1100

Factors Associ ated wi th Tri smus

Severi ty Fol l owi ng I mpacted Lower
Thi rd Mol ar Surgery: A Prospecti ve Study
Ra'ed M A Al -Del ayme
1
, Mona Abdul hadee Al safi
2
,
Wasan A. Abi d Aun
3
, Awf Othman Kadeem
4
ABSTRACT:
Tr i smus a sever el y r estr i cted mouth openi ng after sur gi cal
extr acti on of l ower thi r d i s a pr obl em whi ch i s commonl y
encountered by the dental practi ti oners. Thi s i nterferes wi th
pati ents normal oral hygi ene and eati ng habi ts
OBJ ECTIVE: The purpose of thi s study was to i denti fy the ri sk
factors for tri smus after mandi bul ar thi rd mol ar surgery i n
di fferent post-operati ve ti mes and to assess the ri sk factors
associ ated wi th severi ty of tri smus
METHODS: I n thi s prospecti ve cohort study 159 consecuti ve
cases i n whi ch removal of i mpacted l ower thi rd mol ars were
eval uated. Fi ve groups of vari abl es have been studi ed wi th twenty
three subgroups and forty si x di vi si ons. I nteri nci sal di stance
measurements were carri ed out on 1st, 2nd, 5th and 7th days
postoperati vel y to measure the tri smus i n each ti me respecti vel y
RESULTS: The peak l evel of tri smus was noted on the fi rst post-
operati ve day and then started to subsi de gradual l y, the noti ced
ri sk factors were wi dth I I and I I I (p=0,000), depth B and C
(p=0,000), l i ngual fl ap retracti on (p=0,000), i ncrease di ffi cul ty of
surgi cal extracti on (p=0,000; P.E.S.0.341) and prol ong operati on
ti me (p=0,000).Other factors ei ther have not or have onl y a l i ttl e
si gni fi cant effect.
CONCLUSION: We have noti ced that there i s a l ot of factors
that affect the degree of post-operati ve tri smus, the degree of
di ffi cul ty of the surgi cal extracti on and prol ong surgi cal procedure
were the mai n ri sk factors for the tri smus i n al l post-operati ve
days due to i ncrease i n the amount of ti ssue trauma
Key words: l ower thi r d mol ar , sur gi cal extr acti on, post-
operati ve tri smus
ORI G I N AL RE S E ARCH
doi: 10.5866/2013.511100
1
Seni or Lecturer
4
Juni or
Oral and Maxi l l ofaci al Surgery Dept., Denti stry Dept.,
AL-Yarmuk Uni versi ty Col l ege, Baghdad, I raq.
2
Assi stant Prof
3
Assi stant Lecturer
Dean of Denti stry Dept., AL-Yarmuk Uni versi ty
Col l ege, Baghdad, I raq
Article Info:
Recei ved: October 12, 2012;
Revi ew Compl eted: November 12, 2012;
Accepted: December 13, 2012
Avai l abl e Onl i ne: March, 2013 (www.nacd.i n)
NAD, 2013 - Al l ri ghts reserved
Email for correspondence:
Raedmaxfax@yahoo.com
Quick Response Code
INTRODUCTION
The surgi cal extracti on of l ower thi rd mol ars i s the most frequent i nterventi on i n oral surgery fi el d
1
whi ch i s frequentl y associ ated wi th an unpl easant postoperati ve experi ence by the pati ents, referred to as
postoperati ve morbi di ty
2
the l i mi tati on i n mouth openi ng or tri smus i s one of the most common i mmedi ate
post-operati ve compl i cati on
3
Thi s i s due to a compl ex array of factors, majori ty of whi ch are rel ated to the
i nfl ammatory process
4
INDIAN JOURNAL OF DENTAL ADVANCEMENTS
Jour nal homepage: www. nacd. i n
Indian J Dent Adv 2013; 5(1): 1100-1106
1101
Sev er al factor s h av e been men ti on ed by
authors
5-7
that i nfl uence the occurrence of tri smus
i ncl udi ng age; gender ; medi cati ons; smok i ng;
previ ous i nfecti on; poor oral hygi ene; di ffi cul ty of
extr acti on; l ength of extr acti on; sur gi cal ti me;
techni que and surgeon experi ence
I n thi s pr ospecti ve study, the postoper ati ve
tr i smus associ ated wi th sur gi cal extr ac-ti on of
i mpacted mandi bul ar thi rd mol ars wi l l be measured
and eval uated i n di fferent ti mes and the predi cti ve
r i sk factor s wi th esti mati on of thei r r i sk degr ee
whi ch wi l l enabl e the surgeon to predi ct and counsel
hi gh r i sk pati ents i n or der to offer a pr eventi ve
strategy.
MATERIAL AND METHODS
Data Sampling and Criteria
The pr esent pr ospecti ve cohor t study whi ch
i nvesti gated 231 consecuti ve cases of r emoval of
i mpacted l ower thi rd mol ars i n 107 outpati ents wi th
the mean age of (21.545.41) years and range of (17-
29) years was performed by same surgeon i n Dental
Depar tment of Al Yar mouk Uni ver si ty Col l ege
between November 1, 2010 and Apri l e 31, 2012. The
i ncl usi on cri teri a i ncl uded heal thy i ndi vi dual s wi th
no sy stemi c di seases; Pati ents ar e not gi v en
pr eoper ati v e an ti mi cr obi al dr u gs or oth er
medi cati ons that mi ght i nfl uence heal i ng, onl y one
i mpacted tooth extr acted each vi si t and for al l
pr ocedur es, l ocal anesthesi a al one i s used. The
ex cl usi on cr i ter i a i ncl uded the l i ngual spl i ts
techni que and femal e pati ents who are pregnant or
l actati ng. The study desi gn was appr oved by the
Research and Ethi cs Commi ttees of Uni versi ty. Al l
pati ents wer e i nfor med as to the natur e of the
surgi cal and experi mental procedures, and i nformed
consent was obtai ned before surgery.
Study Variables
The vari abl es of the study are sets of vari abl es
suspected to be rel ated to compl i cati ons. These sets
of predi ctor vari abl es are di vi ded i nto fi ve groups
as shown i n (Tabl e 1):
1- Pati ent vari abl es i ncl uded sex, age
2- I n di cati on for r emov al i n cl u ded pai n ,
prophyl acti c, resorpti on of adjacent di stal root
of s econ d mol ar , or th odon ti c pu r pos ean d
associ ated pathol ogi cal l esi on.
3- Pr eoper ati ve condi ti ons var i abl es i ncl uded
smoki ng and oral contracepti ve.
4- Radi ographi cal vari abl es i n whi ch the Bel l and
Gr egor y
8
an d Wi n ter
9
r adi o-gr aph i cal
cl assi fi cati ons are used to document the posi ti on
of the i mpacted mandi bul ar thi rd mol ars. Then
these cl assi fi cati ons ar e used to pr edi ct the
sur gi cal di ffi cul ty and cl assi fi ed i nto: si mpl e,
moder ate and di ffi cul t i n addi ti on to the
assessment of roots numbers.
5- Oper ati ve-speci fi c var i abl es i ncl uded type of
fl ap (en v el op or tr i an gu l ar ), l i n gu al fl ap
retracti on, bone removal , tooth secti oni ng, and
the operati on ti me, whi ch i s wi th the mean of
22.714.12 mi nutes and range of 7.5-39 mi nutes
and i s cl assi fi ed i nto three groups (<17),(18-25)
and(>25) mi nutes.
Surgical Technique
Al l surgi cal procedures were performed i n the
same cl i ni c wi th si mi l ar equi pment by same surgeon.
The surgi cal fi el d and al l the surgi cal materi al are
steri l e wi th the same surgi cal assi stant i n al l the
cases. One l ower thi r d mol ar extr acted i n each
oper ati on wi th the pr otocol that i ncl ude l ocal
anesthesi a, A 1.8 mL of 2% l i docai ne hydrochl ori de
wi th 1:80,000 adrenal i ne sol uti on was deposi ted at
a rate of 1 mL/mi n, al l teeth were removed from a
buccal approach usi ng ei ther tri angul ar or envel op
fl ap. When i t necessar y to r ai se a l i ngual fl ap, a
Howarth peri osteal el evator i s used to protect the
l i ngual per i osteum and the l i ngual ti ssues. Bone
r emoval i s done wi th bur s i n the conventi onal
manner and, i f necessary, the tooth i s di vi ded wi th
burs before el evati on. The fl aps are sutured wi th a
4-0 si l k suture.
Postoperati ve i nstructi ons and prescri bed drugs
ar e ex pl ai n ed to th e pati en t. For th e fi r s t 5
pos toper ati v e day s al l pati en ts h av e gi v en
anti bi oti cs (amoxi ci l l i n 750 mg every 8 hours), drugs
for pati ent wi th pepti c ul cer (rani ti di ne 300 mg three
ti mes dai l y ) an d an an ti -i n fl ammator y dr u g
(i buprofen 600 mg every 8 hours for 4-5 days). And
a mouth r i nse (0.2% chl or hexi di nedi gl uconate) i s
performed every 12 hours for 15 days.
Postoperative Assessment
Pati ents have been tol d to contact the cl i ni c for
any postoperati ve probl em or i f certai n symptoms
Factors Associ ated wi th Tri smus Severi ty Ra'ed M A Al -Del ayme, et, al .
Indian J Dent Adv 2013; 5(1): 1100-1106
1102
occur, such as pai n that coul d not be rel i eved by the
pr escr i bed anal gesi cs or post-oper ati ve bl eedi ng.
There were no seri ous compl i cati on i n al l the cases.
Al l pati ents have been revi ewed on 1
st
, 2
nd
, 5
th
and
7
th
days postoper ati vel y. The sutur e mater i al i s
removed after one week.
Trismus Assessment and Measurements
A basel i ne measurement was carri ed out just
before the surgery and si mi l ar measurements were
car r i ed ou t on on 1
s t
, 2
nd
, 5
th
an d 7
th
day s
postoper ati vel y. A si ngl e pr ofessi onal oper ator ,
repeati ng the procedure three ti mes on each pati ent,
made the measurements usi ng a ri gi d pl asti c metri c
rul er. The average of measurements was then taken
(i n mm) and recorded.
Tr i s mu s was as s es s ed by meas u r i n g th e
di fferences i n mouth openi ng (i nteri nci sal di stance
preoperati vel y and on post-surgery.
The di fference between the postoperati ve and
pr eoper ati ve measur ements was cal cul ated to
measure the tri smus (mm) i n four di fferent ti mes
as shown i n (tabl e2).
Statistical Analysis
The data obtai ned are stati sti cal l y anal yzed by
SPSS (SPSS for wi ndows, ver si on 13, SPSS I nc.,
Chi cago, I L, USA), the One-way anal ysi s of vari ance
(ANOVA) tests al l ow to deter mi ne i f one gi ven
vari abl es has a si gni fi cant effect on postoperati ve
swel l i ng. The l evel of si gni fi cance i s set at (P) l ess
than. 01or . 05.Par ti al eta-squar ed i s used to
measures the strength of associ ati on and the effect
of si ze of vari abl es on postoperati ve swel l i ng. An
LSD Pai rwi se Compari son Test was appl i ed for each
of th e i n depen den t v ar i abl es wh i ch h av e a
si gni fi cant effect on postoper ati ve tr i smus. The
r esul ts wer e pr esented as the mean standar d
devi ati on and standard error of mean.
RESULTS
Post-Operative Trismus Evaluations
I nter i nci sal di stance measur ements wer e
car r i ed ou t on on 1
s t
, 2
nd
, 5
th
an d 7
th
day s
postoperati vel y to measure the tri smus i n each ti me
r especti vel y, we have found that i nter i nci sal
di stance fal l i n thr ee br oad gr oups as shown i n
(tabl e2). The peak l evel of post-operati ve tri smus i s
i n the fi rst 24 hours and the tri smus conti nues i n
rare cases ti l l the end of 7
th
post-operati ve day.
Risk Factors
Ther e i s no stati sti cal si gni fi cant di ffer ence
between pati ent vari abl es; i ndi cati on for removal
var i abl es and pr eoper ati ve condi ti ons except the
femal e gender whi ch has a si gni fi cant effect on the
postoperati ve tri smus on the 5
th
postoperati ve day
onl y as shown i n (tabl e3)
The most stati sti cs si gni fi cant radi ographi cal
v ar i abl es an d oper ati v e-s peci fi c v ar i abl es of
mu l ti v ar i ate an al y s i s on i n cr eas i n g th e
postoperati ve swel l i ng are shown i n (tabl e 3). The
oth er factor s h av e n o s tati s ti cal s i gn i fi can t
di fferences on the postoperati ve compl i cati ons. Eta
squared val ues i ndi cate that effect si ze of di ffi cul ti es
i n the 5
st
postoperati ve day on postoperati ve tri smus
whi ch was medi um whi l e al l other esti mated effect
si zes were rel ati vel y weak as shown i n (tabl e 3).
Compari sons test was appl i ed for each of the
i ndependent var i abl es whi ch have a si gni fi cant
effect on postoperati ve swel l i ng as shown i n (tabl e
4) to see the most stati sti cs si gni fi cant var i abl es
between sub groups. So the most hi ghl y si gni fi cant
ri sk factors wi th hi gh strengths of correl ati on i n al l
the post-operati ve ti mes as shown i n (tabl e3) are:
1. Wi dth: Cl ass I I and I I I i mpacti on
2. Depth: Level B, C i mpacti on
3. Di ffi cul ty: Moderate di ffi cul ty and very di ffi cul t
4. Li ngual fl ap retracti on
5. Operati on ti me: 18-25 and >25 mi nutes.
DISCUSSION:
The sur gi cal r emoval of l ower thi r d mol ar s
sur ger y i s mostl y char acter i zed by postoper ati ve
tri smus
10
whi ch i s usual l y caused by i nfl ammati on
wi thi n the muscl es of masti cati on l eadi ng to spasm
secondary to the rai si ng of a mucoperi osteal fl ap
11
Set off factor s have been suggested to be
contri buti ng to postoperati ve tri smus. Thi s arti cl e
deal s wi th thi s tri smus as objecti ve parameters for
measurement. An i nvesti gati on has been made to
i denti fy factor s that i nfl uence the occur r ence of
severi ty of tri smus.
I n thi s study the peak l evel of tri smus was noted
on the fi rst post-operati ve day and subsi ded by seven
days but i n some cases the tri smus sti l l i n mi nor
Factors Associ ated wi th Tri smus Severi ty Ra'ed M A Al -Del ayme, et, al .
Indian J Dent Adv 2013; 5(1): 1100-1106
1103
degree whi l e i n most pati ents i t was zero by day
fourteen. Thi s resul t i s i n l i ne wi th the fi ndi ngs of
Sandhuetal .
12
I n our observati on,the age appears to be have
no s i gni fi cant cor r el ati on wi th the degr ee of
postoper ati ve tr i smus, an obser vati on whi ch i s
compl etel y di ffer ent fr om that of other author s
observati ons
1, 6,13
whi l e the femal e i s found to be have
a si gni fi cant effect on tr i smus onl y on fi r st post-
operati ve week.
Regar di ng the i ndi cati ons of r emoval , i t has
been suggested by many authors that the presence
symptoms at the ti me of removal must be consi dered
to be a ri sk factor for postoperati ve compl i cati ons.
6
I n the present study; we have fai l ed to confi rm thi s
hypothesi s.
Smoki ng
14,15
and contr acepti ves
16
have been
shown to have a del eteri ous effect on the oral cavi ty
and have been associ ated wi th postoper ati ve
compl i cati ons after oral surgery. I n the Gi ovanni
etal study,
6
pati ents who smoke were found to have
a h i gh er r i s k for per cei v i n g mor e s ev er e
postoperati ve tri smus. Thi s study fai l s to confi rm
th e h y poth es i s th at s mok i n g an d u s i n g or al
con tr acepti v es ar e a r i s k factor for s ev er e
postoperati ve tri smus.
The angul ati ons of i mpacted thi r d mol ar
i nevi tabl y has a si gni fi cant effect on postoperati ve
tr i smus extendi ng ti l l the 5
th
post-oper ati ve day,
wi th a hi gher degr ee of tr i smus associ ated wi th
di stoangul ar and verti cal type of i mpacti on whereas
Bui et al
17
reported that mesi oangul ar i mpacti ons
were associ ated wi th more tri smus
The cl ass I I and I I I posi ti on and i n l evel B and
C when compar ed wi th cl ass I and i n l evel A of
i mpacti ons i n addi ti on to the vi si bi l i ty of i nferi or
al veol ar nerve i n thi s study have been shown to be
associ ated wi th a hi gher degree of tri smus i n al l post
portati ve days(p=0,000). And thi s observati on i s i n
agreement wi th other studi es
7, 17, 18
As a resul t of the sever angul ati ons, l ack of space
and deepl y seated wi sdom a hi ghl y stati sti cal l y
si gni fi cant di fference i n tri smus was eval uated wi th
moderate and very di ffi cul t surgi cal extracti on i n
al l post-oper ati ve days speci al l y i n the fi r st pot
operati ve day(p=0,000 - P.E.S.0.341). Thi s i s due to
a si gni fi cant degree of ti ssue trauma that causes an
i nfl ammator y r eacti on whi ch l ater wi l l pr oduce
tri smus
19-22
I n our seri es we have recorded greater tri smus
an d s tati s ti cal l y s i gn i fi can t di ffer en ces wi th
tr i angul ar fl ap i n fi r st and second post-oper ati ve
days. However, the resul ts of Ki rk et al
23
showed
that the fl ap desi gn di d not adversel y affect pati ents
i n ter ms of postoper ati ve tr i smus, On the other
hand, l i ngual fl ap r etr acti on has hi gh si gni fi cant
associ ati ons (p=0,000) wi th tri smus i n al l the post-
operati ve days and thi s observati ons i s confi rmed
by other studi es
6,18,24
The bone removal and tooth secti oni ng has a
hi gh si gni fi cant correl ati on wi th the tri smus i n the
fi rst and second post-operati ve day wi th extended
effect to the end of the 5
th
postoperati ve day because
i t produces a si gni fi cant degree of trauma to the bony
str uctur es, potenti al l y r esul ti ng i n a si gni fi cant
i nfl ammatory reacti on
18, 20, 24
The resul t confi rms that the overal l l ength of
the sur gi cal pr ocedur es i s shown to be a r el i abl e
measure of tri smus, and thi s fi ndi ng i s asserted i n
many ar ti cl es
1, 18, 20, 25
whi ch confi r m that the
associ ati on of durati on of surgery and postoperati ve
tri smus was strongl y and si gni fi cantl y correl ated
(p=0,000) i n al l postoperati ve ti mes observati on.
Ther e was a l ot of ar ti cl es publ i shed on the
rel ati onshi p between the experti se of the surgeon
and postoperati ve tri smus
6, 18, 25, 26
but our study have
fai l ed to show any rel ati onshi p becauseal l the cases
done bt the same surgeon.
CONCLUSION
As a summary of our resul t, we have found that
the peak l evel of tri smus was noted on the fi rst post-
operati ve day and then started to subsi de gradual l y.
We have noti ced that there i s a l ot of factors that
affect the degr ee of post-oper ati ve tr i smus, the
degree of di ffi cul ty of the surgi cal extracti on and
pr ol ong sur gi cal pr ocedur e wer e the mai n r i sk
factors for the tri smus i n al l post-operati ve days due
to i ncrease i n the amount of ti ssue trauma
Acknowledgements
We hereby acknowl edge Prof. Dr. Al i Zal aan,
Dean of Al Yarmouk Uni versi ty Col l ege for hi s great
support towards the success of thi s study,
Conflicts of interest
The author deni es any confl i cts of i nter est
rel ated to thi s study
Factors Associ ated wi th Tri smus Severi ty Ra'ed M A Al -Del ayme, et, al .
Indian J Dent Adv 2013; 5(1): 1100-1106
1104
REFRENCESS
1. Gr azi ani F., DAi uto F., Ardui no P. G., Tonel l i M., Gabri el e
M. Per i oper ati ve dexamethasone r educes post-sur gi cal
sequel ae of wi sdom tooth removal . A spl i tmouth randomi zed
doubl e-masked cl i ni cal tri al . I nt. J. Oral Maxi l l ofac. Surg.
2006; 35: 241-246.
2. Bel l o S. A., Abayomi A. Ol ai tan, Aki nol a L. Ladei nde, A
Randomi zed Compari son of the Effectof Parti al and Total
Wound Cl osureTechni ques on Postoperati ve Morbi di tyAfter
Mandi bul ar Thi rd Mol ar Surgery Ameri can Associ ati on of
Or al and Maxi l l ofaci al Sur geons J Or al Maxi l l ofac Sur g
2011;69:24-30.
3. Bui C. H., Edward B. S., Thomas B. D., Types, Frequenci es,
and Ri sk Factor s for Compl i cati ons After Thi r d Mol ar
Extracti on Ameri can Associ ati on of Oral and Maxi l l ofaci al
Surgeons J Oral Maxi l l ofac Surg 2003;61:1379-1389.
4. Satl ms T., Arpac E., Gker K., Assessment of Combi ned
Local Anesthesi a and Ketami ne for Pai n,Swel l i ng, and
Tri smus After Surgi cal Extracti on of Thi rd Mol ars Ameri can
Associ ati on of Or al and Maxi l l ofaci al Sur geons J Or al
Maxi l l ofac Surg 2009; 67:1206-1210.
5. Babatunde O. B., Jel i l i A. A., Wasi u L. A., Aki nol a L. L.,
Godwi n T. A. Mobol anl e O. Effects of co-admi ni ster ed
dexamethasone and di cl ofenacpotassi um on pai n, swel l i ng
and tr i smus fol l owi ng thi r d mol ar sur ger y Head & Face
Medi ci ne 2005, 1:11
6. Gr os s i GB, Mai or an a C, Gar r amon e RA.: As s es s i n g
postoper ati ve di scomfor t after thi r d mol ar sur ger y: A
prospecti ve study. J Oral Maxi l l ofac Surg 2007; 65:901,
7. Ki rk G. I nfl uence of two di fferent fl ap desi gns on i nci dence
of pai n, swel l i ng, tri smus, and al veol ar ostei ti s i n the week
fol l owi ng thi r d mol ar sur ger y Or al Sur g Or al Med Or al
Pathol Oral Radi ol Endod 2007;104:1-6.
8. Pel l GJ, Gregory GT. I mpacted mandi bul ar thi rd mol ars:
cl assi fi cati on and modi fi ed techni que for r emoval Dent
Di g1933; 39:330-338
9. Wi nter GB. Pr i nci pl es of exodonti as as appl i ed to the
i mpacted mandi bul ar thi rd mol ar. St Loui s (MO). Ameri can
Medi cal Book. Co; 1926
10. Fi l ho JRL, Maurette PE, Al l ai s M, Coti nho M, Fernandes
C. Cl i ni cal compar ati ve study of the effecti veness of two
dosages of Dexamethasone to control postoperati ve swel l i ng,
tri smus and pai n after the surgi cal extracti on of mandi bul ar
i mpacted thi rd mol ars. Med Oral Patol Oral Ci r Bucal . 2008;
13(2):E129-32.
11. Yuasa H, Kawai T, Sugi ua M. Cl assi fi cati on of sur gi cal
di ffi cul ty i n extr acti ng i mpacted thi r d mol ar s. Br J Oral
Maxillofac Surg 2002; 40:2631.
12. Sandhu A, Sandhu S., Kaur T.: Compari son of two di fferent
fl ap desi gns i n the surgi cal removal of bi l ateral i mpacted
mandi bul ar thi rd mol ars. I nt. J. Oral Maxi l l ofac. Surg. 2010;
39: 1091-1096.
13. Sato FR. Shor t-ter m outcome of postoper ati ve pati ent
recovery percepti on after surgi cal removal of thi rd mol ars
J Oral Maxi l l ofacSurg 2009; 5:1083.
14. Al -Bel asy FA: The r el ati onshi p of Shi sha (water pi pe)
smoki ng to postextracti on dry socket. J Oral Maxi l l ofac Surg
2004;62:10,
15. Bol ego C, Pol i A, Paol etti R: Smok i n g an d gen der .
Cardi ovasc Res 2002;53:568
16. Gar ci a AG, Gr an a PM, Sampedr o FG, et al : Or al
contracepti ve and compl i cati on i n thi rd mol ar surgery. Br
Dent J 2003; 194:453.
17. Bui CH, Sel di n EB, Dodson B: Types, frequenci es, and ri sk
factors for compl i cati ons after thi rd mol ar extracti on. J Oral
Maxi l l ofac Surg 2003;61:1379
18. Baqai n Z. H.,, Abu Karaky A., Sawai r F.,, Khai sat A., and
Raj ab L.., Fr equency Esti mates and Ri sk Factor s for
Pos toper ati v e Mor bi di ty After Th i r d Remov al Mol ar
Removal : A Prospecti ve Cohort Study J Oral Maxi l l ofacSurg
2008; 66:2276-2283.
19. Othman R. I mpacted mandi bul ar thi r d mol ar s among
pati ents attendi ng Hospi tal Uni ver si ti Sai ns Mal aysi a
Archi ves of Orofaci al Sci ences 2009; 4(1): 7-12
20. Al -Khateeb T. H., Nusai r Y.: Effect of the proteol yti c enzyme
ser r apeptase on swel l i ng,pai n and tr i smus after sur gi cal
ex tr acti on of man di bu l ar th i r d mol ar s . I n t. J .
Oral Maxi l l ofac. Surg. 2008; 37: 264-268
21. Sri ni vas M. Susarl a, BS, Bart F. Bl aeser, Dani el Magal ni ck,
Thi r d mol ar sur ger y and associ ated compl i cati ons Or al
Maxi l l ofaci al Surg 2003;Cl i n N Am 15, 177-18
22. Dh ar n ai P.J. AND Jon ai del O. Tr i s mu s : Aeti ol ogy ,
Di fferenti al Di agnosi s and Treatment Dent Update 2002; 29:
88-94
23. Ki r k DG, Li ston PN, Tong DC, et al : I nfl uence of two
di fferent fl ap desi gns on i nci dence of pai n, swel l i ng, tri smus,
and al veol ar ostei ti s i n the week fol l owi ng thi r d mol ar
surgery. Oral Surg Oral Med Oral Pathol Oral Radi ol Endod
2007;4:1
24. Ki m JC, Choi SS, Wang SJ, et al : Mi nor compl i cati ons after
mandi bul ar thi r d mol ar sur ger y: Type, i nci dence, and
possi bl e preventi on. Oral Surg Oral Med Oral Pathol Oral
Radi ol Endod 2006;102:e4,
25. Chuang S., Perrott D. H., Dodson Th. B. Age as a Ri sk Factor
for Th i r d Mol ar Su r ger y Compl i cati on s Amer i can
Associ ati on of Or al and Maxi l l ofaci al Sur geons J Or al
Maxi l l ofac Surg 2007;65:1685-1692.
26. Bl on deau F., Dan i el N.G... Ex tr acti on of i mpacted
mandi bul ar thi r d mol ar s: postoper ati ve compl i cati ons
andthei r ri sk factors J. Canad. Dent. Assoc. 2007; 73: 325-
329.
Factors Associ ated wi th Tri smus Severi ty Ra'ed M A Al -Del ayme, et, al .
Indian J Dent Adv 2013; 5(1): 1100-1106
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Factors Associ ated wi th Tri smus Severi ty Ra'ed M A Al -Del ayme, et, al .
Table 1. Study variables
Variable N(%) Variable N(%)
Mal e 147(63.6) Tri angul ar fl ap 154 (66.6)
Femal e 84(36.3) Envel op fl ap 77 (33.3)
Age mean 21.545.41 Wi th l i ngual fl ap retracti on 36 (15.5)
Age Range (17-29) Wi thout l i ngual fl ap retracti on 195 (84.4)
Pai n 72 (31.1) Wi th bone removal 182 (78.7)
Prophyl acti c 61 (26.4) Wi thout bone removal 49 (21.2)
Orthodonti c purpose 46 (19.9) Wi th tooth Secti oni ng 149 (64.5)
Associ ated pathol ogi cal l esi on 28 (12.1) Wi thout tooth Secti oni ng 82 (35.4)
Resorpti on of adjacent di stal 24 (10.3) Mean of operati on durati on (22.714.12)
root of 2nd mol ar
Smoker 159 (68.8) Range of operati on durati on (7.5-39 mi nutes)
Non smoker 72 (31.1) <17 (mi nutes) 61 (26.48)
Wi th Contracepti ves 36( 15.5) 18-25 (mi nutes) 120 (51.9)
Wi thout contracepti ves 195 (84.4) >25 (mi nutes) 50 (21.6)
Mesi oangul ar 113 (48.9) Hori zontal 39 (16.8)
Verti cal 54 (23.3) Destoangul ar 25(10.8)
Cl ass I 136 (58.8) Si ngl e root 118 (51)
Cl ass I I 79 (34.1) Mul ti pl e roots 73 (31.6)
Cl ass I I I 16 (6.9) Uncompl eted roots 40 (17.3)
Level A 124 (53.6) Si mpl e accordi ng to 86 (37.2)
di ffi cul ti es i ndex
Level B 81 (53) Moderate accordi ng to 117 (50.6)
di ffi cul ti es i ndex
Level C 26 (11.2) Di ffi cul t accordi ng to 28 (12.1)
di ffi cul ti es i ndex
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Table (2) Trismus (mm) in different post-operative times
Preoperative 1st Post- 2nd Post- 5st Post- 7th Post-
value operative Day operative Day operative Day operative Day
30-39 mm 179 (77.4) 152 (65.8) 173 (74.8) 178 (77) 179 (77.4)
40-49 mm 46 (19.9) 56 (24.2) 51 (6.4) 47 (20.3) 46 (19.9)
>50 mm 6(2.5) 23(9.9) 7(3) 6(2.5) 6(2.5)
Mean 38.364.67 2.295.60 2.075.17 0.351.06 0.070.34
(00) (5.9 %) (5.3 %) (0.9 %) (0.1 %)
Stander Error 0.37 0.44 0.41 0.08 0.03
Mi ni mum 30 00 00 00 00
Maxi mum 53 32 28 6 2
Indian J Dent Adv 2013; 5(1): 1100-1106
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Factors Associ ated wi th Tri smus Severi ty Ra'ed M A Al -Del ayme, et, al .
Table (3) The relation between most statistics significant variables with the postoperative
trismus in different post-operative times
Variable 1st P.O. Day 2nd P.O. Day 5stP.O.Day 7th P.O. Day
Sig. P.E.S Sig. P.E.S. Sig. P.E.S. Sig. P.E.S.
Gender 0.223 - 0.251 - 0.032 0.029 0.161 -
* W
Angul ati ons 0.019 0.062 0.006 0.077 0.004 0.083 0.360 -
* W ** W ** W
Wi dth 0.000 0.164 0.000 0.177 0.000 0.180 0.000 0.195
** W ** W ** W ** W
Depth 0.000 0.158 0.000 0.176 0.000 0.157 0.001 0.086
** W ** W ** W ** W
Di ffi cul ty 0.000 0.233 0.000 0.257 0.000 0.241 0.000 0.235
** W ** W ** M ** W
Fl ap Type 0.044 0.026 0.049 0.025 0.103 - 0.318 -
* W * W
Li ngual Fl ap 0.000 0.540 0.000 0.512 0.000 0.435 0.000 0.220
Retr acti on ** W ** W ** W ** W
Bone Removal 0.006 0.047 0.007 0.045 0.026 0.031 0.173 -
** W ** W * W
Tooth Secti oni ng 0.017 0.036 0.018 0.035 0.067 - 0.633 -
* W * W
Operati on Ti me 0.000 0.149 0.000 0.176 0.000 0.153 0.000 0.146
** W ** W ** W ** W
Abbrevi ati ons: P.O., postoperati ve; Si g., Si gni fi cant; P.E.S., Parti al Eta Squared; W., weak; M., medi um; *: Si gni fi cant
at (p-val ue < 0.05), **: Si gni fi cant at (p-val ue< 0.01)
Table (4) Comparisons Test was applied to each of the independent variables which have a
significant effect on postoperative trismus in different post-operative times
Variable 1st 2nd 5st 7th
P.O. Day P.O. Day P.O. Day P.O. Day
Angulations
Mesi oangul ar Hor i zontal 0.874 0.728 0.694 -
Ver ti cal 0.786 0.866 0.663 -
Destoangul ar 0.003** 0.001** 0.001** -
Hor i zontal Ver ti cal 0.710 0.663 0.948 -
Destoangul ar 0.011* 0.006** 0.001** -
Ver ti cal Destoangul ar 0.006** 0.003** 0.002** -
Width
I I I 0.343 0.405 0.680 1.000
I I I 0.000** 0.000** 0.000** 0.000**
I I I I I 0.000** 0.000** 0.000** 0.000**
Depth
A B 0.063 0.035* 0.328 0.121
C 0.000** 0.000** 0.000** 0.000**
B C 0.000** 0.000** 0.000** 0.009**
Difficulty index
Very Di ffi cul t Moderate Di ffi cul ty 0.000** 0.000** 0.000** 0.000**
Mi ni mum Di ffi cul ty 0.000** 0.000** 0.000** 0.000**
Moderate Di ffi cul ty Mi ni mum Di ffi cul ty 0.689 0.574 0.689 1.000
Operation time
<25 18-25 0.402 0.232 0.772 0.715
>18 0.000** 0.000** 0.000** 0.000**
18-25 <25 0.000** 0.000** 0.000** 0.000**
Abbrevi ati ons: P.O., postoperati ve; *: Si gni fi cant at (p-val ue < 0.05); **. , Si gni fi cant at (p-val ue <0.01).
Indian J Dent Adv 2013; 5(1): 1100-1106