioner, as well as the oral result from the fact that the intervention in older patients and maxillofacial surgeon, it is important to be familiar with lasts longer because of increased bone density. Age depended all the possible complications after this procedure. This im- maturing of tooth root formation and decreased healing ca- proves patient education and leads to prevention, early rec- pacity lead to intensive postoperative complications. Bruce ognition and management. and Chiapasco et al. state that older patients have more pain, edema and trismus as postoperative complications [5]. Key words: third molar surgery, complication, man- It seems that female patients show higher accident and dible, maxilla complication rates [1]. Monaco et al. reported that the inci- dence of postoperative edema in female patients (12.7%) is INTRODUCTION significantly higher than in male patients (1.4%) [5]. Surgical removal of impacted third molars is one of The experience of surgeon also appears to be a deter- the most common procedures carried out in oral and maxil- mining factor in the development of postoperative compli- lofacial surgery. Most third molar surgeries are performed cations and can result in a longer treatment process, social without complications. However, such procedure can lead and financial difficulties and a corresponding decrease in to serious complications to the patient, such as hemorrhage, patient’s life quality [5]. persistent pain and swelling, infection, dry socket (alveolar Prior to any surgical procedure, the patient must be osteitis), dentoalveolar fracture, paresthesia of the inferior informed about the possible accidents and/or complications alveolar nerve and of the lingual nerve, temporomandibular that may occur during the entire treatment, being aware of joint injury and even mandibular fracture. The accident or the fact that any unexpected situation should be dealt with complication rates related to third molar extraction may vary the best possible way [1]. between 2.6 and 30.9 %, being the results influenced by dif- It is thought that complications like pain, edema and ferent factors, such as age and health condition of the pa- trismus are caused by surgical trauma depending on the in- tient, gender, tooth impact level, surgeon’s experience, smok- flammatory process. In surgeries for impacted mandibular ing, intake of contraceptive medicine, quality of oral hy- third molar, time of the intervention is thought to be associ- giene, and surgical technique among others [1]. The overall ated with tooth position, angle and the experience of the incidence of complication and the severity of these compli- surgeon and these parameters determine the difficulty of the cations are associated most directly with the depth of im- surgery and are related to the intensity and time of pain, paction and with the age of the patient [2]. There appears to edema and trismus. Longer surgical interventions are be a direct relation between the degree of impaction of the thought to increase tissue damage and vascular permeabil- extracted tooth and the incidence of postoperative compli- ity can cause postoperative edema and affect its intensity. 1202 http://www.journal-imab-bg.org / J of IMAB. 2016, vol. 22, issue 3/ In addition, it was reported that longer surgical interventions 7 days [7]. lead to increased surgical trauma [5]. In comparing edema with gender, age, position of the While evaluating the postoperative complications tooth, classification of the tooth, retention, angle, systemic regarding the width and depth of impaction, pain and conditions, bad habits, use of oral contraceptives and men- swelling was common in IIIA (37.5%) followed by IIIB struation, statistically significant differences were observed (20%); dry socket was common in IIIA, IA and IIA which between edema and classification of the tooth. More edema was 12.5%, 5% and 4.8% respectively; trismus occurred was observed in class II than in classes I and III. There was a more in Class IIIB (20%), Class IIIA (12.5%) and Class IB statistically significant difference between edema and par- (6.8%) and paresthesia was least common and occurred in tial bony and complete bony impaction [5]. 2 patients (0.7%) [4]. The application of ice packs to the face may make the patient feel more comfortable but has no effect on the Bleeding magnitude of edema [2]. Hemorrhage might happen during (accident) or after Most of the surgeons prescribe corticosteroids to con- (complication) the surgery, being classified as late or recur- trol surgical outcomes and yield a comfortable post-surgi- rent hemorrhage. In situations of intense bleeding classified cal healing period [6]. as late, the hemorrhage happens only once, after the end of In the initial phase of the inflammatory process, the procedure. In recurrent hemorrhages, more than one in- corticosteroids acts by suppressing the production of vasoac- tense bleeding situation takes place, even after initially ex- tive substances such as prostaglandins and leukotrienes. This tinguished. reduces fluid transudation and edema. These drugs help to Anatomical variations, tooth proximity to the vascu- control mild pain hence they should be used in conjuga- lar nerve bundle of the mandibular canal, and coagulopathy tion with potent analgesics. Prolonged use can delay heal- are the main causes of hemorrhage [1]. Patients who have ing and increase patient’s susceptibility to infections. But known acquired or congenital coagulopathies require exten- in dental extraction the doses are for shorter duration, hence sive preparation and preoperative planning (eg, determina- chances of adverse effects are very rare. [6] tion of International Normalized Ratio, factor replacement, The dose of the drug should be more than the corti- hematology consultation) before third molar surgery [2]. sol released normally by the body. Due to this reason, some Bleeding can be minimized by using a good surgical authors consider that 8 mg dexamethasone and 40 mg meth- technique and by avoiding the tearing of flaps or excessive ylprednisolone were used which corresponded to 200 mg of trauma to bone and the overlying soft tissue. When a vessel cortisol. [6] is cut, the bleeding should be stopped to prevent secondary Dexamethasone significantly reduced the incidence hemorrhage following surgery [2]. of swelling as compared to methylprednisolone. This is at- The most effective way to achieve hemostasis follow- tributed to the half-life of the drug which is more than meth- ing surgery is to apply a moist gauze pack directly over the ylprednisolone. The efficacy of dexamethasone is also due site of the surgery with adequate pressure for some minutes to the reason that it reduces the formation of thromboxane or use of bone wax, absorbable hemostats or electrocoagu- A2 which in turn reduces the amount of prostaglandin E2 lation. that is formed [6]. Good results were also obtained with 32 In some patients, immediate postoperative mg methylprednisolone and 400 mg ibuprofen administered hemostasis is difficult. In such situations a variety of tech- 12 h before and 12 h after surgery respectively. niques can be employed to help secure local hemostasis, Postoperative edema can also be controlled with dex- including over suturing and the application of topical amethasone administered in the submucosa [8]. Submucosal thrombin on a small
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