|Year : 2015 | Volume
| Issue : 1 | Page : 8-12
Variables of Clinical Significance Predictive of Difficulty of Third Molar Surgery: An Institutional Analysis of 200 Consecutive Procedures
Harish Srinivas Kulkarni, Gayithri Harish Kulkarni, Ehtesham Iqbal, Jyoti Mallanagouda Biradar, Shahanavaj Imam Husen Khaji
Department of Oral and Maxillofacial Surgery, Tatyasaheb Kore Dental College and Research Centre, New Pargaon, Kolhapur, Maharashtra, India
|Date of Web Publication||19-Oct-2015|
Shahanavaj Imam Husen Khaji
Department of Oral and Maxillofacial Surgery, Tatyasaheb Kore Dental College and Research Centre, Mahatma Gandhi Hospital Campus, New Pargaon - 416 137, Kolhapur, Maharastra
Source of Support: None, Conflict of Interest: None
Aims and Objectives: To successfully evaluate the difficulty of third molar extraction prior to the surgical procedure, clinical and radiographic findings must be taken into account. The purpose of this research oriented study was to evaluate the importance of variables (patient variables, dental and operative variables) such as radio graphically assessed dental factors i.e., tooth morphology, position of the tooth, proximity to the inferior alveolar canal which are of clinical significance posing difficulty in removal of the impacted third molars. Materials and Methods: This prospective study was conducted in 3 years period (January 2012-December 2014) on 200 patients (140 males, 60 females) who had undergone third molar surgery under local anesthesia at Oral and Maxillofacial Surgery Department, Tatyasaheb Kore Dental College and Research Centre, Kolhapur, Maharashtra, India. Certain variables such as preoperative radiographic assessment, surgeon's perspective were assessed accordingly. A variety of data was gathered for each patient including age, gender of the patient, bone impaction, unfavorable root formation, operation time, etc. surgical difficulty was evaluated preoperatively using a parant scale. At the end of each surgery, the clinician recorded the technique used and the duration of each operation. Results and Observations: A total of 200 impacted third molars were removed surgically (140 males, 60 females) over a 3 years period and it was observed that increased age, gender predisposition, unfavorable root pattern, depth of impaction, close relationship to inferior alveolar nerve increased the operative time which was statistically significant. The mean operative time was 37 ± 5 minutes. Conclusion: This study demonstrates that preoperative radiological assessment should be taken into account while planning difficult third molar surgery. Although variables such as patient parameters, dental and surgeon's parameters should be evaluated accordingly.
Keywords: Clinical variables, surgical difficulty, third molar impaction
|How to cite this article:|
Kulkarni HS, Kulkarni GH, Iqbal E, Biradar JM, Khaji SI. Variables of Clinical Significance Predictive of Difficulty of Third Molar Surgery: An Institutional Analysis of 200 Consecutive Procedures. J Dent Allied Sci 2015;4:8-12
|How to cite this URL:|
Kulkarni HS, Kulkarni GH, Iqbal E, Biradar JM, Khaji SI. Variables of Clinical Significance Predictive of Difficulty of Third Molar Surgery: An Institutional Analysis of 200 Consecutive Procedures. J Dent Allied Sci [serial online] 2015 [cited 2019 Aug 17];4:8-12. Available from: http://www.jdas.in/text.asp?2015/4/1/8/167525
| Introduction|| |
Third molars present a high incidence of impaction, and have been associated with the appearance of disorders as diverse as pericoronitis, caries of the distal surface of second molar, myofascial pain, certain types of cysts and odontogenic tumors, dental malocclusion, etc. 
An impacted tooth is the one that fails to erupt into proper functional position in the dental arch within the expected time.  Difficulties in third molar eruption, particularly of the lower molars are attributable to their late formation and to the phylo-genetic evolution of the mandible, which results in a lack of available space for normal eruption. 
Assessment of difficulty and variables of clinical significance predictive of complicated third molar surgery is fundamental to forming an optimal treatment plan is mandatory. A compilation of both clinical and radiological information is essential to make an intelligent estimate of the time required to remove a tooth.  Extraction of third molars accounts for a large volume of cases in contemporary oral surgical practice and requires much planning, surgical skills during both preoperative diagnosis, and postoperative management. 
The aim of this study was to evaluate the variables of clinical significance predictive of difficult third molar surgery, in association with age, gender, third molar position, operative difficulty, and time required for the surgical procedure.
| Materials and Methods|| |
A descriptive clinical study was conducted on 200 patients (140 males, 60 females) who underwent third molar surgery in the Oral and Maxillofacial Surgery Department, Tatyasaheb Kore Dental College and Research Centre, Kolhapur, Maharashtra, India during the period 2012-2014. A complete clinical history was taken at the initial visit with collection of following information - Age, sex, ethnic background, identification of the molar to be removed, level of impaction, space available, and/or presence of associated symptoms [Table 1] and [Table 2]. Panoramic radiographs, intraoral periapical radiographs were taken for predicting the difficulty of the operation accordingly [Figure 1] and [Figure 2]. Surgical difficulty was evaluated preoperatively using a parant scale [Table 3].
All the 200 consecutive cases were included in the study evaluation after obtaining ethical clearance from the Local Ethical Clearance Committee, Tatyasaheb Kore Dental College and research institute, Kolhapur. Meanwhile, informed consent was obtained from all patients, each of whom agreed to be treated and to participate in the study. The predictor variables for the study were analyzed according to a strict protocol; all patients were given prophylactic coverage with Amoxicillin and clavulanic acid (Tab AUGUMENTIN 625MG) 1 prior to the procedure.
|Figure 1: Orthopantomogram showing the relationship of the tooth to the inferior alveolar nerve|
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|Figure 2: Intraoral periapical radiograph for the war lines assessment in a patient for surgical extraction|
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The current research study conducted over a 3 years study period with a total of 200 patients was included in three groups, respectively [Table 4],[Table 5] and [Table 6].
- Group I - Demographic variables of the study population inclusive of the age of the patients, gender relationship, ethnic background, etc.
- Group II - Class-wise distribution of the cases (as per the Pell and Gregory classification of impacted teeth - Class I, II, III).
- Group III - Comparison of the surgical time (operative duration), beginning with the placement of an incision till wound closure was assessed in all the selected cases accordingly.
All surgeries were performed under local anesthesia (2% lignocaine hydrochloride with adrenaline 1:80000 concentration), a standard ward's incision was made, and bone removal was carried out using sterile low speed hand piece with a no. 8 round bur under copious irrigation of normal saline. After removal of impacted third molar wound was inspected carefully followed by wound closure using 3-0 black braided silk [Figure 3] and [Figure 4]. At the end of the surgery, the surgeon recorded the technique used to extract the tooth on a special form. With this information, the observers rated surgical difficulty once again using the modified parant scale. Total surgical time was noted on the record sheet. Postoperative record and follow-up was done in all the selected cases [Figure 5].
| Results and Observations|| |
Over a 3 years study period, a total of 200 patients were included and were randomly divided into three groups, respectively [Table 4],[Table 5] and [Table 6]. Group I it was observed that out of 200 patients male patients (n = 140) had a higher rate of prevalence in comparison with female patients (n = 60) [Graph 1 [Additional file 1]]. Group II showed the class-wise distribution of impacted teeth (Class I - 60, Class II - 80, Class III - 60). Group III it was observed that comparison of the surgical time (operative duration), beginning with the placement of an incision till wound closure was assessed in all the selected cases accordingly.
The most common indication for the wisdom tooth extraction was recurrent pericoronitis (44%) following dental caries. The mean operative time was found to be 37 ± 5 min.
Predictions of the complications were significantly affected by three factors:
- Bone removal, tooth sectioning.
- Operative time and demographic variables like age, gender.
In case of maxillary extractions, prophylaxis was the most frequent reason for removal. The definitive measure of operative difficulty was actual surgical experience and was recorded at the end of each case. The predictor variables for the study were sets of exposure considered plausibly related to complication rates.
| Discussion|| |
Researches on the various aspects of third molar surgery are quite numerous in the literature. Inspite of this many dental professionals and specialists are still faced with the dilemma of explanation regarding operation time, associated risk factors of operative difficulty, and attendant postoperative morbidity. ,
The current research is an attempt to highlight more knowledge on variables of clinical significance such as patient and radiographic variables influencing on the operative difficulty.
The third molars particularly those in the lower jaw are the most frequently impacted teeth with an incidence between 9.5% and 39% depending on the source.  Assessment of difficulty of third molar surgery is fundamental to forming an optimal treatment plan in order to minimize complications. A compilation of both clinical and radiological information is necessary to make an intelligent estimate if the time required for removing a tooth.
Chandler and Laskin suggested that the preoperative assessment of surgical difficulty was unreliable and the best measure was that made during the procedure. The methods of estimating difficulty of extraction have been mainly dependent upon radiological assessment of the dental tissues. 
Winter described three imaginary lines that indicate the depth of tooth in the bone, modification in 1985 by Macgregor to winter's classification, height of the mandible, angulation of second molar, root shape and development, follicle, exit path (WHARFE) which includes the white line, amber line, red line (WAR) lines along with other factors. Pell and Gregory classification was an alternative method based on radiographic features. The current study focused on the variables of clinical significance predictive of surgical difficulty that is,
- Patient factors such as age, gender, ethnic background.
- Dental factors - Increased application depth (>6 mm), bone impaction, root anatomy.
- Surgeon's perspective. 
Peterson et al. also linked increased bone density to age and increased surgical difficulty which could account for the positive relationship. Thus the common factor linking increased age, male gender, influence on both quality and quantity of bone, operative difficulty, respectively. Several studies report a varied operative time for third molar surgery from 7.57 to 105 min. Duration of surgery depends on number of factors such as - Surgical difficulty, experience of the surgeon, surgical technique, how the duration was measured. 
The mean operative time in the current study was found to be 37 ± 5.0 min for unilateral mandibular third molar removal which correlates with the previous studies reported the literature. A tendency to underestimate the difficulty of procedure that was more pronounced in observers with greater levels of experience was noted.
The difficulty related to each surgical procedure was evaluated, in order to study the effect of clinical variables that are associated with the difficulty of extraction.
| Conclusion|| |
Difficulties in third molar eruption are mainly attributable to the late formation leading to lack of available space. In addition, source of debate is represented regarding various variables of clinical significance predictive of difficulty of third molar surgery. The present study analyzes and highlights the importance of operative variables such as expertise clinician, operative time, which were found statistically significant with the present study population.
The overall implication is that the relative importance of operative, dental, and patient variables should be taken in to consideration that are pertinent the preoperative assessment of surgical difficulty for third molar surgery.
The authors would like to thank our surgical colleagues in the Department of Oral and Maxillofacial Surgery of Tatyasaheb Kore Dental College and Research Centre for allowing us to use their patient data. Our sincere thanks to our staff colleagues (Dr. Jyoti Biradar, Dr. Ehtesham I) and to all intern residents (Dr. Kshitij Joshi, Dr. Pratima G, Dr. Tejaswini G, Dr. Shalamali I, Dr. Priyanka J, Dr. Aditya K, Dr. Nibha K, Dr. Snehal P, Dr. Anagha J, Dr. Nupur K) who made this editing work possible otherwise.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lysell L, Rohlin M. A study of indications used for removal of the mandibular third molar. Int J Oral Maxillofac Surg 1988;17:161-4.
Quek SL, Tay CK, Tay KH, Toh SL, Lim KC. Pattern of third molar impaction in a Singapore Chinese population: Aretrospective radiographic survey. Int J Oral Maxillofac Surg 2003;32:548-52.
Esteller-Martínez V, Paredes-García J, Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C. Analgesic efficacy of diclofenac sodium versus ibuprofen following surgical extraction of impacted lower third molars. Med Oral Patol Oral Cir Bucal 2004;9:448-53.
Chandler LP, Laskin DM. Accuracy of radiographs in classification of impacted third molar teeth. J Oral Maxillofac Surg 1988;46: 656-60.
Susarla SM, Dodson TB. Risk factors for third molar extraction difficulty. J Oral Maxillofac Surg 2004;62:1363-71.
Ruta DA, Bissias E, Ogston S, Ogden GR. Assessing health outcomes after extraction of third molars: The postoperative symptom severity (PoSSe) scale. Br J Oral Maxillofac Surg 2000;38:480-7.
Bui CH, Seldin EB, Dodson TB. Types, frequencies, and risk factors for complications after third molar extraction. J Oral Maxillofac Surg 2003;61:1379-89.
Hattab FN, Rawashdeh MA, Fahmy MS. Impaction status of third molars in Jordanian students. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:24-9.
Winter GB. Principles of Exodontia as Applied to the Impacted Third Molar. St. Louis: American Medical Books; 1926.
Peterson LJ, Ellis E 3 rd
, Hupp JR. Contemporary Oral Maxillofacial Surgery. St. Louis, MO: Mosby; 1993. p. 237-49.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]