Complications of third molar surgeryDocument Transcript
Oral Maxillofacial Surg Clin N Am 19 (2007) 117–128 Complications of Third Molar Surgery Gary F. Bouloux, MD, BDS, MDSc, FRACDS, FRACDS(OMS), Martin B. Steed, DDS, Vincent J. Perciaccante, DDS* Division of Oral and Maxillofacial Surgery, Emory University School of Medicine, 1365-B Clifton Road NE, Suite 2300-B, Atlanta, GA 30322, USA In 1994, the American Association of Oral and incidence of complications. Third molar removalMaxillofacial Surgeons Third Molar Clinical Trial is no diﬀerent, yet such a common procedureresearch group began an ambitious longitudinal sometimes results in what are relatively rarestudy that has added an immense amount of complications. The possibility of these eventsscientiﬁc data to our understanding of third molar should be discussed with patients before thesurgery outcomes. Concurrently, the American procedure and handled in a timely and correctiveAssociation of Oral and Maxillofacial Surgeons manner by the surgeon. Complications related toidentiﬁed the need to characterize the clinical third molar removal range from 4.6% to 30.9%outcomes of procedures commonly performed by [2,3]. They may occur intraoperatively or developmembers of the specialty in the 1990s . As a in the postoperative period.result, an outcomes assessment committee was The four most common postoperative compli-created to design ways to track and evaluate the cations of third molar extraction reported in theresults of oral and maxillofacial surgical proce- literature are localized alveolar osteitis (AO),dures. These procedures included the extraction infection, bleeding, and paresthesia. Major com-of third molarsdthe most commonly performed plications discussed in this article, such as man-procedure by oral and maxillofacial surgeons. A dibular fracture, severe hemorrhage, or iatrogenicrecent retrospective cohort study by Bui and col- displacement of third molar teeth, are rare and asleagues  evaluated the multivariate relationships such, studies that evaluate incidence or predispos-among risk factors and complications for third ing factors are diﬃcult to carry out and themolar removal. These eﬀorts represent a continued literature is limited.movement toward the use of evidence-based med- This article addresses the incidence of speciﬁcicine to elucidate outcomes to help provide more complications and, where possible, oﬀers a pre-accurate risk:beneﬁt ratios and allow surgeons to ventive or management strategy. Injuries of thebetter predict the incidence of complications and inferior alveolar and lingual nerves are signiﬁcantidentify individuals likely to experience them. issues that are discussed separately in this text . Third molar extraction remains one of the Periodontal defects also may follow third molarmost ubiquitous procedures performed by oral surgery and are discussed elsewhere in this textand maxillofacial surgeons, and most third molar . Surgical removal of third molars is often asso-surgeries are performed without intra- or post- ciated with postoperative pain, swelling, and tris-operative diﬃculties. In all surgical procedures, mus. They are expected and typically transientproper preoperative planning and the blending of and are not considered complications or discussedsurgical technique with surgical principles is of further.paramount importance for decreasing the Factors thought to inﬂuence the incidence of complications after third molar removal include age, gender, medical history, oral contraceptives, * Corresponding author. presence of pericoronitis, poor oral hygiene, E-mail address: firstname.lastname@example.org smoking, type of impaction, relationship of third(V.J. Perciaccante). molar to the inferior alveolar nerve, surgical time,1042-3699/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.coms.2006.11.013 oralmaxsurgery.theclinics.com
118 BOULOUX et alsurgical technique, surgeon experience, use of and early postoperative infection to be the sameperioperative antibiotics, use of topical antisep- [7,23]. Based on these studies, metronidazole can-tics, use of intra-socket medications, and anes- not be recommended for the prevention of AO, al-thetic technique [1–3,6–19]. Many studies are though the results cannot be extrapolated to theretrospective, subject to selection bias, or poorly use of all systemic antibiotics. Despite the abun-controlled for confounding variables, however. dance of obligate and facultative anaerobic mi-Conclusions drawn from individual studies are of- cro-organisms in odontogenic infections andten not in agreement, which makes an evidence- possibly AO, it is possible that a more appropriatebased preventive or management approach perioperative antimicrobial would reduce the inci-challenging. dence of AO. Perioperative ampicillin recently Complications that are discussed further in- was found to reduce clinical recovery time whenclude AO, postoperative infection, hemorrhage, compared with placebo, although no speciﬁc com-oro-antral communication (OAC), damage to ment was made regarding the incidence of AO oradjacent teeth, displaced teeth, and fractures. infection . Postoperative antibiotics are gener- ally not considered eﬃcacious in reducing the incidence of AO or infection . The incidence of AO after third molar removalAlveolar osteitis may be reduced by adopting several approaches AO is a clinical diagnosis characterized by the that, although not universally accepted, are baseddevelopment of severe, throbbing pain several on the best literature currently available. First,days after the removal of a tooth and often is third molars should be removed only when pre-accompanied by halitosis. The extraction socket is existing pericoronitis has been treated adequately.often ﬁlled with debris and is conspicuous by the Oral hygiene also should be satisfactory before thepartial or complete loss of the blood clot. The surgical procedure. Second, the surgery should befrequency of AO ranges from 0.3% to 26% completed as atraumatically as possible using[1–3,6,8,9,11,12,14,16]. AO is known to occur copious irrigation when a drill/bur is needed tomore frequently with mandibular third molar ex- remove bone or section teeth. Third, an intra-traction sockets, although the exact reason is not alveolar antibiotic, such as tetracycline, may beclear [1,3]. The cause of AO is also poorly under- beneﬁcial when placed in the socket before closurestood. Birn  suggested that AO is the result of [22,26]. The amount of antibiotic should be keptrelease of tissue factors leading to the activation to a minimum to help reduce the likelihood of a gi-of plasminogen and the subsequent ﬁbrinolysis of ant cell reaction or myospheruloma formation.the blood clot. This also may explain the apparent Finally, chlorhexidine 0.12% mouthwash shouldincreased incidence of AO when the surgery is more be used on the day of surgery and for severaldiﬃcult and traumatic. Nitzan  suggested that days thereafter .AO is primarily the result of a localized bacterial The management of AO is less controversialinfection. It is likely that AO is a result of a com- than the etiology and prevention. A combinationplex pathophysiology that involves a localized of antibacterial dressings, obtundant dressings,bacterial infection and subsequent ﬁbrinolysis. and topical anesthetic agents is used to alleviate In an extensive review of the literature, Alex- severe pain. A multitude of diﬀerent medicamentsander  found numerous studies that supported and carrier systems are commercially availableincreasing age, female gender, oral contraceptives, with little scientiﬁc evidence to guide the choice.smoking, surgical trauma, and pericoronitis as The authors have used alvogyl containing butam-risk factors for AO, although a signiﬁcant number ben, eugenol, and iodoform with good success.of studies also refuted these purported associa- Eugenol is a phenolic compound that denaturestions. The same author found a majority of stud- protein, is neurotoxic, and interrupts neural trans-ies that supported the use of generous mission, whereas iodoform is an antibacterialintraoperative lavage, perioperative antiseptic agent. Patients should be seen regularly aftermouth wash, intra-alveolar medicaments, and sys- placement of the dressing, which may need to betemic antibiotics to reduce the incidence of AO. changed several times to eliminate the symptoms.Unfortunately, however, the literature concerning The use of intra-alveolar dressings in socketsAO is not consistent. Two recent prospective stud- when the inferior alveolar neurovascular bundleies comparing systemic perioperative metronida- is exposed is not recommended. Systemic analge-zole with placebo found the incidence of AO sics may be used as an adjunct, but they are often
COMPLICATIONS OF THIRD MOLAR SURGERY 119unnecessary after local management measures metronidazole (either alone or in combination)have been undertaken. continue to be the antimicrobials of choice in the United Kingdom [31,32]. The use of clindamycin as an alternative has become popular because it provides aerobic and anaerobic coverage . TheInfections choice of antibiotic should be made carefully con- Postoperative infections after third molar re- sidering the likely micro-organisms involved, themoval have been reported to vary from 0.8% to potential for allergic reactions, side eﬀects, and4.2% [1–3,6,11,12,14,16]. Infections may develop complications, such as the increased risk for thein the early or late postoperative period, with development of pseudomembranous colitis withmandibular third molar sites more commonly af- broad-spectrum antibiotics, such as clindamycin.fected [1,3]. It has been suggested that age, degreeof impaction, need for bone removal or toothsectioning, exposure of the inferior alveolar neu- Bleeding and hemorrhagerovascular bundle, presence of gingivitis or peri-coronitis, surgeon experience, use of antibiotics, The reported range of clinically signiﬁcantand location of surgery (hospital versus oﬃce pro- bleeding as a result of third molar extraction hascedure) are all risk factors for postoperative infec- ranged from 0.2% to 5.8% and can be classiﬁed astions [3,6,11–14,16]. The beneﬁt of perioperative either intra- or postoperative with causes that canor postoperative systemic antibiotics on the inci- be local or systemic. In the recent Americandence of infection remains questionable and cannot Association of Oral and Maxillofacial Surgeonsbe recommended currently [7,18,23,25,27]. Perio- Age-Related Third Molar Study, the investigatorsperative antibiotics are discussed in detail elsewhere found an intraoperative frequency of unexpectedin this issue . Odontogenic infectionsdboth hemorrhage of 0.7% and a postoperative fre-pre- and postoperativedare typically mixed infec- quency of unexpected or prolonged hemorrhagetions with a predominance of anaerobic micro- of 0.1% . In a study of 583 patients, Bui andorganisms, although streptococci are usually the colleagues  found the frequency of clinically sig-largest single group of organisms [28,29]. When in- niﬁcant bleeding to be 0.6% and noted that thefections develop they can spread in multiple direc- variability on reported rates is at least partly a re-tions depending on the anatomic location of the sult of varying deﬁnitions. This value is similar toinfection and adjacent tissue planes. Maxillary third that found by Chiapasco and colleagues , inmolar infections may extend to the maxillary which they found excessive intraoperative bleed-vestibule, buccal space, deep temporal space, or ing in 0.7% of mandibular third molars andinfratemporal fossa. Mandibular third molar infec- a 0.6% incidence of postoperative excessive bleed-tions may spread to the mandibular vestibule, ing. Maxillary third molars showed a 0.4% inci-buccal space, submasseteric space, pterygomandib- dence of postoperative excessive bleeding. Aular space, parapharyngeal space, or submandibu- higher incidence of excessive hemorrhage waslar space. Parapharyngeal and submandibular found in distoangular teeth, deep impactions,infections may produce signiﬁcant airway embar- and older patients. Excessive hemorrhage result-rassment. Infections also may involve the ing from extraction of mandibular molars isretropharyngeal tissues and subsequently the medi- more common than bleeding from maxillaryastinum, with disastrous results. molars (80% and 20%, respectively) . The management of postoperative infection The causes of hemorrhage can be either localinvolves the systemic administration of appropriate or systemic in nature. Systemic conditions, such asantibiotic and surgical drainage. Penicillin con- hemophilia A or B and von Willebrand’s disease,tinues to be a good ﬁrst choice antibiotic given the are often identiﬁed early in a patient’s life andmixed nature of the infection and the presence of extractions can be approached in a systematicstreptococci, although increasing resistance to manner to maximize the patient’s ability to formpenicillin has been reported [29,30]. Amoxicillin a stable clot. Patients with severe hemophilia Amay be substituted because it has a wider spectrum who have been treated previously with plasma-of activity and is only dosed two or three times derived or recombinant factor VIII products maya day. Metronidazole also can be added to the anti- develop inhibitors to the factor products andbiotic regimen to increase coverage against anaero- prove to be diﬃcult to manage, however. Alloan-bic organisms. Penicillin or amoxicillin and tibodies against foreign factor VIII develop in
120 BOULOUX et al25% to 30% of patients with severe hemophilia A extraction site may be curetted and suctionedwho receive therapeutic infusions of factor VIII gently. If the bleeding is from soft tissue and is. The inhibitor level is measured in Bethesda arterial in nature but does not involve the neuro-Units, and patients are placed into either a low vascular bundle, it is usually amenable to cautery.or high responder group. Approximately 75% of Bony bleeders may be managed with bone wax orpatients fall within the high responder group. various hemostatic agents (Table 1). These mate-The therapy of choice for patients who have he- rials may be stabilized and maintained withinmophilia with inhibitors is the induction of im- the socket with sutures. Oral ﬁbrinolysis from sal-mune tolerance, and multiple protocols exist to ivary enzymes may play a role in some cases, andachieve this, including the Bonn protocol and the use of ﬁbrin-stabilizing factors, such as epsi-the Malmoe regimen. In the preparation for an lon-aminocaproic acid (Amicar) or tranexamicelective procedure in a patient in whom long- acid (Cyclokapron), may be helpful (Table 1).term immune tolerance has not been accom- Massive intraoperative bleeding is a rare oc-plished, recombinant FVIIa (Novo-Seven) and currence and can be secondary to a mandibularactivated prothrombin complex concentrates arteriovenous malformation, which can be eitherwith FVIII inhibitor bypass activity (FEIBA) are low ﬂow (venous) or high ﬂow (arterial). Thewell-established therapeutic modalities . presence of such a malformation in the maxilla orFEIBA contains the proenzymes of prothrombin mandible is potentially life threatening secondarycomplex proteins II,VII, IX, and X and small to unmanageable bleeding upon attempted toothamounts of their activation products. Its eﬀects extraction. Eight percent of patients died as a re-occur mainly through factors II, Xa, and V–de- sult of massive bleeding during tooth extraction inpendent activation of the clotting cascade and the series reported by Guibert-Tranier and col-avoid dependence on factor VIII. There are diﬃ- leagues . Arteriovenous malformations areculties with Novo-Seven and FEIBA related to a rare condition in the maxillofacial region, occur-diﬃculty in determining correct dosage and lack ring with a higher incidence in other regions of theof laboratory tests capable of determining dosage body. Arteriovenous malformations in the maxil-suﬃciency . Management of these patients lofacial region are often apparent on physical ex-should include close coordination with a hematol- amination and panoramic radiography. A historyogist and the maximal use of local measures, in- of recurrent spontaneous bleeding from the gingi-cluding the fabrication of an individually ﬁtted val is the most frequent objective sign. Otherdressing plate before surgery. physical ﬁndings include gingival discoloration, Antithrombotic medications, such as Couma- hyperthermia over the lesion, a subjective feelingdin (warfarin sodium), can be discontinued if of pulsation, and the presence of a palpable bruit.medically feasible, switched via protocol to a hep- Mandibular arteriovenous malformations usuallyarin regimen during the perioperative period, or appear as multilocular radiolucencies on radio-dealt with in a local manner in an anticipatory graphic studies, although signiﬁcant lesions mayfashion. be nonapparent . Angiography is necessary Local factors that result from soft-tissue and and essential to conﬁrm the diagnosis and assessvessel injury represent the most common cause of the extent and vascular architecture of the lesionpostoperative hemorrhage and respond best to . Treatment of mandibular arteriovenous mal-local control, which includes meticulous surgical formations involves either surgical excision or em-technique with avoidance of the inferior alveolar bolization. Multiple reports describing the use ofneurovascular bundle and particular care at the permanent embolic agents support their use anddistolingual aspect of the mandible. Patients who suggest that many arteriovenous malformationsexperience continued postoperative bleeding whose angioarchitecture support transvenousshould be instructed to apply gauze pressure to approach can be cured without surgical resection.the extraction site for 45 minutes. The patient’smedical history should be reinvestigated and vitalsigns should be monitored. If the application of Damage to adjacent teethpressure proves unsuccessful, the patient and theextraction site should be examined closely. Local The incidence of damage to adjacent restora-anesthesia administered at this time should not tions of the second molar has been reported to becontain a vasoconstrictor to enable accurate 0.3% to 0.4% . Teeth with large restorationsidentiﬁcation of the cause of bleeding. The or carious lesions are always at risk of fracture
COMPLICATIONS OF THIRD MOLAR SURGERY 121Table 1Local hemostatic agents useful for oral bleedingName Source Action ApplicationGelfoam Absorbable gelatin sponge Scaﬀold for blod Place into clot formation socket and retain in place with sutureSurgicel Oxidized regenerated Binds platelets Place into socket (Note: methylcellulose and chemically cannot be mixed with precipitates thrombin) ﬁbrin through low pHAvitene Microﬁbrillar collagen Stimulates platelet Mix ﬁne powder with saline adherence and stabilizes to desired consistency clot; dissolves in 4–6 weeksCollaplug Preshaped, highly Stimulates platelet Place into extraction site cross-linked collagen adherence and stabilizes plugs clot; dissolves in 4–6 weeksCollatape Highly crosslinked collagen Stimulates platelet Place ribbon into extraction adherence and stabilizes site clot; dissolves in 4–6 weeksThrombin Bovine thrombin (5000 Causes cleavage Mix ﬁne powder with CaCl2 or 10,000 U) of ﬁbrinogen to ﬁbrin and spray into area and positive feedback desired; alternatively, mix to coagulation cascade with Gelfoam before applicationTiseel Bovine thrombin, Antiﬁbrinolytic action Requires specialized human ﬁbrin, CaCl2, of aprotinin heating, mixing and and aprotinin delivery system; inject into extraction site Adapted from Moghadam H, Caminiti MF. Life threatening hemorrhage after extraction of third molars: case reportand management protocol. J Can Dent Assoc 2002;68(11):671.or damage upon elevation. Correct use of surgical Other studies cite even lower incidence. Allingelevators and bone removal can help prevent this and colleagues  retrospectively showed an in-occurrence. Discussion should take place preoper- traoperative mandibular fracture rate of 1 inatively with patients at high risk. Maxillary me- 30,583 patients and a postoperative rate of 1 insioangular impactions with a Pell and Gregory 23,714, whereas Nyul  reported one fractureclass B (crown to cervical relationship) and man- in 29,000 cases.dibular vertical impactions may be at a slightly Possible predisposing conditions, such as in-higher risk . creased age, mandibular atrophy, the concurrent presence of a cyst or tumor, and osteoporosis, have been implicated in increasing the risk of mandible fracture. The preangular region of theMandibular fracture mandible is an area of lowered resistance to fracture Mandibular fracture as a result of third molar secondary to its thin cross-sectional dimension, andremoval is a recognized complication and has an impacted tooth occupies a relatively signiﬁcantimportant medicolegal and patient care implica- space within the bone of this region. The concurrenttions. It should be included on all third molar presence of a dentigerous or follicular cyst aroundextraction consent forms. Mandibular fracture the third molar or a radicular cyst around theduring or after surgical third molar removal is second molar and removal of the tooth and anya rare but major complication. The incidence of surrounding bone necessary to mobilize it furthermandibular fracture during or after third molar mechanically weakens this area. Studies thatremoval has been reported to be 0.0049% . have attempted to characterize the small number
122 BOULOUX et alof patients who have experienced a mandibular posterior portion has no support, and the internalfracture after or during extraction of a third composition may be signiﬁcantly maxillary sinusmolar include Iizuka and colleagues , who or soft osteoporotic bone. Preoperative radio-retrospectively evaluated the clinical and radio- graphic evaluation of the sinus proximity andgraphic data of 12 patients with 13 mandible bone thickness can help anticipate tuberosityfractures after removal of wisdom teeth. They fracture. In a study by Chiapasco and colleaguesfound that patients older than 30 to 40 years , the extraction of 500 maxillary impactedwith tooth roots superimposed on the inferior al- third molars was accompanied by three fracturesveolar canal or adjacent to the canal on pano- of the maxillary tuberosity, indicating an inci-ramic evaluation are at increased risk for dence of 0.6%. Two instances occurred with teethfracture. The study found few intraoperative classiﬁed as class C (crown to root position) byfractures (one) and found that the late fractures the Pell and Gregory classiﬁcation scheme,(eight) occurred on average 6.6 days after the whereas one was class B (crown to cervical posi-surgery exclusively upon mastication. Libersa tion). The fractures occurred with equal incidenceand colleagues  evaluated 37 fractures from in all patient age groups.750,000 extractions and identiﬁed 17 intraopera- Upon encountering a fractured tuberositytive fractures and 10 late fractures. Of the 10 during an erupted third molar extraction, thelate fractures, 8 occurred in men and 6 occurred surgeon must revisit the reason why the toothduring mastication. Most late fractures occurred was to be extracted in the ﬁrst place. If the tooth isbetween 13 and 21 days after surgery, which asymptomatic, it may be left in place and thecould be caused by an increase in masticatory region stabilized with an arch bar. If the tooth isfunction and occlusal forces outstripping the infected or symptomatic and the extraction mustbony healing. be completed, then the tuberosity can be sepa- Exclusively late fractures were found in a study rated from the tooth with a high-speed hand pieceby Krimmel and Reinert  in a retrospective se- and the roots sectioned. The tooth can be re-ries of six patients who sustained mandibular frac- moved atraumatically and the tuberosity assessedture from third molar removal. The fractures for viability through evaluation of the attachedoccurred 5 to 28 days (mean, 14 days) after the periosteum and vascular supply. Attention musttooth removal. The ages of all six patients were be given to fastidious closure of palatal and buccalbetween 42 and 50 and all had full dentition. mucosal tears. Possible preventive measures in-Pell and Gregory vertical classiﬁcations for the clude use of a periosteal elevator to ensureteeth were Class B in two cases and Class C in separation of the periodontal ligament from thefour cases. The authors concluded that the major tooth and palpation with a ﬁnger from the non-risk factor for the complication seemed to be ad- operating hand to evaluate the expansion of thevanced age in combination with a full dentition. cortical plate upon luxation. Regardless of the mechanism, mandibularfractures that occur during or soon after theextraction of a mandibular third molar are usually Displacement of third molarsnondisplaced or minimally displaced. Such hair- Maxillary third molarsline fractures that extend from an extraction siteare not always easily identiﬁed, and clinical Iatrogenic displacement of maxillary thirdsuspicion may require CT if the initial panoramic molars can occur, although it is a rarely reportedﬁlm produces negative results. The practitioner complication with an unknown incidence. Maxil-should treat the fracture deﬁnitively just as if the lary third molars that are superiorly positionedpatient were a trauma patient. Failure to do so may have only a thin layer of bone posteriorlymay result in further complications. separating them from the infratemporal space. The tooth can be displaced in a posterosuperior direction into the infratemporal space if distal elevation is not accompanied by a retractor placedMaxillary tuberosity fracture behind the tuberosity within the designed muco- Fracture of the maxillary tuberosity on extrac- periosteal ﬂap (Fig. 1). The literature shows thattion of maxillary third molars is a clinically management of a third molar displaced into theknown occurrence. The anatomic position at the infratemporal space is varied. Venous bleedingend of the dentoalveolar arch is such that the from the pterygoid plexus often makes intraoral
COMPLICATIONS OF THIRD MOLAR SURGERY 123 patient placed on a course of antibiotics and nasal decongestants. Retrieval can be accomplished with a Caldwell-Luc approach at a second proce- dure in concert with closure of the oro-antral ﬁs- tula and an intranasal antrostomy to facilitate maxillary sinus drainage . There seems to be some discussion as to the timing of this removal. Sverzut and colleagues  stated that the removal should be accomplished during the same procedure but indicated that de- layed treatment does not always precipitate active sinus disease and that this asymptomatic interval can last several months. Mandibular third molars Mandibular third molars can be iatrogenicallyFig. 1. Coronal cut CT. Bony window of a maxillary displaced into the sublingual, submandibular,third molar #01 displaced into the right infratemporal pterygomandibular, and lateral pharyngeal spacesfossa. [46,49–51]. Anatomic considerations, such as a dis- tolingual angulation of the tooth, thin or dehisced lingual cortical plate, and excessive or uncon-visualization of the tooth diﬃcult . Observa- trolled force upon luxation, are important factorstion may be chosen but can require secondary re- that can lead to this complication.moval in the setting of infection, limited range of Lower third molars that are pushed throughmotion, or a patient’s wishes to have the tooth re- a perforation in the thin lingual alveolar bonemoved. Delayed removal after ﬁbrosis takes place normally pass inferiorly to the mylohyoid muscle.around the tooth also has been advocated because Pogrel  recommended that the operator placeit can more readily be localized radiographically his or her thumb underneath the inferior borderand intraoperatively. This secondary procedure of the mandible in an attempt to direct the toothis often completed in the operating room under back along the lingual surface of the mandible.general anesthesia after a CT scan is obtained to The lingual gingiva may be reﬂected as far asprecisely locate the tooth position. Various ap- the premolar region and the mylohyoid muscle in-proaches to retrieving a tooth in the infratemporal cised to gain access to the submandibular spacespace have been described, including an intraoral and deliver the tooth. In this approach, careapproach from a sagittal split osteotomy incision, should be taken to avoid injury to the linguala hemicoronal approach, and manipulating the nerve in this anatomic region. Locating the dis-tooth via a straight needle placed cutaneously in placed tooth is challenging secondary to limitedan inferior direction and delivering it through an working area and hemorrhage with resultant com-intraoral incision . promised visualization and blind probing that Displacement of a maxillary third molar into may result in further displacement. Yeh  de-the maxillary sinus also can occur and has been scribed a technique that is a combination intraoralreported [46–48]. Excessive apical force and incor- and lateral neck approach in which the originalrect surgical technique are thought to be the most wound is extended lingually to the distal of thecommon cause. The accepted treatment of such ﬁrst molar. A 4-mm skin incision is made in thea displaced tooth is removal to prevent future in- submandibular region and a hemostat insertedfections. Pogrel  stated that the initial attempt along the lingual surface of the mandible to stabi-at retrieval should be a suction placed at the open- lize the tooth while the surgeon palpates the toothing into the sinus. If suction applied to the open- with an index ﬁnger. A Kelly clamp can be in-ing does not allow delivery, then the sinus may be serted to deliver the tooth upward into the mouth.irrigated with saline and the suction tip reapplied The author believed this approach prevents fur-to the opening. If the second attempt is unsuccess- ther displacement of the tooth and limits theful, further attempts should be stopped and the length of lingual ﬂap reﬂection necessary.
124 BOULOUX et al Gay-Escoda and colleagues  reported treatment this communication may epithelializea case in which a patient underwent unsuccessful and become an oro-antral ﬁstula (OAF).extraction of a displaced mandibular third molar OAC occurs most frequently from extractionthat was found between the platysma and sterno- of ﬁrst molar teeth, followed by second molarcleidomastoid muscle. It was removed via a trans- teeth . An incidence of 0.008% to 0.25% OACcutaneous approach and the authors stated that has been reported with maxillary third molar re-the tooth may have undergone progressive exteri- moval [11,53]. It is likely that the incidence oforization as a result of a prolonged inﬂammatory OAC from maxillary third molar removal isreaction. underestimated, because it may be self-limiting Esen and colleagues  described a case in in some cases and, in the case of impacted thirdwhich a patient presented months after attempted molars, usually a ﬂap is closed over the extractionextraction of a mandibular third molar with pro- site, leading to healing. OAC smaller than 2 mmgressive limitation in mouth opening, left neck in diameter likely closes spontaneously withoutedema, and diﬃculty swallowing. A panoramic any treatment [54,55].ﬁlm was obtained and revealed a tooth in the pter- Various methods for closure of OAC and OAFygomandibular region. CT scans showed the pre- have been described over the years, including goldcise location of the tooth at the anterior border of foil, buccal ﬂaps, various palatal ﬂaps, tonguethe lateral pharyngeal space underlying the left ﬂaps, pedicled buccal fat pad (PBFP), cheek ﬂaps,tonsillar region. The tooth was removed transor- and placement of bioabsorbable root analogs [56–ally from the tonsillar fossa (after completion of 69]. The authors prefer the use of the PBFP fora tonsillectomy) through a vertical incision from closure of OAFs.the tonsillar fossa to the retromolar trigone. The buccal fat pad was ﬁrst described by Delayed intervention in the setting of a dis- Heister in 1732 as a glandular structure andplaced tooth into the lateral pharyngeal space recharacterized as fatty tissue by Bichat in 1802carries the risk of infection, thrombosis of the . It is a biconvex mass of fatty tissue in a ﬁneinternal jugular vein, erosion of the carotid artery capsule with a body and four projections; the totalor one of its branches, and interference with volume is described as approximately 10 mLcranial nerves IX through XII . [68,70–73]. The four projections are buccal, ptery- goid, and superﬁcial and deep temporal exten-Displaced roots sions. The blood supply to the buccal fat pad comes from the buccal and deep temporal Maxillary and mandibular root tips rarely may branches of the maxillary, transverse facial branchbe displaced into the aforementioned spaces. The of the superﬁcial temporal, and branches of the fa-management of these displaced roots remains cial arteries. The use of the PBFP for closure ofmuch the same. A mandibular third molar root OAF was ﬁrst described by Egyedi in 1977 .may be displaced into the inferior alveolar canal. The description of this technique included theAttempts at retrieval may further injure the placement of a split-thickness skin graft over theneurovascular bundle and should be limited to PBFP. Research has shown that this graft doesone attempt with suction. not need to be covered and epithelializes within a few weeks [55,70,75–77]. The procedure’s re-Aspiration ported success rate ranges from 92.8% to several All third molar extraction procedures carry the reports of 100% [55,78–82].risk of tooth aspiration. The use of properlyplaced oropharyngeal gauze is essential in prevent- Techniqueing this complication. The use of intravenous deepsedation by deﬁnition compromises the protective The procedure can be performed under localreﬂexes of the airway. The aspiration or swallow- anesthesia or intravenous sedation (Fig. 2). If a ﬁs-ing of a tooth or portion of a tooth is usually the tula is present, an incision with a 3-mm margin isresult of a patient coughing or gagging. made around the OAF. The ﬁstula is excised or closed and inverted with a purse string suture of 3-0 chromic gut. Two divergent cuts are madeOro-antral communication/ﬁstula from the remaining OAC extending anteriorly An OAC is any opening between the maxillary and posteriorly into the vestibule. The trapezoidalsinus and the oral cavity. Without diagnosis and buccal mucoperiosteal ﬂap is reﬂected. A 1-cm
COMPLICATIONS OF THIRD MOLAR SURGERY 125Fig. 2. The BFP method for the closure of OAF. (A) Incision line (dotted line). (B) The mucoperiosteal ﬂap and the in-cision of the periosteum at the zygomatic buttress (dotted line). (C) Advancement of BFP into the bony defect and su-turing to the palatal gingiva. (D) Replacement and suturing of mucoperiosteal ﬂap into its original position. (FromHanazawa Y, Itoh K, Mabashi T, et al. Closure of oroantral communications using a pedicled buccal fat pad graft.J Oral Maxillofac Surg 1995;53:771; with permission. Ó Copyright 1995 – The American Association of Oral and Max-illofacial Surgeons.)incision is made in the periosteum posterior to the the PBFP under the edge of the palatal mucosa.zygomatic buttress. Curved hemostats are used to The buccal ﬂap is returned to its original position.spread within the submucosal space until the fat The releasing incisions are closed and a suture isherniates. The buccal fat pad is teased from its placed from the tip of the buccal ﬂap to the PBFP,bed and gently advanced, without tension, and su- leaving the PBFP exposed to the oral cavity overtured to the palatal mucosa using 4-0 monoﬁla- the OAC. The fat epithelializes over the next fewment poliglecaprone (Monocryl) sutures. The weeks. Alternatively the buccal mucoperiostealsutures to the palate can be interrupted or, after ﬂap may be advanced over the PBFP and primar-elevation of the edge of the palatal tissue, vertical ily sutured to the palatal mucosa to form a doublemattress sutures can be used to ‘‘tuck’’ the tip of layered closure. Appropriate antibiotic coverage
126 BOULOUX et alfor sinus micro-organisms and decongestants are Referencesprovided for 1 week. Standard sinus precautions  Haug RH, Perrott DH, Gonzalez ML, et al. Theare followed. The authors have not yet had a fail- American Association of Oral and Maxillofacialure with this technique, even in smokers, although Surgeons age-related third molar study. J Oralsmoking cessation is strongly encouraged. Maxillofac Surg 2005;63:1106.  Bui CH, Seldin EB, Dodson TB. Types, frequencies, and risk factors for complications after third molarTemporomandibular joint complications extraction. J Oral Maxillofac Surg 2003;61:1379.  Sisk AL, Hammer WB, Shelton DW, et al. Compli- A causal relationship between the extraction of cations following removal of impacted third molars:third molars and temporomandibular injury cur- the role of the experience of the surgeon. J Oralrently has little support in the literature. It has Maxillofac Surg 1986;44:855.been suggested that because the procedure of  Ziccardi V, Zuniga J. Nerve injuries after third mo-extracting mandibular third molars involves the lar removal. Oral Maxillofac Surg Clin North Ampatient opening his or her mouth wide for an 2007;19:105–15.  Dodson TB. Risk of periodontal defects after thirdextended period of time and exerting a variable molar surgery: an exercise in evidence-based clinicalamount of force on the mandible, it is possible to decision-making. Oral Maxillofac Surg Clin Northoverload or injure one or both temporomandibu- Am 2007;19:93–8.lar joints . This result would be the case espe-  Benediktsdottir IS, Wenzel A, Petersen JK, et al.cially if the surgeon did not use correct surgical Mandibular third molar removal: risk indicatorstechnique or failed to support the mandible while for extended operation time, postoperative pain,removing the mandibular third molars or if the and complications. Oral Surg Oral Med Oral Patholpatient’s protective mechanism for opening was Oral Radiol Endod 2004;97:438.exceeded while under general anesthesia.  Bergdahl M, Hedstrom L. Metronidazole for the In a matched case control study by Threlfall and prevention of dry socket after removal of partially impacted mandibular third molar: a randomisedcolleagues , they compared 220 patients diag- controlled trial. Br J Oral Maxillofac Surg 2004;42:nosed with disc displacement with reduction to 555.1100 controls drawn from the participants in the  Bloomer CR. Alveolar osteitis prevention by imme-1998 UK Adult Dental Health Survey. They found diate placement of medicated packing. Oral Surgthat patients with diagnosed anterior disk displace- Oral Med Oral Pathol Oral Radiol Endod 2000;90:ment with reduction were not signiﬁcantly more 282.likely to have undergone extraction of third molars  Bruce RA, Frederickson GC, Small GS. Age of pa-than the controls (odds ratio 1.28; conﬁdence inter- tients and morbidity associated with mandibularval 95%). The study showed that 21 (9.5%) of the third molar surgery. J Am Dent Assoc 1980;101:240.220 patients reported that they had a third molar  Caso A, Hung L-K, Beirne OR. Prevention of alve- olar osteitis with chlorhexidine: a meta-analyticextracted in the 5 years before the diagnosis of an review [see comment]. Oral Surg Oral Med Oralanterior disc displacement with reduction. The Pathol Oral Radiol Endod 2005;99:155.data did not exclude the possibility that patients  Chiapasco M, De Cicco L, Marrone G. Side eﬀectswho have extractions under general anesthesia and complications associated with third molar sur-and patients who have lengthy/traumatic proce- gery. Oral Surg Oral Med Oral Pathol 1993;76:412.dures may be at increased risk of developing a tem-  de Boer MP, Raghoebar GM, Stegenga B, et al.poromandibular disorder, but data did suggest that Complications after mandibular third molar extrac-in most patients with anterior disk displacement tion. Quintessence Int 1995;26:779.with reduction, extraction of a third molar was un-  Figueiredo R, Valmaseda-Castellon E, Berini-Ayteslikely to have been the etiologic factor. L, et al. Incidence and clinical features of delayed- onset infections after extraction of lower third mo- Oral and maxillofacial surgeons should include lars. Oral Surg Oral Med Oral Pathol Oral Radiolan examination of the temporomandibular region, Endod 2005;99:265.including an evaluation of joint sounds, opening  Goldberg MH, Nemarich AN, Marco WP II.and excursive movements, and temporal/masseter/ Complications after mandibular third molar sur-pterygoid muscle tenderness in all preoperative gery: a statistical analysis of 500 consecutive pro-third molar extraction patients. Care should be cedures in private practice. J Am Dent Assoctaken in judicious application of force and a bite 1985;111:277.block should be used to stabilize the mandible upon  Larsen PE. Alveolar osteitis after surgical removalsurgical mobilization of the lower third molar teeth. of impacted mandibular third molars: identiﬁcation
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