Third molar surgery

Oral Maxillofacial Surg Clin N Am 15 (2003) 177 – 186

Third molar surgery and associated complications
Srinivas M. Susarla, BSa, Bart F. Blaeser, DMD, MDb,*,
Daniel Magalnick, DMDa,b
a
Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115, USA
b
Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA

Third molar surgery is the most common proce- direct focused pressure. Persistent intraoperative
dure performed by oral and maxillofacial surgeons. A bleeding commonly can be controlled with additional
thorough understanding of the complications associ- sutures to the wound. Other surgical adjuncts include
ated with this procedure will enable the practitioner to the application of topical thrombin to the wound or
identify and counsel high-risk patients, appropriately the use of a packing medium, such as Gelfoam or
manage more common complications, and be cog- Surgicel. Arterial bleeding, if identified, is best
nizant of less common sequelae and the most effec- treated with vessel identification and subsequent
tive methods of management. ligation or cautery.
Surgical extraction of third molars is often accom- Surgical edema is an expected sequela of removal
panied by pain, swelling, trismus, and general oral of impacted teeth. Swelling usually reaches a max-
dysfunction during the healing phase. Careful sur- imum level 2 to 3 days postoperatively and should
gical technique and scrupulous perioperative care can subside by 4 days and be completely resolved by
minimize the frequency of complications and limit 7 days [1]. The use of ice and head elevation in the
their severity. Although this article discusses compli- perioperative period may limit postoperative swelling
cations and management, it is by no means an and improve patient comfort [1]. The preoperative
exhaustive appraisal of the current body of literature. use of systemic corticosteroids has been advocated to
reduce immediate swelling, but debate still exists as
to their efficacy [2,3].
Mild bleeding, surgical edema, trismus, and Trismus is often the result of surgical trauma and
postoperative pain is secondary to masticatory muscle and fascial
inflammation. As with surgical edema, there is evi-
Complications such as pain, swelling, and trismus dence to support the preoperative use of steroids in
are anticipated after the removal of third molars. reducing postoperative trismus [2]. No current agree-
Although transitory, these conditions can be a source ment exists as to the most beneficial dose, type, or
of anxiety for the patient. Much of this anxiety can be timing of its administration, however. Measurement
alleviated if there is a preoperative discussion of the of interincisal opening preoperatively and at follow-
expected perioperative course. up ensures that the patient returns to the preoperative
Mild bleeding can be managed effectively with level of function.
local measures. Most bleeding can be managed by Pain caused by third molar surgery usually begins
applying gauze packing over the extraction site with after the anesthesia from the procedure subsides and
reaches peak levels 6 to 12 hours postoperatively.
Pain is anticipated, and the use of numerous analge-
* Corresponding author. North Shore Medical and sics, including nonsteroidal antiinflammatory drugs
Dental Center, Salem Peabody Oral Surgery Inc., 6 Essex and narcotics, has been advocated for management.
Center Drive, Peabody, MA 01960. Selected studies have suggested a role for the pre-

1042-3699/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1042-3699(02)00102-4

178 S.M. Susarla et al. / Oral Maxillofacial Surg Clin N Am 15 (2003) 177–186

operative use of nonsteroidal antiinflammatory drugs for development of osteitis, which suggests the role
to decrease postoperative pain [4]. of bacteria in fibrinolysis [5].
Methods for reducing the incidence of alveolar
osteitis have been recommended. Depending on the
Common complications and their management risk level of the patient, different courses of action
may be indicated. Some researchers have advocated
Alveolar osteitis the routine use of prophylactic agents for inexperi-
enced surgeons [5]. Various measures can be taken to
Alveolar osteitis is one of the most common reduce the incidence of alveolar osteitis, including
complications associated with third molar surgery evacuation of the vacant socket via saline irrigation
[5,6]. It is characterized by a severe throbbing pain [12], the use of topical antibiotics, such as tetracy-
that usually begins 3 to 5 days postoperatively [5]. By cline powder, within the socket [16], placement of
this time, most of the pain and swelling associated Gelfoam packing soaked in antibiotic media [17], and
with surgical trauma should disappear, and residual the perioperative use of chlorhexidine rinses [18].
radiating pain to the ear is a common complaint in
patients with alveolar osteitis. The causes of this Early postoperative infections
painful condition, commonly known as ‘‘dry socket,’’
are not completely known but are considered to be Because of the large variety of indigenous oral
related to malformation or disruption of blood clots in flora, postoperative infection is of concern. Although
a newly vacated third molar socket [7]. Although data the use of aseptic technique, hemostasis, meticulous
support the rationale that alveolar osteitis can be tissue management, and complete and thorough la-
caused independent of fibrinolysis, destruction of a vage of extraction sites can decrease the likelihood of
formed thrombus by invading oral bacteria is gen- postoperative infection, the routine use of antibiotic
erally accepted as a more important etiologic factor therapy to prevent infection is still debated [18 – 20].
[8,9]. This conclusion is supported by data that The overall incidence of infection from third
indicate that the use of antifibrinolytic agents de- molar extraction has been reported to be in the range
creases the incidence of alveolar osteitis and that of 3% to 5% [14,21]. It has been suggested that the
saliva with a high bacterial count is associated with rates of postoperative infection are higher for man-
an increased incidence [5]. dibular bony impactions than for any other type of
Overall rates of alveolar osteitis vary in the extractions, reflective of the increased surgical trauma
literature from 1% to 30% [5,10]. The variability of [13 – 15]. Surgical experience also can influence the
reported percentages can be attributed largely to rate of secondary infection [14,15]. Systemic anti-
ambiguous diagnostic criteria. Multiple authors have biotics have been of suggested value for infection
shown that factors such as age, sex, surgical experi- prevention in patients with gingivitis, pericoronitis, or
ence, type of extraction, tobacco use, oral contracep- general debilitating diseases, but their effectiveness in
tive use, and use of irrigation intraoperatively affect reducing postoperative infections overall remains
the incidence of alveolar osteitis, but the mechanism controversial [19,20,22].
of their effects is not clear. Mandibular third molar The incidence of deep fascial space infection is
surgery is more commonly associated with alveolar low [6,23,24]. Management of these more severe
osteitis than maxillary third molar surgery [11,12]. infections depends on the severity. Treatment should
Incidence also increases with patient age. Patients include proper assessment and management of the
under the age of 20 are considered a low-risk popu- airway, adequate imaging, dependent drainage with
lation for this problem, which may be because the culture and sensitivity testing, and appropriate use
bone in these patients has more elasticity, circulation, of antibiotics.
and greater healing capacity [6,13,14]. Patients who
take oral contraceptives [6] and patients who are Excessive postoperative bleeding
habitual tobacco users [5] seem to be at a greater
risk for development of alveolar osteitis. The onset of Excessive bleeding is defined as bleeding beyond
alveolitis has been found to be higher in women than that expected from the extraction or continued bleed-
in men, possibly skewed by the use of oral contra- ing beyond the postoperative window for clot forma-
ceptives [5,6]. Surgical experience seems to be inver- tion (6 – 12 hours). Various risk factors for excessive
sely related to the incidence of alveolar osteitis postoperative bleeding related to third molar surgery
[5,15]. Patients with preexisting pericoronitis and have been identified, and methods for management
patients with poor oral hygiene are at increased risk have been studied [6,15,25 – 28].

S.M. Susarla et al. / Oral Maxillofacial Surg Clin N Am 15 (2003) 177–186 179

Excessive bleeding and hemorrhage have been second molar, increased mesioangular positioning of
reported to occur in the range of 1% to 6% of third the third molar, close proximity and contact of second
molar surgery [25,26]. Preoperative assessment of and third molar roots, and resorption of the second
intrinsic coagulation disorders and the use of anti- molar root [30]. Identification of high-risk patients
coagulant and antiplatelet medications (ASA, Cou- preoperatively and case-specific intervention are the
madin, Plavix) are essential. Of the predisposing risk best courses of action to minimize this problem.
factors reported, the most important is the level of
the impaction and its proximity to the neurovascu-
lar bundle [15,27,28]. Excessive bleeding has been Less common complications and
reported to occur more frequently with the extraction their management
of mandibular third molars versus their maxillary
counterparts. Excessive bleeding is more frequent, Fractures
regardless of the type of impaction, for inexperienced
surgeons [15,27]. It is also more commonly reported Although they occur infrequently (0.00049%)
in older patients, probably because of vascular fra- during the extraction of third molars, fractures of
gility and less effective coagulation mechanisms the mandible (Fig. 1) are of serious consequence,
[26,27]. It is reported that men are as much as 60% particularly if associated with nerve injury [31].
more likely to suffer from excessive bleeding than Fractures usually occur when excessive force is used
women, possibly because of the higher incidence of to extract a tooth, although even small forces can
contraceptive use in women and the positive effect of cause fractures for deeply impacted teeth. Because of
oral contraceptives on coagulation [6,27]. extremely small numbers, specific risk factors are
Identification of patients at risk is a critical first difficult to identify. Some studies have shown older
step in appraising the likelihood of bleeding compli- age as a risk factor [32]. Fracture also can occur in
cations after third molar surgery. During the preop- delayed fashion, sometimes weeks after tooth remov-
erative consultation, it is imperative that the surgeon al. Treatment should include a standard approach of
inquire about any past surgeries and the occurrence of reduction and stabilization using intermaxillary fixa-
associated bleeding complications. Any family his- tion or rigid internal fixation (Fig. 2).
tory of bleeding abnormalities should be elicited. Ex-
cessive bleeding with loss of deciduous teeth and, in Damage to adjacent teeth
women, a history of menorrhagia, can be suggestive
of an underlying coagulopathy. Intraoperatively, care- Because of the force required to remove third
ful soft tissue management and local measures can molars, it is possible to damage adjacent teeth during
control and prevent most bleeding problems. Hemor- the procedure [33]. Inadvertent fracture of adjacent
rhage that cannot be controlled with local measures is teeth can be minimized if care is taken to visualize the
rare. In such isolated cases, interventional radiology entire operating field rather than the tooth or teeth
with selective embolization or proximal vessel iden- being extracted. A surgeon who is aware of the pe-
tification and ligation may be required [29]. riphery of the operating field often is able to anticipate
possible damage and take action to prevent its occur-
Wound healing problems rence. Even with adequate awareness and careful
surgical technique, however, fractures of carious or
Risk factors for poor wound healing have been heavily restored teeth are sometimes unavoidable.
identified. A 1993 workshop of the American Asso- Preoperative discussion regarding fractures is the best
ciation of Oral and Maxillofacial Surgeons (AAOMS) measure. When carious teeth or restorations exist, the
identified the following patient risk factors: patho- practitioner should advise the patient of the possibility
genic accumulation and periodontal compromise ad- that these structures may sustain damage and explain
jacent to the wound site, tobacco use, and increasing what is done if such a situation occurs.
age over 25 years [30]. The report of the workshop If an adjacent tooth is luxated or avulsed inadver-
also stated that wound healing is more rapid and tently, the most common course of action is reposi-
complications less frequent when third molars are tioning of the tooth followed by fixation, if needed
removed before complete root development and that [33]. Fixation often can be obtained using additional
various factors affect wound healing independent of sutures placed laterally across the occlusal surface,
age. Patients who display at least three of the fol- thereby holding the tooth in place. Use of other
lowing factors were defined to have an increased risk means of fixation, including dental wires, arch bars,
of wound compromise: bony defects distal to the and composite splints, also has been effective [33].


Fig. 1. Postoperative panoramic radiograph displaying a displaced right mandibular angle fracture in the line of a recently
removed lower third molar.

Fig. 2. Panoramic radiograph after reduction and rigid internal fixation of the mandible fracture.


Periodontal defects may be required to contain the blood clot and facilitate
healing, along with a course of antibiotics and the
Periodontal defects after third molar surgery often continued use of commercial oral or nasal deconges-
can be anticipated before surgery based on the tants. For larger fistulae ( 7 mm in diameter) and for
patient’s age and preoperative periodontal health. patients with a history of secondary chronic sinusitis,
Although there is controversy regarding the removal ´
surgical intervention, including sinus debridement and
of asymptomatic third molars, it is generally accepted drainage, polypectomy, and closure by flap devel-
that prophylactic removal of deeply impacted third opment, are recommended. Antibiotic and deconges-
molars is contraindicated in older patients with good tant therapies also should be prescribed.
periodontal health [34 – 38].
Of general concern is the effect of removal of Displacement of teeth
third molars on the periodontal health of the second
molars, specifically bone height and pocket depth Displacement of teeth or tooth fragments into
[39,40]. In most cases, there is negligible difference either fascial spaces or the maxillary sinus, although
between the preoperative and postoperative height of not a common occurrence, is one that demands
bone on the distal aspect of the second molar [41,42]. attention. Anecdotal descriptions of such occurrences
With this in mind, it is generally accepted that bone are common. Decisions to remove teeth after dis-
healing is more predictable if the third molar is placement should be planned using three-dimensional
removed before the presence of bone loss along the analysis from radiographs or tomographic cuts.
distal aspect of the second molar [42 – 44].
In general, periodontal defects after third molar
surgery are most likely to occur in older patients Nerve injuries after third molar removal
( 35 years), especially if there is existing bone loss
along the distal aspect of the second molar and if Among the most serious and often discussed
periodontal lesions, which are commonly associated postoperative complications that arise from third
with partially erupted third molars, exist. For these molar surgery is trigeminal nerve injury, specifically,
patients, it is not advisable to perform the extrac- involvement of either the inferior alveolar or lingual
tions unless pathologic indications necessitate such nerve. These nerves can be damaged as the result of
surgery [45]. direct or indirect forces. Direct injuries include those
that result from anesthetic injections, crush injuries,
Oroantral communication and fistula formation injuries sustained during the extraction process or soft
tissue management, and damage caused by the use of
Occasionally, the removal of maxillary third mo- instruments. Indirect injuries to nerves can be the
lars results in a communication between the oral cav- result of physiologic phenomena, including root
ity and the maxillary sinus [33]. For deeply impacted infections, pressure from hematomas, and postsurgi-
maxillary molars and teeth that have roots with large cal edema [46].
surface area, it is possible that the antral floor will be The overall risk of inferior alveolar nerve injury
violated during tooth removal. Two common sequelae associated with third molar removal ranges from
associated with this complication are maxillary sinusi- 0.5% to 5% [47,48]. In most cases, the injured nerve
tis and chronic oroantral fistula formation. The degree recovers spontaneously. The reported rate of perma-
of severity of these conditions is dictated largely by nent inferior alveolar nerve injury is considerably less
the size of the communication and the preoperative than 1% [49 – 55].
sinus status. Preoperative imaging is helpful but not The proximity of the mandibular third molar root
entirely predictive of sinus involvement. and the inferior alveolar nerve may be suspected from
Treatment of oroantral fistulae depends on the size panoramic or periapical radiographs. Statistically sig-
of the opening between the maxillary sinus and the nificant high-risk radiologic signs include a narrow-
oral cavity [33]. If the opening is small ( 2 mm in ing or deviation of the canal, a loss of the canal
diameter), surgical intervention is seldom required cortical outline, and increased radiolucency over the
and closure usually follows effective medical man- root [52]. Although these features provide prelim-
agement. Patients should be instructed not to engage inary evidence that the nerve may be encountered
in activities that rapidly change the pressure equilib- during extraction, injuries may occur independent of
rium of the sinuses, including nose blowing, sucking the presence of any of these factors.
on straws, smoking, and forceful sneezing. For larger The incidence of lingual nerve injury is consid-
openings (2 – 6 mm in diameter), additional suturing erably lower than for inferior alveolar nerve injury


Fig. 3. Close-up image of an impacted mandibular third molar. Note the associated pericoronal lucency and clear evidence of
high-risk findings: divergence of the inferior alveolar canal, loss of the cortical white line, and darkening of the root. This patient
was symptomatic with one previous episode of infection.

and ranges from 0.02% to 0.06%. In the presence of rants careful investigation into the possibility of
injury, however, spontaneous recovery is less com- nerve injury. Complete and thorough neurosensory
mon [56 – 60]. The anatomic position of the lingual testing and documentation are imperative. Accepted
nerve varies considerably. Although the nerve itself is methods include examination of fine touch and di-
commonly located near the lingual cortex of the rection proprioception, two-point discrimination, use
mandibular third molar, it can be located anywhere of sequential von Frey’s hairs, temperature sensation,
within the space between the mylohyoid muscle and and detection of sharp and dull objects. A subjective
the gingival crevice [61]. Soft tissue manipulation evaluation of taste also should be documented. Dia-
that involves elevation and protection of the lingual gram and chart use is recommended [63]. Although
periosteum (as routinely performed during the lingual the incidence of permanent nerve dysfunction is rare,
split technique) has been discussed as an etiologic early consultation with a microsurgical specialist is
factor for transitory lingual nerve injury. encouraged because early surgical repair has been
Descriptive nomenclature exists for categorizing shown to be associated with the most favorable
nerve injury. A commonly accepted classification outcome [64,65].
separates neural trauma into three categories: neuro- Factors that predispose patients to specific nerve
praxia, axonotmesis, and neurotmesis [62]. Inhibition injuries have been investigated and identified thor-
of conduction signals caused by damage of the oughly [66]. Dental, radiologic, and patient variables
myelin sheath is known as neuropraxia. Disruption can affect the incidence of nerve injuries. Root
of the axonal system without accompanying injury to proximity to the inferior alveolar canal, as ascertained
the nerve trunk is known as axonotmesis. Neuro- from radiographs, has been shown to be predictive of
tmesis involves damage to nerve fibers, usually the injury. Surgical removal of horizontal and mesioan-
result of severing a nerve and destroying the adjacent gular impacted teeth also is more likely to result in
connective tissue. nerve injuries, probably because of the increased
Aside from direct recognition of nerve injuries surgical manipulation and exposure required to
intraoperatively, postoperative subjective neural dys- remove such teeth. Postoperative hemorrhage from
function (dysesthesia, paresthesia, anesthesia) war- the extraction site also has been implicated in the


Fig. 4. Selected formatted coronal CT images. Note the presence of the inferior alveolar canal traversing the substance of the
roots of the third molar.

onset of dysesthesias. There is no conclusive evi- injury incidence, with no conclusive results [66].
dence currently regarding the relationship with age, The most effective method of managing nerve inju-
sex, and race and the incidence of nerve injuries. ries remains a combination of preoperative assess-
Various investigators have attempted to study ment of radiographs, discussion with patients about
the effects of modified surgical techniques on nerve the possibility of injury, and a cautious approach to

Fig. 5. Close-up image of intentionally retained roots after crown sectioning and enucleation of pericoronal dentigerous cyst.


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