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Complications of third molar surgery

Complications of third molar surgery






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    Complications of third molar surgery Complications of third molar surgery Document 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 [1]. 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 [2] 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 [4]. 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 [5]. 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: vpercia@emory.edu 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 [24]. Postoperative antibiotics are gener- ally not considered efficacious in reducing the incidence of AO or infection [25]. 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 [20] 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 [21] suggested that days thereafter [10].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 [22] 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 [33]. 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 [18]. 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% [1]. In a study of 583 patients, Bui andorganisms, although streptococci are usually the colleagues [2] 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 [11], 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) [34]. 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[35]. 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 [35]. 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 [36]. 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 [35]. 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 [37]. 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 [38]. 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% [11]. 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 [40] 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 [41] 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 [11]. 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% [39]. 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 [42], 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 [11], 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 [39] 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 [43] 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 [44]. There seems to be some discussion as to the timing of this removal. Sverzut and colleagues [48] 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 [44]. 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 [44] 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 [45]. promised visualization and blind probing that Displacement of a maxillary third molar into may result in further displacement. Yeh [46] 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 [44] 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 [51] 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 [52]. 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 [50] 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 [70]. 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 [50]. [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 [74].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 [1] 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. [2] 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. [3] 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 [4] 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. [5] 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 [83]. This result would be the case espe- [6] 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. [7] 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 [84], 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 [8] 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 [9] 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 [10] 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 [11] 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- [12] 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- [13] 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 [14] 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 [15] Larsen PE. Alveolar osteitis after surgical removalsurgical mobilization of the lower third molar teeth. of impacted mandibular third molars: identification
    • COMPLICATIONS OF THIRD MOLAR SURGERY 127 of the patient at risk. Oral Surg Oral Med Oral [32] Gill Y, Scully C. The microbiology and management Pathol 1992;73:393. of acute dentoalveolar abscess: views of British oral[16] Osborn TP, Frederickson G Jr, Small IA, et al. A and maxillofacial surgeons. Br J Oral Maxillofac prospective study of complications related to man- Surg 1988;26:452. dibular third molar surgery. J Oral Maxillofac [33] Kirkwood KL. Update on antibiotics used to treat Surg 1985;43:767. orofacial infections. Alpha Omegan 2003;96:28.[17] Pogrel MA. Complications of third molar surgery. [34] Jensen S. Hemorrhage after oral surgery: an analysis In: Kaban LB, Pogrel MA, Perrot DH, editors. of 103 cases. Oral Surg Oral Med Oral Pathol 1974; Complications of oral and maxillofacial surgery. 37:2. Philadelphia: WB Saunders Co.; 1997. p. 59–68. [35] Heiland M, Weber M, Schmelzle R. Life-threatening[18] Mehrabi M, Allen JM, Roser SM. Therapeutic bleeding after dental extraction in a hemophilia A agents in perioperative third molar surgical proce- patient with inhibitors to factor VIII: a case report dures. Oral Maxillofac Surg Clin North Am 2007; received from University Hospital Hamburg-Eppen- 19:69–84. dorf, Hamburg, Germany. J Oral Maxillofac Surg[19] Susarla S, Blaeser B, Magalnick D. Third molar sur- 2003;61:1350. gery and associated complications. Oral Maxillofac [36] Guibert-Tranier F, Piton J, Riche MC, et al. Vascu- Surg Clin North Am 2003;15:177. lar malformations of the mandible (intraosseous[20] Birn H. Etiology and pathogenesis of fibrinolytic haemangiomas): the importance of preoperative em- alveolitis. Int J Oral Surg 1973;2:211. bolization. A study of 9 cases. Eur J Radiol 1982;[21] Nitzan DW. On the genesis of ‘‘dry socket.’’ J Oral 2:257. Maxillofac Surg 1983;41:706. [37] Larsen PE, Peterson LJ. A systematic approach[22] Alexander RE. Dental extraction wound manage- to management of high-flow vascular malforma- ment: a case against medicating postextraction tions of the mandible. J Oral Maxillofac Surg sockets. J Oral Maxillofac Surg 2000;58:538. 1993;51:62.[23] Sekhar CH, Narayanan V, Baig MF. Role of antimi- [38] Kawano K, Mizuki H, Mori H, et al. Mandibular ar- crobials in third molar surgery: prospective, double teriovenous malformation treated by transvenous blind, randomized, placebo-controlled clinical coil embolization: a long-term follow-up with special study. Br J Oral Maxillofac Surg 2001;39:134. reference to bone regeneration. J Oral Maxillofac[24] Foy SP, Shugars DA, Phillips C, et al. The impact of Surg 2001;59:326. intravenous antibiotics on health-related quality of [39] Libersa P, Roze D, Cachart T, et al. Immediate and life outcomes and clinical recovery after third molar late mandibular fractures after third molar removal. surgery. J Oral Maxillofac Surg 2004;62:15. J Oral Maxillofac Surg 2002;60:163.[25] Poeschl PW, Eckel D, Poeschl E. Postoperative pro- [40] Alling C, Alling R. Indications for management of phylactic antibiotic treatment in third molar surgery: impacted teeth. In: Alling C, Helfrick J, Alling R, ed- a necessity? [see comment]. J Oral Maxillofac Surg itors. Impacted teeth. Philadelphia: WB Saunders 2004;62:3. Co.; 1993. p. 43–64.[26] Blum IR. Contemporary views on dry socket (alveolar [41] Nyul L. Kieferfracturen bei zahnextractionen. Zah- osteitis): a clinical appraisal of standardization, aetio- larztl Welt 1959;60. ¨ pathogenesis and management: a critical review [see [42] Iizuka T, Tanner S, Berthold H. Mandibular frac- comment]. Int J Oral Maxillofac Surg 2002;31:309. tures following third molar extraction: a retrospec-[27] Bulut E, Bulut S, Etikan I, et al. The value of routine tive clinical and radiological study. Int J Oral antibiotic prophylaxis in mandibular third molar Maxillofac Surg 1997;26:338. surgery: acute-phase protein levels as indicators of [43] Krimmel M, Reinert S. Mandibular fracture after infection. J Oral Sci 2001;43:117. third molar removal. J Oral Maxillofac Surg 2000;[28] Peltroche-Llacsahuanga H, Reichhart E, Schmitt W, 58:1110. et al. Investigation of infectious organisms causing [44] Pogrel M. Complications of third molar surgery. pericoronitis of the mandibular third molar. J Oral Oral Maxillofac Surg Clin North Am 1990;2:441. Maxillofac Surg 2000;58:611. [45] Gulbrandsen SR, Jackson IT, Turlington EG. Re-[29] Quayle AA, Russell C, Hearn B. Organisms isolated covery of a maxillary third molar from the infratem- from severe odontogenic soft tissue infections: their poral space via a hemicoronal approach. J Oral sensitivities to cefotetan and seven other antibiotics, Maxillofac Surg 1987;45:279. and implications for therapy and prophylaxis. Br J [46] Yeh C-J. A simple retrieval technique for acciden- Oral Maxillofac Surg 1987;25:34. tally displaced mandibular third molars. J Oral[30] Labriola JD, Mascaro J, Alpert B. The microbio- Maxillofac Surg 2002;60:836. logic flora of orofacial abscesses. J Oral Maxillofac [47] Patel M, Down K. Accidental displacement of im- Surg 1983;41:711. pacted maxillary third molars. Br Dent J 1994;177:57.[31] Falconer DT, Roberts EE. Report of an audit into [48] Sverzut CE, Trivellato AE, Lopes LM dF, et al. Ac- third molar exodontia. Br J Oral Maxillofac Surg cidental displacement of impacted maxillary third 1992;30:183. molar: a case report. Braz Dent J 2005;16:167.
    • 128 BOULOUX et al[49] Ertas U, Yaruz MS, Tozoglu S. Accidental third mo- case-cohort study. Oral Surg Oral Med Oral Pathol lar displacement into the lateral pharyngeal space. Oral Radiol Endod 2006;101:558. J Oral Maxillofac Surg 2002;60:1217. [68] Cheung LK, Samman N, Tideman H. Reconstruc-[50] Esen E, Aydogan LB, Akcali MC. Accidental dis- tive options for maxillary defects. Ann R Australas placement of an impacted mandibular third molar Coll Dent Surg 1994;12:244. into the lateral pharyngeal space. J Oral Maxillofac [69] Awang MN. Closure of oroantral fistula. Int J Oral Surg 2000;58:96. Maxillofac Surg 1988;17:110.[51] Gay-Escoda C, Berini-Aytes L, Pinera-Penalva M. [70] Tideman H, Bosanquet A, Scott J. Use of the buccal Accidental displacement of a lower third molar: re- fat pad as a pedicled graft. J Oral Maxillofac Surg port of a case in the lateral cervical position. Oral 1986;44:435. Surg Oral Med Oral Pathol 1993;76:159. [71] Dubin B, Jackson IT, Halim A, et al. Anatomy of the[52] Ehrl PA. Oroantral communication: epicritical buccal fat pad and its clinical significance. Plast study of 175 patients, with special concern to second- Reconstr Surg 1989;83:257. ary operative closure. Int J Oral Surg 1980;9:351. [72] Stuzin JM, Wagstrom L, Kawamoto HK, et al.[53] Punwutikorn J, Waikakul A, Pairuchvej V. Clinically The anatomy and clinical applications of the buccal significant oroantral communications: a study of inci- fat pad [see comment]. Plast Reconstr Surg 1990; dence and site. Int J Oral Maxillofac Surg 1994;23:19. 85:29.[54] Schuchardt K. Treatment of oro-antral perforations [73] Tostevin PM, Ellis H. The buccal pad of fat: a review. and fistulae. Int Dent J 1955;5. Clin Anat 1995;8:403.[55] Hanazawa Y, Itoh K, Mabashi T, et al. Closure of [74] Egyedi P. Utilization of the buccal fat pad for clo- oroantral communications using a pedicled buccal sure of oro-antral and/or oro-nasal communica- fat pad graft. J Oral Maxillofac Surg 1995;53:771. tions. J Maxillofac Surg 1977;5:241.[56] Sachs SA, Kay SA, Specter J, et al. Treatment of [75] Stajcic Z, Todorovic L, Pesic V, et al. Tissucol, gold a persistent oro-antral fistula with a posteriorly plate, the buccal fat pad and the submucosal palatal based lateral tongue flap. Int J Oral Surg 1979;8:225. island flap in closure of ororantral communication.[57] Carstens MH, Stofman GM, Sotereanos GC, et al. Dtsch Zahnarztl Z 1988;43:1332. A new approach for repair of oro-antral-nasal fistu- [76] Loh FC, Loh HS. Use of the buccal fat pad for cor- lae: the anteriorly based buccinator myomucosal rection of intraoral defects: report of cases. J Oral island flap. J Craniomaxillofac Surg 1991;19:64. Maxillofac Surg 1991;49:413.[58] Yamazaki Y, Yamaoka M, Hirayama M, et al. The [77] Hai HK. Repair of palatal defects with unlined buc- submucosal island flap in the closure of oro-antral cal fat pad grafts. Oral Surg Oral Med Oral Pathol fistula. Br J Oral Maxillofac Surg 1985;23:259. 1988;65:523.[59] Berger A. Oroantral openings and their surgical cor- [78] Abuabara A, Cortez ALV, Passeri LA, et al. Evalu- rection. Arch Otolaryngol 1939;30:400. ation of different treatments for oroantral/oronasal[60] Goldman EH, Stratigos GT, Arthur AL. Treatment communications: experience of 112 cases. Int J of oroantral fistula by gold foil closure: report of Oral Maxillofac Surg 2006;35:155. case. J Oral Surg (Chic) 1969;27:875. [79] Stajcic Z. The buccal fat pad in the closure of oro-[61] Mainous EG, Hammer DD. Surgical closure of antral communications: a study of 56 cases. J Cra- oroantral fistula using the gold foil technique. niomaxillofac Surg 1992;20:193. J Oral Surg (Chic) 1974;32:528. [80] Baumann A, Ewers R. Application of the buccal fat[62] Magnus WW, Castner DV Jr. Closure of oronasal pad in oral reconstruction. J Oral Maxillofac Surg fistula with gold plate implant. Oral Surg Oral 2000;58:389. Med Oral Pathol 1971;31:460. [81] Martin-Granizo R, Naval L, Costas A, et al. Use of[63] Fredrics HJ, Scopp IW, Gerstman E, et al. Closure buccal fat pad to repair intraoral defects: review of of oroantral fistula with gold plate: report of case. 30 cases. Br J Oral Maxillofac Surg 1997;35:81. J Oral Surg (Chic) 1965;23:650. [82] Dolanmaz D, Tuz H, Bayraktar S, et al. Use of ped-[64] Killey HC, Kay LW. An analysis of 250 cases of oro- icled buccal fat pad in the closure of oroantral com- antral fistula treated by the buccal flap operation. munication: analysis of 75 cases. Quintessence Int Oral Surg Oral Med Oral Pathol 1967;24:726. 2004;35:241.[65] James RB. Surgical closure of large oroantral fistu- [83] Huang GJ, LeResche L, Critchlow CW, et al. Risk fac- las using a palatal island flap. J Oral Surg (Chic) tors for diagnostic subgroups of painful temporoman- 1980;38:591. dibular disorders (TMD). J Dent Res 2002;81:284.[66] Ito T, Hara H. A new technique for closure of the [84] Threlfall AG, Kanaa MD, Davies SJ, et al. Possible oroantral fistula. J Oral Surg (Chic) 1980;38:509. link between extraction of wisdom teeth and tempo-[67] Thoma K, Pajarola GF, Gratz KW, et al. Bioab- romandibular disc displacement with reduction: sorbable root analogue for closure of oroantral com- matched case control study. Br J Oral Maxillofac munications after tooth extraction: a prospective Surg 2005;43:13.