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ComplicationsDuringandAfterSurgicalRemovalofThirdMolarsOralHealthGroup

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ComplicationsDuringandAfterSurgicalRemoval
ofThirdMolars
June1,2013
byHansUlrichBrauer,DDS,DrMedDent,MARobertA.Green,DDS,MD,Msc,FRCD(C)BruceR.
Pynn,Ms
PrintEdition
June2013
Topics
Dentistry
OralSurgery

MoreFeatures
INTRODUCTION
Thirdmolarsurgeryisoneofthemostcommonproceduresperformedinoralandmaxillofacialsurgery
offices.16Nevertheless,thisprocedurerequiresaccurateplanningandsurgicalskills.Withsurgicalprocedures
ingeneral,complicationscanalwaysarise.Thereportedfrequenciesofcomplicationsafterthirdmolarremoval
arereportedbetween2.6percentand30.9percent.1Thespectrumofcomplicationsrangefromminorexpected
sequelaeofpostoperativepainandswelling,topermanentnervedamage,mandibularfractures,andlife
threateninginfections.Minorcomplicationsaregenerallydefinedascomplicationsthatcanrecoverwithoutany
furthertreatment.Majorcomplicationscanbedefinedascomplicationsthatneedfurthertreatmentandmay
resultinirreversibleconsequences.5,6Althoughimpactedthirdmolarsmayremainsymptomfreeindefinitely,
theymayberesponsibleforsignificantpathology.7Pain,pericoronitis,developmentofperiodontaldiseaseon
thesecondmolar,crownand/orrootresorptionofthesecondmolar,cariesinthirdorsecondmolarsandTMJ
symptomsareassociatedwithretainedthirdmolars.2Moresignificantpathologysuchasfascialspace
infections,spontaneousfractureofthemandible,andodontogeniccystsortumorsmayalsooccur.2
There are numerous recent studies, which identify risk factors for intraoperative and/or postoperative
complications.1,5,6,815Commonintraandpostoperativecomplicationsandsideeffectsassociatedwiththird
molar removal are summarized in Table 1. For the general dental practitioner, as well as the oral and
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maxillofacialsurgeon,itisimportanttobefamiliarwithallthepossiblecomplications.Thisimprovespatient
educationandleadstoearlyrecognitionandmanagement.Inthisreview,complicationsareconsideredrareor
unusualiftheincidenceiscommonlyquotedbelow1percent.Theaimofthissystematicreviewistoremindus
oftheunusualcomplicationsassociatedwiththirdmolarsurgery.
METHODANDMATERIALS
StudieswerefoundusingsystematicsearchesinMedlineandtheCochraneLibraryelectronicdatabases
between1990andthepresent.Additionally,handsearchingofkeytexts,references,andreviewsrelevanttothe
fieldwasperformed.Keywordsincludedthetermsthirdmolar,wisdomtooth,complications,unusual,
andrare.
Datawasincludedifthefollowingcriteriaweremet:
1.Thestudyhadtodealwithintraorpostoperativecomplicationsassociatedwiththeremovalofthirdmolars.
2.Thedateofpublishinghadtobebetween1990and2013.
3.ThetexthadtobepublishedinEnglishorGermanlanguage.
Inordertogatheralltheimportantstudies,thereferencesfromthefoundstudiesweredoublechecked.
RESULTS
Therearemanystudiesreviewingpermanentinferioralveolarandlingualnerveinjuriesandmandibular
fracturesduringandafterlowerthirdmolarremoval.Severalotherstudies/reportsincludeinflammatory
processes,unusualabscessformationsanddisplacementofteethindifferentspaces.Anoverviewisshownin
Table2.Allofthesecomplicationsareconsideredmajor.
Furthermore, there are single case reports that describe extreme events, such as asphyxial death caused by
postextractionhematoma,lifethreateninghemorrhage,benignparoxysmalpositionalvertigo,subcutaneousand
tissue space emphysema, subdural empyema, and herpes zoster syndrome. The reviewed case reports are
presentedinTable3.
Themainpatientageamongthecaseswas28(SD12.7)years.Inthemajorityofthecases,thecomplication
occurred after third molar removal of the lower jaw. A second surgical intervention was needed in nearly all
cases.Inordertofindthecauseofthecomplication,computertomography(CT)ormagneticresonanceimaging
(MRI) was need all of the cases. In the majority of the cases, the first surgical procedure was described as
complicatedandtheinterventionwasreportedasextensiveorlengthy.
DISCUSSION
Permanentnervedamage
Permanentinferioralveolarorlingualnervedamagesisextremelyrare,butingeneral,wellknownrisks
associatedwiththirdmolarsurgery.Injuryofthelingualortheinferioralveolarnervesduringremovaloflower
thirdmolarsisamongthemostcommoncausesoflitigationindentistry.16Acloseanatomicrelationship
betweenthesenervesandthethirdmolarplacesthematriskforinjury.Theincidenceoftheseextremelyrare
complicationsvaryamongthestudiesandaredifficulttobedeterminedexactlyduetothesmallstudy
populations.Theincidenceofpermanentinferioralveolarnervelesionsrangesfrom0percent17,18to0.9
percent19theusualacceptedrateisabout0.3percent.20,21Thecomplicationratefortemporarylingualnerve
damageisaround0.4percent22andforpermanentlingualnervedamage,itisevenlower.2,20
Mandibularfracture
Immediateorlatefractureofthemandibleisarareevent,butamajorcomplication.23Thereductionofbone
strengthmaybecausedbyphysiologicatrophy,osteoporosis,pathologicprocesses,orcanbesecondaryto
surgicalintervention.24Thereisnovaliddataontheincidenceofmandibularfracturesandtheriskfactorsare
notclearlyunderstood.24Libersaetal.,foundanincidenceof0.0049percent.25InastudybyArrigoni&
Lambrecht,3980thirdmolarremovalswereanalyzed.8Thisgroupdetectedacomplicationrateofabout0.29
percent.Thepeakincidenceoccursinpatientsover25years,withameanageof40years.2426Duetoa
greatermasticatoryforce,menmaybemorelikelytohavelatefractures.25Intraoperativefracturesmayoccur
withimproperinstrumentationandexcessiveforcetotheboneduringtoothremoval.Mostlatefracturesoccur
betweentwotofourweeksaftersurgeryduringmasticating.51,62
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Unusualinflammatoryprocessesandabscessformation
Inthereviewedcasereports,extensionsoftheinflammatoryprocessestoatypicalregionsofthebrainand
cervicalregionarediscussed.Inonecase,asubperiostealabscessoftheorbitappearedina57yearoldman
followingtheuneventfulextractionoftheleftmaxillarythirdmolar27whichmighthavebeencausedby
extensionofinfectionviathepterygopalatineandinfratemporalregionstotheinferiororbitalfissure.Another
grouppresentsasubduralempyemaandherpeszostersyndrome(Huntsyndrome).28Inthiscase,a21yearold
manhadallfourthirdmolarsremoved.Anabscessinvolvingtherightpterygomandibularandsubmasseteric
spacesandextendingtotheinfratemporalfossawasfound.Althoughantibiotictherapyanddrainagewas
initiated,hedevelopedseverefrontalheadacheandvomitingwithaGlasgowcomascoreof13.Magnetic
resonanceimaging(MRI)showedasubduralcollectionintherighttemporoparietalregion.Hehademergency
craniotomyandsubduraldrainage.28Burgessreportedacaseofepiduralabscessofa20yearoldwomanafter
extractionofawisdomtooth.29First,shewasdiagnosedwithamusculoskeletalnecksprainresultingfrom
postureduringtheoperation.Threedayslater,thepatientpresentedwithanincreasedrightsidedneckpainand
sensationalnumbnesstotherightarm.Ninedaysaftersurgery,anepiduralabscesstotherightsideofC4/C5
vertebraewasseenintheMRI29.Inanothercase,abrainabscessdevelopedafterremovaloftherightlower
thirdmolarofa26yearoldman.Heneededemergencyneurosurgeryandantibiotictreatmentforeight
weeks.30
Displacementofthirdmolarsandinstruments
Accidentaldisplacementofimpactedthirdmolars,eitherarootfragment,thecrown,ortheentiretooth,isnot
commonduringextraction,butisneverthelessawellrecognizedcomplicationthatisfrequentlymentionedin
theliterature.3133,58However,thereisonlylimitedinformationaboutitsincidenceandmanagement.
Displacementofmandibularteeth/rootsusuallyoccurswhenitislocatedlingually,orwhenthelingualcortical
plateisfenestratedandifsurgicaltechniqueispoor.32Whenarootfragmentdisappearsduringextraction,its
retrievalshouldnotbeattempted.Immediatereferraltoaspecialistshouldbearranged.34,35Upperthird
molarscanbedisplacedintotheinfratemporalfossa.38,39,52,56Furtherreportsdescribethirdmolar
displacementintothesubmandibularspace,33,38thesublingualspace,39,40,60thepterygomandibular
space,35,41thelateralpharyngealspace42,43orintothelateralcervicalarea.Inonecase,thesymptomsstarted
aftertwomonths.Thepatientexperiencedrecurrentinflammatoryswellingintherightsubmandibularspace.
Overaperiodof14months,thesamedentistsupervisedtreatmentwithantibiotics.Afterextensiveimaging
proceduresandsurgerythetoothwaslocatedbeneaththeplatysmamuscle.44Partsofdentalequipmentorburs
canalsobelostintheadjacenttissues.A35yearoldwomanhadseveretrismus,swelling,andpainthreeweeks
afterremovaloftooth48.A20mmlongdiamondburwasfoundinthesubmandibularspace.33
Furtherunusualcomplications
AirwaycompromisewasdescribedbyMoghadam&Caminiti.45A32yearoldmanexperiencedswellingof
thesoftpalateduetopostextractionhemorrhageafterhehadundergoneextractionofteeth18,38,and48athis
dentistsoffice.Computedtomographyrevealedahematomainthesubmandibularandlateralpharyngeal
spaceswhichresultedindeviationoftheoropharynxandconstrictionoftheairwayatthelevelofthe
oropharynx.Thepatientwasintubatedfortwodaysandwastreatedwithantibioticsandhighdosesteroids.45
Funayamaet.al.,46reportacaseofasphyxiationcausedbyapostextractionhematomaina71yearoldman.
Respiratoryarrestoccurred12hoursaftertreatment.Thehematomainvolvedthesubmandibular,lingualand
buccalspacesleadingtoseverenarrowingoftheoropharynx.Wassonet.al.,reportedacaseofsevere
hemorrhageduringtheremovalofanimpactedthirdmolarina60yearoldmalepatient.Over2Lofbloodloss
occurredpriortoobtainingcontrol,usingembolizationofthefacialandinferioralveolararteries.57Asingle
casereportbyGoshlasbyetal.,discussedthedevelopmentofarightsidedretrobulbarhemorrhageafterthe
removalofanimpactedmaxillaryrightthirdmolar.Theresultinghematomacausedrightperiorbitalswelling
andecchymosiswithevidenceofproptosis.Themaxillaryincisionwasextendedandthehematomawas
drainedandbleedingwascontrolled.Itwasbelievedthatabranchoftheposteriorsuperioralveolararterywas
injuredduringtheextractionandbleedingtrackedintotheorbitviatheinfraorbitalfissure.53Severe
intraoperativeorpostoperativehemorrhageisoneofthefewlifethreateningcomplicationsinwhichadentist
mayhavetoinitiatemanagement.45
Thoraciccomplicationsareveryrare,buthave been reported in the literature.47,48,49,55,61 Sekine et. al.,47
reportsonacaseofextensivesubcutaneousemphysemawithabilateralpneumothoraxduringremovalofthe
leftlowerthirdmolarina45yearoldman.Aswithmanycasesofemphysema,anairturbinedentalhandpiece
wasused.4749Recognitionofmediastinalemphysemafollowingsurgicalextractionisdifficultbecausethere
arenoabsoluteclinicalsymptomsandsigns.48,49

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Benignpositionalparoxysmalvertigowasdescribedinonecaseaftertheremovalofallthirdmolarteeth.50
CONCLUSION
Thirdmolarsurgeryisaverycommonprocedure,butisassociatedwithmanyattendantrisksand
complications.Fortunately,significantcomplicationsarerare,butneedtobediagnosedandmanagedearlyin
ordertoreducemorbidity,andperhaps,mortality.Forthegeneraldentalpractitioner,aswellastheoraland
maxillofacialsurgeon,itiscriticaltobefamiliarwithallpotentialcomplicationsassociatedwiththisprocedure.
OH
HansUlrichBrauer,DDS,DrMedDent,MA,OralSurgeon,CenterforDentistry,ImplantologyandOral
Surgery,Lahr,Germany.Email:info@drbrauerma.de
RobertA.Green,DDS,MD,Msc,FRCD(C),Oral&MaxillofacialSurgeon,StoneyCreek,Ontario.Email:
oralmaxsurg@gmail.com
BruceR.Pynn,Msc,DDS,FRCD(C),Oral&MaxillofacialSurgeon,ThunderBay,Ontario.Email:
b.pynn@shaw.ca
OralHealthwelcomesthisupdatedversionoftheQuimtessenceInt4056572,2009article.
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