International Journal of Social Rehabilitation

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 3  |  Issue : 1  |  Page : 14--23

Prediction of postoperative outcome in mandibular third molar surgery based on preoperative variables: A Prospective clinical study


Kamal Kanthan Ravikumar1, Vinod Narayanan2, Mathivanan2,  
1 International Medical Center, Jeddah, Saudi Arabia
2 Departmant of OMFS, Saveetha Dental College, Chennai, Tamil Nadu, India

Correspondence Address:
Dr. Kamal Kanthan Ravikumar
International Medical Center, PO Box: 2172, Jeddah 21451
Saudi Arabia

Abstract

Aims: The aim of the present study is to investigate the relationship between preoperative findings and the postoperative outcome following surgical removal of lower third molar. Settings and Design: This is a prospective observational study conducted at the Department of Oral and Maxillofacial Surgery, Saveetha University. A total of 104 patients requiring surgical removal of unilateral third molar were evaluated. Patients who were on antibiotics and analgesic for an underlying problem related to impacted third molars preoperatively were excluded. Preoperative variables evaluated were age, sex, maximum interincisal distance, facial measurements both vertical and horizontal, radiographic measurement of position, class, angulation of impacted lower third molar, experience of operator, and duration of surgery. Postoperative evaluation was done on the 1st and 4th day and 7th postoperative day, and the following parameters were evaluated: facial swelling, pain, dry socket, secondary infection, paresthesia, postoperative bleeding, and fracture of jaw. Statistical Analysis Used: The preoperative parameters and postoperative outcomes were compared and correlated using one-way ANOVA, independent “t” test, and Chi-square test. Results: There is statistically significant result to demonstrate that pain and swelling increase with age, the depth of impaction, and when there is no adequate available space between the anterior border of ramus and second molar. As duration of surgery increases, pain, swelling, trismus, and frequency of dry socket increase in our study. Frequency of dry socket increases with increased depth of impaction. Conclusions: In our study, age, sex, the depth of impaction, the space available for the impacted tooth between the anterior border of ramus and second molar, duration of surgery, and horizontal and distoangular impactions have a positive correlation with the outcome of surgical removal of third molar.



How to cite this article:
Ravikumar KK, Narayanan V, Mathivanan. Prediction of postoperative outcome in mandibular third molar surgery based on preoperative variables: A Prospective clinical study.Int J Soc Rehabil 2018;3:14-23


How to cite this URL:
Ravikumar KK, Narayanan V, Mathivanan. Prediction of postoperative outcome in mandibular third molar surgery based on preoperative variables: A Prospective clinical study. Int J Soc Rehabil [serial online] 2018 [cited 2019 Jul 21 ];3:14-23
Available from: http://www.ijsocialrehab.com/text.asp?2018/3/1/14/244543


Full Text



 Introduction



Anthropologists state that the constantly increasing cerebration of man enlarges his braincase at the expense of his jaws. The surgical removal of third molar is and will still be in the light of changing aspects of dentistry as we know them, the most common and at times, the most perplexing oral surgical problem. All the clear-cut basic principles applicable in surgery are made use of here. Mandibular third molar impaction is a common condition, giving rise to symptoms, which necessitates its removal. Some of these teeth can be extracted without prior removal of surrounding bone, but most impacted lower wisdom teeth require surgical intervention. The surgical removal of impacted third molar is the most common surgical procedure in oral and maxillofacial surgery, and the postoperative course is not without complication.[1],[2],[3],[4],[5],[6] Patients are becoming more demanding in their expectation of treatment. Surgical extraction techniques are constantly being refined to minimize postoperative morbidity. There have been few attempts to study patients' expectations of outcome although patients' perception of recovery after third molar surgery has been reported.[7],[8] It is more informative from a patient's point of view to relate outcome to factors that can be measured preoperatively than to rely on an overall probability.

Aim of the study

The aim of the present study is to investigate the relationship between preoperative findings and the postoperative outcome following surgical removal of lower third molar.

 Subjects and Methods



This is a prospective observational study conducted at the Department of Oral and Maxillofacial Surgery, Saveetha University. The study was approved by the institutional ethics committee. Any patients requiring unilateral surgical removal of the impacted lower molar are included. Patients who are already on medications such as antibiotics and analgesic for problems related to impacted third molars preoperatively. Preoperative variables evaluated were age, sex, maximum interincisal distance (MID), facial measurements both vertical – measured from outer canthus of eye to angle of mandible and horizontal – measured from tragus to angle of mandible, radiographic measurement of position, class, angulation of impacted lower third molar, experience of operator, and duration of surgery [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13].{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}{Figure 10}{Figure 11}{Figure 12}{Figure 13}

Surgical procedure

All operations were done under local anesthesia by the 2nd year and 3rd year oral and maxillofacial surgery postgraduate trainees with uniform institutional surgical training in the same operating room and under similar operating conditions. Anesthesia was achieved by inferior alveolar nerve (IAN) block and buccal nerve block and with 2 ml of 2% lignocaine with 1:200,000 adrenaline. The incision used in the surgery was a three-cornered flap with an anterior releasing incision at distal aspect of the first or second molar depending on the individual requirements.

For the first 5 postoperative days, all patients were given antibiotics such as amoxicillin 500 mg thrice daily for 5 days and analgesics such as ibuprofen 400 mg + paracetamol 500 mg 8th h for 5 days. At the end of each surgery, the duration of the surgery was noted. The following parameters were measured on the 1st, 4th, and 7th postoperative days: pain measured by visual analog scale (VAS), MID measured subjectively by the same examiner, dry socket, paresthesia, postoperative bleeding, and fracture of Jaw.

 Results



Of 104 patients, 61 were male and 43 were female. The mean age was 31 ± 7 years. According to the radiographic assessment of impacted tooth, the following variables were noted: number of teeth (Position A – 62, Position B – 38, Position C – 4, Class relation I – 52, Class II relation – 50, Class III relation – 2, and horizontal impaction – 28), mesioangular impaction – 44, vertical impaction – 16, and distoangular impaction – 16.

The preoperative parameters and postoperative outcomes were compared and correlated using one-way ANOVA, independent “t” test, and Chi-square test:

Correlation between age and swelling [Table 1]: As the age of the patient increases, swelling increases, but it is not statistically significant. There is a positive correlation between age and swellingCorrelation between age and pain [Table 2]: As the age of the patient increases, pain measured using VAS also increases. There is a positive correlation between age and pain. There is mild statistically significant value (P = 0.053)Correlation between age and interincisal distance (trismus) [Table 3]: There was no correlation between age and trismusCorrelation between position of tooth (depth of impaction) and swelling [Table 4]: As the depth of impaction increases from Position A to Position C, the swelling also increases. It is statistically significant. The mean value of Position B is larger than that of Position A. However, the mean value of Position C is less compared to A and B. This is because the number of impacted teeth in Position C was only 4Correlation between position and pain [Table 5]: There is a statistically significant value to prove that as the depth of impaction increases, pain also increases (P = 0.00). The mean value of Position C is 2.61, which is higher than that in Position A and Position BCorrelation between position and mean interincisal distance [Table 6]: As the depth of impaction increases, trismus also increases. There is a positive correlation, but it is not statistically significant. The mean value in Position C is less than that as compared to Position A and Position B which demonstrates that the mouth opening is restricted as the depth of impaction increasesCorrelation between space availability for impacted third molar and swelling (class and swelling) [Table 7]: As the space available for the impacted third molar decreases, that is, as the relationship between the second molar and anterior border of ramus proceeds from Class I to Class III, swelling increases in size. There is a positive correlation and it is statistically significant (P = 0.051)Correlation between space available for impacted third molar and pain (class and pain) [Table 8]: As the space available for the impacted third molar decreases, that is, as the relationship between the second molar and anterior border of ramus proceeds from Class I to Class III, pain increases. There is a positive correlation and it is statistically significant (P = 0.00)Correlation between space available for impacted third molar and MID [Table 9]: As the available space between the second molar and anterior border of ramus decreases, the mean interincisal distance also decreases. The mean value in Class III is 37 and is less as compared to Class I and Class II, which shows that there is an increased trismus when the available space for the impacted third molar decreasesCorrelation between angulation of impacted third molar and long axis of second molar and swelling [Table 10]: Horizontally impacted third molar has increased postoperative swelling followed by distoangular, mesioangular, and vertical impaction (mean value). However, it was not statistically significantCorrelation between angulation of impacted third molar and long axis of second molar and pain [Table 11]: The distoangular impaction (mean value: 2.21) has more pain as compared to horizontal impaction (mean value: 2.18) followed by mesioangular (mean value: 2.10) and vertical impaction (mean value: 2.07). However, it was not statistically significantCorrelation between angulation of impacted third molar and long axis of second molar and MID [Table 12]: There is no statistically significant correlation between angulation of impacted third molar and long axis of second molar and MID, but distoangular impaction results in restricted mouth opening postoperatively (mean value: 39.4) as compared to the rest of the typesCorrelation between duration of surgery and swelling [Table 13]: In our study, there is a positive correlation between the duration of surgery and swelling. The swelling increases as the duration of surgery increases. It is statistically significant (P = 0.01 on day 4 and P = 0.03 on day 7)Correlation between duration of surgery and pain [Table 14]: There is a positive correlation between duration of surgery and pain. As the duration of surgery increases, pain also increases. It is statistically significant (P = 0.001)Correlation between duration of surgery and dry socket [Table 15]: There is a positive correlation between dry socket and duration of surgery. In our study, as the duration of surgery increases, the frequency of dry socket increases. It is statistically significant (P = 0.012)Correlation between depth of impaction and dry socket [Table 16]: Of three cases of dry socket, all three were in Position B. No statistically significant value was obtained. Of 38 cases in Position B, there were 3 reported cases of dry socket as supposed to 61 impacted teeth in Position A and 4 impacted teeth in Position CCorrelation between class of impaction and dry socket [Table 17]: There is no statistically significant correlation between the class of impaction and the occurrence of dry socket. Of three cases of dry socket, two impacted lower teeth were in Class I relation and one in Class II relationCorrelation between angulation of third molar and second molar and dry socket [Table 18]: Of three cases of dry socket occurring, two teeth were distoangular impactions and one was mesioangular impaction. There was no statistically significant result.{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}{Table 9}{Table 10}{Table 11}{Table 12}{Table 13}{Table 14}{Table 15}{Table 16}{Table 17}{Table 18}

 Discussion



Surgical removal of impacted third molar is the single most commonly performed operation by oral and maxillofacial surgeons; however, like many other clinical problems, the impacted third molar presents more a question of management than of treatment. Although many asymptomatic third molars are discovered on routine panoramic radiographic examination, frequently pain is the sole presenting complaint.[9] Surgical removal of impacted third molars often involves pain, swelling, and dysfunction during postoperative period.[10],[11],[12],[13],[14],[15] The factors that contribute to determining this situation are many and complex, but they originate with the inflammatory process initiated by surgical trauma.[16]

Numerous studies in literature reported the incidence of postoperative complications, but few have prospectively evaluated the variables that can affect the postoperative recovery. Extraction of totally impacted third molars inevitably causes postoperative pain and discomfort. The factors that affect postoperative recovery are many; some are unknown or inferred from retrospective analysis, but studies have always been limited to analysis of one or a few variables at a time. This has often led to conflicting results as a result of the different study samples used by various authors, the different types of patients and survey times, or the different objective clinical evaluation of the variable studied.

In this, all the variables have been analyzed for a full week in the context of a single and wide study population. Age is commonly cited as a risk factor for postextraction complication.[17],[18] This positive correlation may be related to increased bone density which may result in more manipulation during the operation.[19] In addition to change in bone density, increased age is associated with complete bone formation and diminished wound healing capacity, which can result in higher operative and inflammatory complications. In our study, increase in age resulted in increased swelling, but it was not statistically significant.

However, there was a statistically significant value (P = 0.053) to demonstrate an increase in pain resulted with increase in age. There was no correlation between age and trismus from our study. All 3 phenomena swelling, pain and trismus may reflect the formation of prostaglandins and other mediators of pain and swelling from membrane phospholipids released as a result of surgery. It thus seems reasonable to support that the severity of pain, swelling, and trismus should be related to aggressiveness of surgery.[20] In our study, as the depth of impaction increases, the swelling also increases. It is statistically significant (P = 0.051).

There is statistical significance (P = 0.00) to demonstrate that as the depth of impaction increases, pain also increases. There is a positive correlation between depth of impaction and trismus. Although not statistically significant, the mean value in Position C is less than that as compared to Position A and Position B, which shows that the mouth opening is restricted as the depth of impaction increases. In our study, there is a statistically significant data (P = 0.051) to support that as the space available for the third molar to erupt decreases, swelling increases. There is also a positive correlation between space availability and pain, and it is statistically significant (P = 0.00). Correlation between space availability and trismus shows that the mean value in Class III is 37 and is less as compared to Class I and Class II, which explains the above correlation.

In our study, horizontally impacted third molars (mean value: 104.7) resulted in swelling compared to other types of impaction, but there was no statistical significance. Similarly, distoangular impaction (mean value: 2.21) resulted in more pain compared to other types of impaction, and distoangular impaction (mean value: 39.4) resulted in trismus; this again can be explained by the fact that as the duration of surgery increases, pain also increases and mostly distoangular impactions considered to be the most difficult of surgical removal methods may prevent patient from opening the mouth due to pain.

The reported incidence of alveolar osteitis following removal of third molar teeth generally ranges from 0.5%[21] to 16.6%,[22] but figures as high as 37.5% or even 68.4% have also been reported. In our study, increase in duration of surgery and increase in depth of impaction increased the chances of occurrence of dry socket. The result of the study is not age dependent as reported by MacGregor.[23]

There is a positive correlation between duration of surgery and pain and it is statistically significant and P = 0.001. There is also a statistically significant value (P = 0.012) to demonstrate that as the duration of surgery increases, the frequency of dry socket also increases. Position and class of impaction do not have any statistically significant correlation with the occurrence of dry socket.

Alveolar osteitis is a clinical complication of considerable importance. Its prevention would benefit both patients and profession alike. The amount of facial swelling varied depending on age and sex.[23] Pain after third molar removal has to be a useful clinical model for the evaluation of analgesic.[24],[25] The assessment of pain using VAS is subjective, and pain assessed in this way varies considerably among individual.[26]

The four most common postoperative complications reported in literature were alveolar osteitis, infection, bleeding, and paresthesia.[27] Although three cases of alveolar osteitis were encountered in our study, other complications such as postoperative infection, bleeding, and paresthesia were not encountered. Reported infection rate ranges from 0.9% to 4.3%.[28] The frequency of clinically significant bleeding ranges between 0.2% and 5.8%.[27] In literature, IAN injuries ranges from 1.3% to 5.3% and lingual nerve was between 0% and 23%.

 Conclusions



In our study, age, sex, the depth of impaction, the space available for the impacted tooth between the anterior border of ramus and second molar (class), duration of surgery, and horizontal and distoangular impactions have a positive correlation with the outcome of surgical removal of third molar. There is a statistically significant outcome when comparing age and the postoperative pain and swelling in which swelling and pain increased with age which is synonymous with previous studies. There is also a positive outcome of statistical significance comparing the depth of impaction (position) to pain, swelling, and trismus, in which all the above show an increasing tendency when the depth of impaction increases. The class of impaction, that is, the space available between the anterior border of ramus and second molar, has a statistically significant outcome on pain, swelling, trismus, and dry socket. In other words, as the available space for the third molar decreases, we observed an increase in outcomes such as pain, swelling, and trismus in our study. Finally, as the duration of surgical procedure increased, there was an increase in swelling, pain, and occurrence of dry socket, which was statistically significant. However, our study has certain limitations and that is because of the observational nature of the study, our results should be interpreted with caution. Although we were able to include a number of significant preoperative variable to correlate postoperative outcomes, we did not compare the individual experience of the operators as done in other studies.[29] Although the surgical procedure was done by second year and third year maxillofacial surgical trainees with uniform institutional training and working in the same operating room under similar operating conditions, further studies of the association between preoperative findings and short-term outcome with a much larger sample size will help elucidate the true nature of the association.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The author would like to acknowledge his parents and Dr. Vinod Narayanan, MDS, FDSRCS, MOMSRCPS.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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