Srinivas M. Susarla. 2003.pdf

Third molar surgery and associated complications

Srinivas M. Susarla, BSa, Bart F. Blaeser, DMD, MDb,*,Daniel Magalnick, DMDa,b

aHarvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115, USAbDepartment of Oral and Maxillofacial Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA

Third molar surgery is the most common proce-

dure performed by oral and maxillofacial surgeons. A

thorough understanding of the complications associ-

ated with this procedure will enable the practitioner to

identify and counsel high-risk patients, appropriately

manage more common complications, and be cog-

nizant of less common sequelae and the most effec-

tive methods of management.

Surgical extraction of third molars is often accom-

panied by pain, swelling, trismus, and general oral

dysfunction during the healing phase. Careful sur-

gical technique and scrupulous perioperative care can

minimize the frequency of complications and limit

their severity. Although this article discusses compli-

cations 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

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 max-

imum 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 evi-

dence to support the preoperative use of steroids in

reducing postoperative trismus [2]. No current agree-

ment exists as to the most beneficial dose, type, or

timing of its administration, however. Measurement

of interincisal opening preoperatively and at follow-

up 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 analge-

sics, including nonsteroidal antiinflammatory drugs

and narcotics, has been advocated for management.

Selected studies have suggested a role for the pre-

1042-3699/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved.

doi:10.1016/S1042-3699(02)00102-4

* Corresponding author. North Shore Medical and

Dental Center, Salem Peabody Oral Surgery Inc., 6 Essex

Center Drive, Peabody, MA 01960.

Oral Maxillofacial Surg Clin N Am 15 (2003) 177–186

operative use of nonsteroidal antiinflammatory drugs

to decrease postoperative pain [4].

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 gen-

erally accepted as a more important etiologic factor

[8,9]. This conclusion is supported by data that

indicate that the use of antifibrinolytic agents de-

creases 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 experi-

ence, type of extraction, tobacco use, oral contracep-

tive 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 popu-

lation 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 contra-

ceptives [5,6]. Surgical experience seems to be inver-

sely 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 inexperi-

enced 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 tetracy-

cline 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 la-

vage 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 man-

dibular 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 anti-

biotics 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 bleed-

ing beyond the postoperative window for clot forma-

tion (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].

S.M. Susarla et al. / Oral Maxillofacial Surg Clin N Am 15 (2003) 177–186178

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 anti-

coagulant and antiplatelet medications (ASA, Cou-

madin, Plavix) are essential. Of the predisposing risk

factors reported, the most important is the level of

the impaction and its proximity to the neurovascu-

lar 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 fra-

gility 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 compli-

cations after third molar surgery. During the preop-

erative consultation, it is imperative that the surgeon

inquire about any past surgeries and the occurrence of

associated bleeding complications. Any family his-

tory of bleeding abnormalities should be elicited. Ex-

cessive bleeding with loss of deciduous teeth and, in

women, a history of menorrhagia, can be suggestive

of an underlying coagulopathy. Intraoperatively, care-

ful soft tissue management and local measures can

control and prevent most bleeding problems. Hemor-

rhage that cannot be controlled with local measures is

rare. In such isolated cases, interventional radiology

with selective embolization or proximal vessel iden-

tification and ligation may be required [29].

Wound healing problems

Risk factors for poor wound healing have been

identified. A 1993 workshop of the American Asso-

ciation of Oral and Maxillofacial Surgeons (AAOMS)

identified the following patient risk factors: patho-

genic accumulation and periodontal compromise ad-

jacent 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 fol-

lowing 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 remov-

al. Treatment should include a standard approach of

reduction and stabilization using intermaxillary fixa-

tion 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 pe-

riphery of the operating field often is able to anticipate

possible damage and take action to prevent its occur-

rence. 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 inadver-

tently, the most common course of action is reposi-

tioning 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].

S.M. Susarla et al. / Oral Maxillofacial Surg Clin N Am 15 (2003) 177–186 179

Fig. 2. Panoramic radiograph after reduction and rigid internal fixation of the mandible fracture.

Fig. 1. Postoperative panoramic radiograph displaying a displaced right mandibular angle fracture in the line of a recently

removed lower third molar.


Periodontal defects

Periodontal defects after third molar surgery often

can be anticipated before surgery based on the

patient’s 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 extrac-

tions unless pathologic indications necessitate such

surgery [45].

Oroantral communication and fistula formation

Occasionally, the removal of maxillary third mo-

lars results in a communication between the oral cav-

ity 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 sinusi-

tis 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 man-

agement. Patients should be instructed not to engage

in activities that rapidly change the pressure equilib-

rium 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 deconges-

tants. For larger fistulae (� 7 mm in diameter) and for

patients with a history of secondary chronic sinusitis,

surgical intervention, including sinus debridement and

drainage, polypectomy, and closure by flap devel-

opment, are recommended. Antibiotic and deconges-

tant 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 dis-

placement 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 postsurgi-

cal 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 perma-

nent 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 sig-

nificant high-risk radiologic signs include a narrow-

ing or deviation of the canal, a loss of the canal

cortical outline, and increased radiolucency over the

root [52]. Although these features provide prelim-

inary 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 consid-

erably lower than for inferior alveolar nerve injury


and ranges from 0.02% to 0.06%. In the presence of

injury, however, spontaneous recovery is less com-

mon [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: neuro-

praxia, 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. Neuro-

tmesis 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 dys-

function (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 di-

rection proprioception, two-point discrimination, use

of sequential von Frey’s hairs, temperature sensation,

and detection of sharp and dull objects. A subjective

evaluation of taste also should be documented. Dia-

gram 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 thor-

oughly [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 mesioan-

gular 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

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.


onset of dysesthesias. There is no conclusive evi-

dence 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 inju-

ries remains a combination of preoperative assess-

ment of radiographs, discussion with patients about

the possibility of injury, and a cautious approach to

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.

Fig. 5. Close-up image of intentionally retained roots after crown sectioning and enucleation of pericoronal dentigerous cyst.


‘‘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 three-

dimensional 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 poten-

tial 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 treat-

ment 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.

Summary

Recent literature and long-term experience have

improved the understanding of the origin and treat-

ment 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 eluci-

dated. Until such a time when there is a concrete

and unambiguous literature regarding such complica-

tions, however, the strongest asset at the surgeon’s

disposal remains open lines of communication and

the timely transfer of information to patients. Early

recognition and appropriate management of compli-

cations as they arise hopefully will minimize perma-

nent and disabling consequences.

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