|Year : 2021 | Volume
| Issue : 3 | Page : 163-167
Surgical difficulty assessment in patients undergoing impacted mandibular third molar extraction. A single center evaluation in Najran, Kingdom of Saudi Arabia
Ramat Oyebunmi Braimah1, Dawood Ali-Alsuliman2, Abdulrazaq Olanrewaju Taiwo3, Adebayo Aremu Ibikunle4, Reham Mohammed Hassan Makarami2, Abdullah Saleh Al-walah2, Saeed Turki Al-Sagoor2
1 Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran, Saudi Arabia
2 Department of Oral and Maxillofacial Surgery, Najran Regional Specialty Dental Centre, Medical Village Complex, Najran, Saudi Arabia
3 Department of Surgery, College of Health Sciences, Usmanu Danfodiyo University Sokoto, Sokoto, Nigeria
4 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Submission||01-Mar-2021|
|Date of Acceptance||19-Apr-2021|
|Date of Web Publication||23-Aug-2021|
Ramat Oyebunmi Braimah
Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran
Source of Support: None, Conflict of Interest: None
Introduction: The evaluation of surgical difficulty preoperatively is important during mandibular third molar (MTM) extraction. This study aimed to evaluate the difficulty index for the removal of impacted MTM using Pederson difficulty index (PDI), Parant Scale (PS), and total operation time (TOT). Materials and Methods: This was a prospective study of patients referred for the extraction of impacted MTM between April, 2019 and July, 2020. Estimated level of difficulty was done before a standardized surgery using the PDI and classified as: Minimally difficult (I), moderately difficult (II), and very difficult (III). Intraoperatively, it was classified as extraction requiring ostectomy only (II); extraction requiring ostectomy and coronal section (III); and complex extraction requiring coronal and root sectioning (IV) using the Modified PS. TOT was recorded by a resident with stopwatch. Results: A total of 502 patients (203 [40.4%] males and 299 [59.6%] females) with an M:F of 1:1.5. The age ranged from 17 to 69 years with a mean age ± standard deviation (SD) (31.6 ± 9.6) years. The majority of the patients were in the age group of 21–40 years. TOT ranged from 10 to 35 min with mean TOT ± SD (15.35 ± 7.02) min. The mean TOT according to PDI was 11.30 ± 2.22, 12.74 ± 4.14, and 26.44 ± 4.39 min in I, II, and III, respectively, while according to PS were 10.91 ± 0.9, 19.60 ± 4.5, 28.82 ± 3.5 min in II, III, and IV, respectively. The observed correlation coefficients® for PDI and PS were 0.716 and 0.870, respectively. Conclusion: Analysis of the surgical difficulty of impacted MTM extraction is essential for treatment planning and patient satisfaction. PS has been found to be significantly associated with TOT.
Keywords: Impaction, mandibular third molar, ostectomy, parant scale, Pederson difficulty index, surgical extraction
|How to cite this article:|
Braimah RO, Ali-Alsuliman D, Taiwo AO, Ibikunle AA, Hassan Makarami RM, Al-walah AS, Al-Sagoor ST. Surgical difficulty assessment in patients undergoing impacted mandibular third molar extraction. A single center evaluation in Najran, Kingdom of Saudi Arabia. J Dent Res Rev 2021;8:163-7
|How to cite this URL:|
Braimah RO, Ali-Alsuliman D, Taiwo AO, Ibikunle AA, Hassan Makarami RM, Al-walah AS, Al-Sagoor ST. Surgical difficulty assessment in patients undergoing impacted mandibular third molar extraction. A single center evaluation in Najran, Kingdom of Saudi Arabia. J Dent Res Rev [serial online] 2021 [cited 2022 Dec 1];8:163-7. Available from: https://www.jdrr.org/text.asp?2021/8/3/163/324414
| Introduction|| |
Extraction of the impacted third molar is one of the most common minor oral surgical procedures carried out in oral surgery. The most common postoperative complications following third molar removal are alveolar osteitis and surgical site infection., Others are permanent nerve damage, pain, trismus, swelling, and difficulty in swallowing., Evaluation of the effort of the surgery preoperatively to prevent these complications is the most important factor to be considered in the surgical removal of impacted third molar.,
It is difficult to appraise the factors which increase the difficulty of the surgery because of the huge disparity among patients. Therefore, the operating surgeon must have scientific, evidence-based information regarding the estimated level of surgical difficulty of every case.,,
One of the established preoperative tool for difficulty assessment in the surgical removal of impacted mandibular third molar (MTM) is a Pederson Difficulty Index (PDI). PDI was determined using Winter's and Pell and Gregory classifications which was based on the depth of the third molar, the relation to the mandibular ramus and the anatomical position in relation to the longitudinal axis of the adjacent second molar teeth [Table 1]. Another surgical difficulty index used for both pre and intra-operative surgical difficulty assessment is the Parant scale (PS) modified by Garcia-Garcia et al. This scale describes four levels of difficulty based on the surgical tactics needed for the removal of lower third molars: (I) Extraction not requiring ostectomy; (II) extraction requiring ostectomy; (III) extraction requiring ostectomy and coronal section; and (IV) complex extraction requiring root sectioning [Table 1]. Recently, researchers have looked into the total operation time (TOT) in the assessment of surgical difficulty related to the extraction of impacted MTMs. In Korean insurance industry, TOT is one of the most important criteria for the evaluation of surgical difficulty during the removal of impacted MTM.
|Table 1: Classification of surgical difficulty with Pederson index and Parant scale|
Click here to view
Till date and to the best of our knowledge, a literature search did not reveal any study on surgical difficulty assessment using PDI, PS, and TOT in the Kingdom of Saudi Arabia, hence the rational for the current study.
| Materials and Methods|| |
Patients who were referred to the Department of Oral and Maxillofacial Surgery for the extraction of impacted MTMs between August 2019 and July 2020 were included in the study. Approval for the study was obtained from the General Directorate of Health Affairs, Najran Region, Kingdom of Saudi Arabia, and informed consent was obtained from all participating patients before the surgery. Patients with only soft-tissue impaction not requiring ostectomy were excluded.
Preoperative clinical and radiologic data were collected, and based on this, estimated level of difficulty of all extractions was done before surgery using the Pederson scale [Table 1] before the extractions. All the panoramic radiographs were digital and were taken with (Carestream Dosimetry of the 9500 3D Cone Beam System, Carestream Dental LLC, 3625, Cumberland Blvd. Ste. 700, Atlanta, GA 30339). The surgical extractions were classified as simple, moderately difficult, and very difficult preoperatively.
The operator (researcher) did all operations on an outpatient basis. Each subject had similar surgical procedures (flap raising, ostectomy using surgical bur, tooth elevation, and tooth sectioning were required and flap suturing with 3/0 vicryl suture using two interrupted sutures), in the same operating room and under similar conditions using lignocaine 2% with adrenaline 1: 100,000 as a local anesthetic. No simultaneous medication was used during surgery other than the local anesthetic. Thereafter, a three-sided mucoperiosteal flap was raised by a gingival margin incision around the mandibular second and third molars with anterior and posterior relieving incisions using a #15 surgical blade. Bone removal was done by bucco-distal guttering technique using a fast hand piece (80,000–150,000 rev/min) and #10 surgical round cutting bur under continuous irrigation with sterile 0.9% saline solution. Tooth sectioning when indicated was performed with a tapering fissure bur in a fast hand piece. After tooth removal by the use of Coupland elevators, the alveolus was inspected, curetted for granulation tissue removal (for those with associated periapical granuloma and cysts. A 3/0 black braided silk suture material was used to close the wound without tension.
Immediately, after the surgery, details were recorded. A dental surgery assistant recorded duration of surgery in minutes (from the incision time to insertion of the last suture) with a stopwatch. This was used for all the subjects to ensure standardization. All patients were given IM Voltaren 75 mg and IM Dexamethasone 8 mg immediately after the surgery. They were thereafter given Tabs Augmentin 625 mg tid for 7 days, Tabs Ibuprofen 400 mg tid for 3 days and Chlorhexidine mouth wash qid for 1 week as take home medications. Follow-up appointments to monitor wound healing were given to all the participants.
Data analysis was carried out using the IBM SPSS Statistics for IOS Version 20 (Armonk, NY: IBM Corp). Descriptive statistics were carried out for sociodemographic variables such as age and gender. The descriptive variables that are continuous parameters such as mean ± standard deviations (SD), minimum and maximum were determined. For descriptive variables that are categorical, simple frequency, and percentages were also determined. Pearson's Chi-square test was used to assess the level of significance among the categorical variables such as age group of patients, sex, and position of the impacted MTMs. One-way ANOVA was used to analyze the difference in TOT between difficulty indices (PDI and PS) and laterality of the impacted MTM. P < 0.05 was considered statistically significant.
| Results|| |
A total of 502 patients (203 males and 299 females with an M:F of 1:1.5) had surgical extraction of impacted MTM during the study period. Their age ranged from 17 to 69 years with a mean age ± SD (31.6 ± 9.6) years. The majority of the patients were in the age group of 21–40 years [Table 2]. There was statistical significance when age group was compared with gender of patients (χ2 = 22.623, df = 5, P = 0.000). TOT ranged from 10 to 35 min with mean TOT ± SD (15.35 ± 7.02) min.
|Table 2: Distribution of age group of patients and indications for extractions according to gender|
Click here to view
There is no positive correlation between TOT, gender, and age group of patients, as shown in [Table 3] as the observed correlation coefficient ® was 0.003 and 0.012, respectively.
|Table 3: Association between extraction time, gender, age group and laterality of impaction|
Click here to view
A total of 227 (45.2%) extractions were performed on the right (48) side within (15.30 ± 6.9 min), and 275 (54.8%) were completed on the left (38) side within (15.39 ± 7.1 min). TOT exhibited no statistical difference according laterality of the impaction (P = 0.888). The observed correlation coefficient ® for laterality is 0.000 meaning there is no positive correlation between TOT and laterality of impaction of the MTMs [Table 3].
[Table 4] showed the association between TOT and the difficulty indices. The mean extraction times according to PDI were 11.30 ± 2.22, 12.74 ± 4.14, and 26.44 ± 4.39 min in I, II, and III, respectively. While according to PS were 10.91 ± 0.9, 19.60 ± 4.5, 28.82 ± 3.5 min in II, III, and IV, respectively. The observed correlation coefficients® for PDI and PS were 0.716 and 0.870, respectively. Very difficult (III) and complex extraction requiring root sectioning (IV) were significant in PDI and PS scales, respectively (P < 0.0001).
|Table 4: Association between extraction time and difficulty indices of impacted mandibular third molars|
Click here to view
| Discussions|| |
In the planning of surgical extraction of impacted MTMs, preoperative prediction of surgical extraction difficulty is important for anticipating postoperative complications. This evaluation is not only important to the oral surgeon to decide the mode of anesthesia whether local or general were surgical environment is more controlled,, but also so the patient to be well informed and to be satisfied with the level of treatment received. Sequelae of surgical removal of impacted MTM is frequently associated with overall poor health-related quality of life, therefore efforts to minimize these sequelae will be beneficial to the patient.
In the current study, the majority of the patients were within the age group of 21–40 years (79.4%) which has been supported by the literature the age group with the most prevalent cases of third molar impaction.,,,
Recently, researchers have been advocating TOT as an index of surgical difficulty in the extraction of MTMs., Erstwhile difficulty indices, however, have focused mainly on possibilities of complications, while very few clinical studies have reported on TOT.,, As a result of the extremely divergent morphology of third molars and different surgical techniques used in its extraction, estimating TOT is difficult. Therefore, surgeon expertise and technique of surgical extraction must be standardized. In the current study, only one consultant, oral and maxillofacial surgeon performed the surgical extraction with standardized technique.
From the current study, as the age group of patient increases, TOT also increased. This observation has been reported in some Korean studies wherein they reported that the oral surgeon should consider the patient's age in the difficulty index evaluation.,, Regarding gender of patients and laterality of impaction, the current study is in agreement with other studies that observed no association between them and TOT.
The modified PS used in this study had comparable percentage distribution for extraction requiring ostectomy alone (64.3%), extraction requiring ostectomy and coronal section (21.1%) and extraction requiring ostectomy, coronal and root sectioning (14.5%) to that reported by Gbotolorun et al.
Studies have shown that PDI which was based on the radiographic evaluation may not really determine the course of the intraoperative surgery. In a meta-analysis, it was reported that PDI may not be accurately right in predicting the surgical difficulty of impacted mandibular 3rd molar. Furthermore, Diniz-Freitas et al. stated in their study that preoperative classification as “difficult” on the PDI was not an accurate predictor of true difficulty. From the current study, the mean extraction times according to PDI were 11.30 ± 2.22, 12.74 ± 4.14, and 26.44 ± 4.39 min in I, II, and III, respectively. While that of the PS were 10.91 ± 0.9, 19.60 ± 4.5, 28.82 ± 3.5 min in II, III, and IV, respectively. The correlation between TOT and difficulty index was significant (P < 0.001) in both scales suggesting a moderate positive correlation, i.e., as the surgical indices becomes more difficult, TOT also increased. The observed correlation coefficients ® for PDI and PS were 0.716 and 0.870, respectively, suggesting positive correlations with TOT. Although both observed correlation coefficient ® were high, that of PS was higher (0.870) suggesting stronger positive correlations. The limitation of the current study is that a three-dimensional (3D) cone beam computed tomography (CBCT) to locate the exact position in bucco-lingual axis was not carried out as this could contribute to the prediction to the surgical difficulty. Therefore, we recommend prospective designs that will utilize a 3D CBCT to locate bucco-lingual position of fully impacted MTMs in predicting surgical difficulty and associating it with the TOT.
| Conclusion|| |
Analysis of the surgical difficulty of MTM extraction is essential for treatment planning for the surgeon and for the patient to be able to take informed decision and be satisfied with treatment received. From the present study, both surgical difficulty indices (PDI and PS) have been found to be significantly associated with TOT with the PS having more stronger association.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kang F, Xue Z, Zhou X, Zhang X, Hou G, Feng Y. Coronectomy: A useful approach in minimizing nerve injury compared with traditional extraction of deeply impacted mandibular third molars. J Oral Maxillofac Surg 2019;77:2221.e1-14.
Ryalat S, AlRyalat SA, Kassob Z, Hassona Y, Al-Shayyab MH, Sawair F. Impaction of lower third molars and their association with age: Radiological perspectives. BMC Oral Health 2018;18:58.
Monaco G, De Santis G, Pulpito G, Gatto MR, Vignudelli E, Marchetti C. What Are the types and frequencies of complications associated with mandibular third molar coronectomy? A follow-up study. J Oral Maxillofac Surg 2015;73:1246-53.
Bali A, Bali D, Sharma A, Verma G. Is pederson index a true predictive difficulty index for impacted mandibular third molar surgery? A meta-analysis. J Maxillofac Oral Surg 2013;12:359-64.
Ku JK, Chang NH, Jeong YK, Baik SH, Choi SK. Development and validation of a difficulty index for mandibular third molars with extraction time. J Korean Assoc Oral Maxillofac Surg 2020;46:328-34.
Sammartino G, Gasparro R, Marenzi G, Trosino O, Mariniello M, Riccitiello F. Extraction of mandibular third molars: Proposal of a new scale of difficulty. Br J Oral Maxillofac Surg 2017;55:952-7.
Bali A, Bali D, Sharma A, Verma G. Is pederson index a true predictive difficulty index for impacted mandibular third molar surgery? A meta-analysis. J Maxillofac Oral Surg 2012;12(3): 359-364. [doi: 10.1007/s12663-012-0435-x].
Carter K, Worthington S. Predictors of third molar impaction: A systematic review and meta-analysis. J Dent Res 2016;95:267-76.
Garcia Garcia A, Gude Sampedro F, Gandara Rey J, Gallas Torreira M. Trismus and pain after removal of impacted lower third molars. J Oral Maxillofac Surg 1997;55:1223-6.
Shin YS. How to improve the national health insurance fee-forservice schedule. Health Welf Policy Forum 2019;273:39-52.
Khan M, Mehmboob B, Katpar S. Extraction of wisdom teeth under general anesthesia – A study. J Khyber Coll Dent 2014;5:20-4.
Savanheimo N, Sundberg SA, Virtanen JI, Vehkalahti MM. Dental care and treatments provided under general anaesthesia in the Helsinki Public Dental Service. BMC Oral Health 2012;12:45.
Barreiro-Torres J, Diniz-Freitas M, Lago-Méndez L, Gude-Sampedro F, Gándara-Rey JM, García-García A. Evaluation of the surgical difficulty in lower third molar extraction. Med Oral Patol Oral Cir Bucal 2010;15:e869-74.
Braimah RO, Ndukwe KC, Owotade FJ, Aregbesola SB. Oral health related quality of life (OHRQoL) following third molar surgery in Sub-Saharan Africans: An observational study. Pan Afr Med J 2016;25:97.
Gisakis IG, Palamidakis FD, Farmakis ET, Kamberos G, Kamberos S. Prevalence of impacted teeth in a Greek population. J Investig Clin Dent 2011;2:102-9.
Shetty DC. Epidemiological status of 3rd
molars-their clinical implications. J Oral Health Comm Dent 2010;4:12-15.
Hyam DM. The contemporary management of third molars. Aust Dent J 2018;63 Suppl 1:S19-26.
Ishii S, Abe S, Moro A, Yokomizo N, Kobayashi Y. The horizontal inclination angle is associated with the risk of inferior alveolar nerve injury during the extraction of mandibular third molars. Int J Oral Maxillofac Surg 2017;46:1626-34.
Eshghpour M, Nejat AH. Dry socket following surgical removal of impacted third molar in an Iranian population: Incidence and risk factors. Niger J Clin Pract 2013;16:496-500.
] [Full text]
Kim JY, Yong HS, Park KH, Huh JK. Modified difficult index adding extremely difficult for fully impacted mandibular third molar extraction. J Korean Assoc Oral Maxillofac Surg 2019;45:309-15.
Gbotolorun OM, Arotiba GT, Ladeinde AL. Assessment of factors associated with surgical difficulty in impacted mandibular third molar extraction. J Oral Maxillofac Surg 2007;65:1977-83.
Diniz-Freitas M, Lago-Méndez L, Gude-Sampedro F, Somoza-Martin JM, Gándara-Rey JM, García-García A. Pederson scale fails to predict how difficult it will be to extract lower third molars. Br J Oral Maxillofac Surg 2007;45:23-6.
[Table 1], [Table 2], [Table 3], [Table 4]