Removal Of Lower Third Molars Research Articles

Changes in life quality following third molar surgery – the immediate postoperative period

This study describes patients' perceptions of changes in oral health related quality of life (OHQOL) in the early postoperative period following third molar surgery. One hundred patients were enrolled in a prospective cohort study of the surgical removal of lower third molars under local anaesthetic. Two specific oral health related quality of life measures, OHIP-14 and OHQoLUK, were administered to the study group prior to surgery. Standardized surgical and analgesic protocols were followed. Patients kept a diary of changes in life quality each postoperative day (POD) for 7 days, completing both OHIP-14 and OHQoLUK daily. Both oral health related quality of life measures identified a significant deterioration in quality of life on POD1 (P<0.01) and this remained evident on POD2 (P<0.01), POD3 (P<0.01), POD4 (P<0.01) and POD5 (P<0.05). By POD6 and POD7 there was no significant difference in quality of life compared with preoperative status (P>0.05). Deterioration in life quality over the study period was associated with postoperative clinical findings (P<0.05): swelling and trismus. The study concludes that there is a significant deterioration in oral health related quality of life in the immediate postoperative period following third molar surgery; particularly during the first five days. This is associated with postoperative clinical findings. This has implication for patients deciding on third molar surgery and informed consent.

Third molar surgery and postoperative pain relief

Objectives This study describes patients' perceptions of changes in oral health related quality of life (OHQOL) in the early postoperative period following third molar surgery. Methods One hundred patients were enrolled in a prospective cohort study of the surgical removal of lower third molars under local anaesthetic. Two specific oral health related quality of life measures, OHIP-14 and OHQoLUK Results Both oral health related quality of life measures identified a significant deterioration in quality of life on POD1 (P 0.05). Deterioration in life quality over the study period was associated with postoperative clinical findings (P<0.05): swelling and trismus. Conclusion The study concludes that there is a significant deterioration in oral health related quality of life in the immediate postoperative period following third molar surgery; particularly during the first five days. This is associated with postoperative clinical findings. This has implication for patients deciding on third molar surgery and informed consent.

Links between anaesthetic modality and nerve damage during lower third molar surgery

Objective To investigate the relationships between eruption status, gender, social class, grade of operator, anaesthetic modality and nerve damage during third molar surgery. Design Two centre prospective longitudinal study. Setting The department of oral and maxillofacial surgery, University Hospital Birmingham NHS Trust and oral surgery outpatient clinics at Birmingham Dental Hospital. Subjects A total of 391 patients had surgical removal of lower third molars. Sensory disturbance was recorded at one week post operatively. Patients with altered sensation were followed up at one month, three months and six months following surgery. Results 614 lower third molars in 391 patients were removed. Forty-six procedures (7.5%) were associated with altered sensation at one week with three procedures (0.49%) showing persistent symptoms at six months. Of these 46 nerve injuries, 26 (4.23%) involved the lingual nerve and 20 (3.25%) the inferior dental nerve (IDN). All three persistent sensations were IDN related. A logistic regression model found that the use of a lingual retractor χ2=11.559, p=0.003 was more significant than eruption status χ2=12.935, p=0.007. There was no significant relationship between anaesthetic modality, age, social class, sex and seniority of operator. Conclusions There was no link between the choices of local or general anaesthesia and nerve damage during lower third molar removal when difficulty of surgery was taken into account.

Relationship between type of anaesthetic and nerve damage in lower third molar surgery

Objective To investigate the relationships between eruption status, gender, social class, grade of operator, anaesthetic modality and nerve damage during third molar surgery. Design Two centre prospective longitudinal study. Setting The department of oral and maxillofacial surgery, University Hospital Birmingham NHS Trust and oral surgery outpatient clinics at Birmingham Dental Hospital. Subjects A total of 391 patients had surgical removal of lower third molars. Sensory disturbance was recorded at one week post operatively. Patients with altered sensation were followed up at one month, three months and six months following surgery. Results 614 lower third molars in 391 patients were removed. Forty-six procedures (7.5%) were associated with altered sensation at one week with three procedures (0.49%) showing persistent symptoms at six months. Of these 46 nerve injuries, 26 (4.23%) involved the lingual nerve and 20 (3.25%) the inferior dental nerve (IDN). All three persistent sensations were IDN related. A logistic regression model found that the use of a lingual retractor χ2=11.559, p=0.003 was more significant than eruption status χ2=12.935, p=0.007. There was no significant relationship between anaesthetic modality, age, social class, sex and seniority of operator. Conclusions There was no link between the choices of local or general anaesthesia and nerve damage during lower third molar removal when difficulty of surgery was taken into account.

Links between anaesthetic modality and nerve damage during lower third molar surgery.

To investigate the relationships between eruption status, gender, social class, grade of operator, anaesthetic modality and nerve damage during third molar surgery. Two centre prospective longitudinal study. The department of oral and maxillofacial surgery, University Hospital Birmingham NHS Trust and oral surgery outpatient clinics at Birmingham Dental Hospital. A total of 391 patients had surgical removal of lower third molars. Sensory disturbance was recorded at one week post operatively. Patients with altered sensation were followed up at one month, three months and six months following surgery. 614 lower third molars in 391 patients were removed. Forty-six procedures (7.5%) were associated with altered sensation at one week with three procedures (0.49%) showing persistent symptoms at six months. Of these 46 nerve injuries, 26 (4.23%) involved the lingual nerve and 20 (3.25%) the inferior dental nerve (IDN). All three persistent sensations were IDN related. A logistic regression model found that the use ofa lingual retractor chi2 = 11.559, p = 0.003 was more significant than eruption status chi2 = 12.935, p = 0.007. There was no significant relationship between anaesthetic modality, age, social class, sex and seniority of operator. There was no link between the choices of local or general anaesthesia and nerve damage during lower third molar removal when difficulty of surgery was taken into account.

In reply

We would like to thank Dr Üçok for his careful reading of our article. The omission of the article he cites in the letter demonstrates one of the limitations of systematic reviews. Computer database searches are used to identify articles for inclusion in these reviews. Because we were evaluating lingual nerve and third molars, these words, as well as the other combinations outlined in our review, were linked together for the search. If the individual indexing an article for the computer database does not include both terms, the article will not be found when searching for the combination of words. In fact, we repeated the search using the combinations of words and did not find the article. The article is cited when morbidity and third molars are used in combination. Because the combination of morbidity and third molars produced so many citations of unrelated articles, we decided not to use the combination. It is not surprising that the article was not found through use of our search methods. The title of the manuscript does not include comments related to sensory impairment, and the abstract does not report the incidence of sensory impairment associated with the 2 surgical techniques used to remove the third molars. In the article, the only mention of sensory function is in the last part of the last sentence in “Results,” which states, “… and no one experienced sensory impairment of the inferior alveolar or lingual nerves.” Although the article was missed, the results from the 20 patients who participated in the study do not alter the outcome of our systematic review. Temporary numbness of the lingual nerve caused by using the lingual split technique would be 9.54% instead of 9.63%, and permanent numbness would remain the same, 0.14%. Temporary numbness of the lingual nerve caused by using the buccal approach with a retractor would be 6.30% instead of 6.35%, and permanent numbness would be 0.62% instead of 0.63%. We certainly apologize for missing Dr Üçok's article and thank him for carefully reading our review and letting us know about our omission. Even though computer database searches sometimes miss an article, it is the best method currently available to systematically review the literature and find evidence to support clinical decisions. Dr Üçok's letter also gave us an opportunity to find 2 recent articles that were published after the submission of our systematic review. Gargallo-Albiol et al 1 Gargallo-Albiol Buenechea-Imaz R Gay-Escoda C. Lingual nerve protection during surgical removal of lower third molars. Int J Oral Maxillofac Surg. 2000; 29: 268-271 Abstract Full Text PDF PubMed Google Scholar reported the results of a randomized controlled trial comparing protection of the lingual nerve with and without a lingual retractor. This study meets our inclusion criteria for review and included the extraction of 300 third molars. These investigators did not find a significant difference in temporary numbness to the lingual nerve with and without the lingual retractor and no patients had permanent numbness. Adding these data to our results did not change the results of our review. The investigators found that 3 patients had numbness with the retractor and 1 patient had numbness without the retractor. A second study 2 Valmaseda-Castellon E Berini-Aytes L Gay-Escoda C. Lingual nerve damage after third lower molar surgical extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000; 90: 567-573 Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar reported in this Journal found greater lingual nerve damage after third molar removal with a lingual retractor than without the retractor. This was a prospective clinical study involving consecutive patients having third molars removed by various surgeons. The decision to use the lingual retractor was based on the surgeon's preference. This study does not meet our inclusion criteria and would not have been considered for detailed analysis. These 2 articles demonstrate that systematic reviews must not be based on a particular outcome but on the validity of the study. The systematic review establishes inclusion and exclusion criteria to identify the “best” evidence available. Sometimes the studies available for review are inadequate to make a definite conclusion. The current evidence for the use of a lingual retractor when removing lower third molars indicates that there is greater tendency for temporary numbness of the lingual nerve. It is unclear whether the retractor protects the lingual nerve from permanent numbness, because permanent numbness is very low for extraction done with and without the lingual retractor.

Risk and prevention of lesions of the lingual nerve in wisdom tooth osteotomy. Analysis of the literature and faculty opinion in maxillofacial surgery in German-speaking countries

Disturbance of lingual nerve function is one of the relevant complications after surgical removal of lower third molars. In the literature, however, protective measures against this complication are not unanimously recommended. In order to find out the current opinion in terms of the state of the art in this field, a questionnaire was sent to the heads of 39 University Departments for Oral and Maxillofacial Surgery in Germany, Austria, and Switzerland. All of them responded. In 54% of the departments, a periosteal elevator or similar instrument is recommended for the protection of the lingual nerve in every instance, whereas in 8% of the departments this is not recommended. In the remaining departments, the decision about protective measures is made according to the individual anatomical situation. The literature review revealed insufficient data quality for a sound data-based decision on whether and when to use an instrument to protect the lingual nerve. In any case, the statistical risk of a temporary disturbance of the lingual nerve seems to be higher with use of the lingual split (0.5%-19.8%) than with the lateral osteomtomy technique (0%-1.9%). In contrast to widespread opinion, even in anatomically difficult cases, there seems to be no statistical advantage of the standardized use of a protective instrument either in respect to temporary or permanent nerve damage. Yet, a slight increase of temporary lesions seems to be documented when the instrument is used. According to the current literature data, the subperiosteal insertion of an instrument to protect the lingual nerve cannot be considered an essential standard procedure in each case.

Inferior alveolar nerve damage after lower third molar surgical extraction: A prospective study of 1117 surgical extractions

The purpose of this study was to determine the incidence of inferior alveolar nerve (IAN) damage after surgical removal of lower third molars, to identify the causes, and to construct a predictive model to assess the risk of IAN injury. We performed a nonrandomized forward prospective study of 946 consecutive outpatients subjected to surgical extraction of 1117 lower molars in the University of Barcelona Oral Surgery Department. Preoperative, intraoperative, and postoperative data were gathered, and suspected causal factors of IAN damage were identified by using nonparametric tests, the Pearson chi-square test, and the Fisher exact test. Logistic regression predicted the risk of IAN injury. Although only 1.3% of the extractions caused temporary nerve damage, 25% of the lesions were permanent. All of the following significantly increased the risk of IAN damage (P < .05): age, the radiologic relationship between the apices and the mandibular canal, deflection of the root when approaching the mandibular canal, distal ostectomy, the distance of the apices of the third molar to the mandibular canal, ostectomy, crown sectioning, pain during root luxation, primary closure of the wound, prolonged operating time, bleeding, exposure of the nerve, and postoperative ecchymosis. The first 4 factors were included in a predictive logit model. Patient age, ostectomy of the bone distal to the third molar, the radiologic relationship between the roots of the third molar and the mandibular canal, and deflection of the mandibular canal increased the risk of IAN damage. Older patients were at a higher risk for suffering permanent injuries.

Role of antimicrobials in third molar surgery: prospective, double blind,randomized, placebo-controlled clinical study

Aim: To test the efficacy of two dosing regimens of antimicrobial prophylaxis during the removal of impacted lower third molars. Design: Double blind, prospective, placebo-controlled trial. Setting: Teaching hospital, India. Subjects: 151 patients aged 19–36 having impacted lower third molars removed.Methods : Random allocation into three groups: placebo (n= 34), metronidazole 1g orally, 1 hour preoperatively (n= 44), or metronidazole 400mg orally eight hourly for 5 days postoperatively (n= 47). Patients were recalled on the sixth postoperative day for assessment of pain scores on the second and sixth days, swelling, differences in mouth opening between preoperative and the sixth postoperative day, and the state of the wound. Results: There were no significant differences in the outcome between the three groups (P= 0.09). Conclusion: Antimicrobial prophylaxis does not seem to reduce morbidity after removal of lower third molars.

Lingual nerve damage after third lower molar surgical extraction.

Our objectives were to establish the incidence of lingual nerve damage after surgical removal of lower third molars, to identify the causes of the damage, and to construct a predictive model to assess the risk of lingual nerve injury. We conducted a nonrandomized prospective study of 946 consecutive outpatients subjected to surgical extraction of 1117 lower molars in a university department of oral surgery. Preoperative, intraoperative, and postoperative data were gathered, and causal factors of lingual nerve damage were identified by using nonparametric tests and Pearson chi-square and Fisher exact tests. A prediction of lingual nerve injury risk was obtained by using logistic regression. Of the extractions, 2.0% caused temporary nerve damage, though no lesion lasted more than 13 weeks. Lingual flap retraction, vertical sectioning of the tooth, surgeon inexperience, lingual angulation of the tooth, and prolonged operating time significantly increased the risk of nerve damage (P <. 05). The first 3 factors were included in a predictive logistic regression model. Anatomical factors such as lingual angulation of the third molar, surgical maneuvers such as retraction of the lingual flap or vertical tooth sectioning, and surgeon inexperience all increase the risk of lingual nerve damage, although permanent lesions seem to be very rare.

Lingual nerve protection during surgical removal of lower third molars. A prospective randomised study

Lingual nerve protection during surgical removal of lower third molars. A prospective randomised study

Lingual nerve protection during surgical removal of lower third molars: A prospective randomised study

A prospective randomised study was designed to evaluate the efficacy of protecting the lingual nerve by subperiosteal insertion of a retractor in 300 patients. All operations were performed under local anaesthesia and only one molar was removed at a time. In one group, the lower third molar was removed with protection of the lingual nerve and in another group, without protection. Molars which did not need to be sectioned were excluded from the study. The position of the molar, the degree of surgical difficulty and patient gender and age were also recorded. The results indicate 1.33% incidence of temporary lingual nerve dysaesthesia — this being low in comparison with other studies. No permanent disturbances were found. The intergroup percentage difference was not significant. It is suggested that routine application of a lingual protecting instrument during surgical removal of a third molar is not necessary in the hands of an experienced surgeon.

Lingual nerve protection during the removal of lower third molars not necessary

Objective: To evaluate the efficacy of lingual flap retraction in order to prevent lingual nerve injury during the removal of lower third molars.Design: Prospective randomised trial involving two surgeons.Intervention Intervention surgical removal of lower third molars with or without protection of the lingual nerve by sub-periosteal insertion of a retractor.Outcome Outcome measures verbal and sensory testing 1 week after surgery.Results: Only four cases of sensory disturbance (1.33%) were noted, all of which were transitory. No significant difference between the two groups (see table).Conclusions: Routine use of lingual protection with a retractor is not necessary in the hands of an experienced surgeon.

Malpractice claims for permanent nerve injuries related to third molar removals

On the basis of the register of the Finnish Patient Insurance Association, the aim of this study was to examine malpractice claims for nerve injuries associated with third molar removals and determine whether they are concentrated among specialists, among less experienced dentists, or in certain geographic areas. During 1987-93 there were 139 claims for permanent sensory or motor disturbances related to removal of lower third molars in Finland. The lingual nerve was injured in 54% and the inferior alveolar nerve in 41% of the claims. In 91% of the cases the injury occurred in relation to surgical removal of the tooth and in 6% in relation to simple extraction. The claims were distributed among 123 dentists, of whom 78% were dental surgeons, 15% specialists in oral and maxillofacial surgery, and 7% other specialists. These figures represented 2% of the dental surgeons and 26% of the oral surgeons in Finland (P < 0.01). More than half the claims were associated with dentists with less than 10 years' experience. Claims originated more often from the eastern and northern (rural) areas of Finland than from urban areas (3.8 claims versus 2.4 claims per 100,000 inhabitants, P < 0.05). Compensation was paid to the patients in two-thirds of the cases, indicating that the dentists authorized to decide claims very often considered these injuries avoidable. Therefore, proper diagnosis, treatment planning, surgical techniques, and detailed patient information must be emphasized. In cases where risks are obvious, referral to an oral surgeon is recommended.

Surgical removal of lower third molars after computed tomography

The lateral arm flap is well established in microvascular reconstructive surgery for covering small and moderate-sized defects both of the extremities and in the head and neck region. In the last 3 years 25 patients underwent a lateral upper arm flap for primary repair of tumour related defects of the tongue (n=10), floor of the mouth (n=7), mandible (n=4), inner cheek (n=2), oropharynx (n=1) and lower lip (n=1). Defects extended from the anterior floor of the mouth to the oral tongue in three cases and in four cases the defect reached the pharyngeal tongue. Two flaps had neurovascular anastomoses between the posterior cutaneous nerve of the arm and the lingual nerve. In all patients the donor defect was closed primarily. Twenty four lateral upper arm flaps healed uneventfully although six patients developed severe alcoholic delirium. One flap was lost on the fourth postoperative day due to venous insufficiency. There were no significant complications at the donor site. At the time of this report 16 patients were taking a normal diet while nine patients were taking pureed food. Among the advantages of this flap are anatomically reliable vascular supply, its good aesthetic quality, and position of the donor site. Furthermore the posterior radial collateral artery is a nonessential vessel of the arm. The flap is also potentially sensate. Among the disadvantages are smaller vessels for microvascular anastomoses. In conclusion, we believe that for repair of moderate-sized defects of the maxillofacial area the lateral upper arm flap can be recommended as the first choice.

An investigation of the rationality of lower third molar removal, based on USA National Institutes of Health criteria.

The appropriateness of surgical removal of lower third molars was audited in relation to 500 consecutive patients referred to hospital for third molar management during 1993/4. The National Institutes of Health (NIH) criteria were used as the validating standard. Immediately after patients had been seen for treatment planning, research workers repeated history taking and clinical examination and recorded the treatment that was planned. Appropriateness of treatment planning was then assessed. A total of 95% of patients had bilateral and 5% had unilateral lower third molars (976 teeth in all); 69% were partially erupted, 35% unerupted and 5% fully erupted. There was a weak correlation between eruption status of bilateral third molars. The most frequent reason for removal of third molars (31%) was pericoronitis, though the next most frequent reason was that the contralateral tooth had been scheduled for removal under general anaesthesia. Allowing this as a legitimate reason for surgery, of 859 teeth scheduled for removal, 59% were justified according to NIH criteria. Some 169 (34%) of patients might have avoided surgery altogether if NIH criteria had been the basis for intervention and a further 147 (30%) could have been scheduled for removal of only one lower third molar. These findings suggest that criteria for removal other than NIH criteria are being applied. Further research is necessary to identify these.

Stereophotogrammetric and clinical evaluation of morbidity after removal of lower third molars by two different surgical techniques

Stereophotogrammetric and clinical evaluation of morbidity after removal of lower third molars by two different surgical techniques

Stereophotogrammetric and clinical evaluation of morbidity after removal of lower third molars by two different surgical techniques

Purpose: This study compared swelling, pain, and trismus after using the conventional buccal approach and the lingual split technique for the removal of impacted third molars. Materials and Methods: Twenty patients with a mean age of 21.5 years were included. Postoperative edema was followed stereophotogrammetrically for 48 hours by transferring photogrammetric data from three-dimensional profile views into orthographic maps. A visual analog scale was used for 6 days for determining pain. Mouth opening was measured on the 1st, 2nd, and 7th postoperative days. Results: Maximal swelling was noted in both groups on the second postoperative day. In both groups, maximal trismus was noted on the first postoperative day. Approximately 98% of the measurements of interincisal distances had returned to the preoperative values by the 7th day. There was no significnt difference in the pain intensity between the two groups on postoperative days 1 through 6. Swelling ( P = .88) and pain ( P = .12) were not significantly different in either groups. Trismus was found to be significantly less ( P = .03) in the lingual split group. Conclusion: Although swelling and pain were comparable in both groups, the amount of trismus was less with the lingual split technique. This may be an advantage of the latter technique.

A new method of assessment of clinical teaching: ROC analysis

Twenty-five clinical dental students with varying clinical experience were presented with case records consisting of a clinical history and a panoramic radiograph for 25 patients with bilateral lower third molars ('wisdom teeth'). The students were asked to indicate how certain they were that each lower third molar tooth needed removal using a 6-point rating scale. Immediately following the task, the students were presented with information on the indications for removal of lower third molars in the form of a lecture by a senior academic clinical teacher. One week later the students were asked to repeat the rating study, under the same conditions as before, using a further 25 clinical cases. Receiver operating characteristics (ROC) analysis, which provides a graphical and quantitative assessment of a group of observers' ability to detect need for treatment, was utilized to examine differences between junior and senior students and between the matched pre-training and post-training experiments. The ability of junior students to assign lower third molars for surgery was statistically no better than random selection of cases. Formal clinical teaching significantly improved this group's performance, but had no effect on the performance of senior students. Senior students were significantly better able correctly to assign lower third molars for surgical intervention than junior students. Therefore this study shows that clinical experience has a significantly greater influence on treatment-planning ability than formal teaching. ROC analysis is a useful tool for assessing the effectiveness of methods of undergraduate training.

A comparison of morbidity following the removal of lower third molars by the lingual split and surgical bur methods

Fifty-two consecutive healthy patients with bilateral, similarly impacted mandibular third molars were studied. For each patient, both third molars were removed at the same operation by the same experienced operator. On one side, the lingual split method by chisel was used; on the other, the buccal approach with surgical bur. Standard preoperative and postoperative drug regimens were used. Pain, facial swelling (visual analogue scales), and lingual and labial sensory disturbance were recorded for each side by the patients at home 6, 24, and 48 h and 7 days after surgery. Wound healing was assessed at 4 weeks. There were no statistically significant differences between methods in relation to pain, facial swelling, sensory loss, infection, or periodontal pocket depth distal to the second molar, although 2% of third molars removed by chisel had lingual sensory, disturbance at 7 days, as compared with 8% where burs had been used. There were no statistically significant differences between duration of procedures; mean operating time with burs was 8.28 min (range 4–15 min) and with chisels 7.57 min (range 4–15 min). This study provided no evidence of difference in either efficiency or outcome between two standard methods of removing lower third molars.