Q U I N T E S S E N C E I N T E R N AT I O N A L
ORAL SURGERY
Carlo Lajolo
Surgical recommendations for the extraction of erupted maxillary third molars: Landmarks emerging from a clinical study Carlo Lajolo, MD, DDS, PhD1/Domenico Piselli, MD, DDS1/Benedicta Tedeschini, DDS2/Antonio D’Addona, DDS3/ Christian Miranda, DDS 4/Massimo Petruzzi, DDS, PhD5/Michele Giuliani, MD, DDS1 Objective: This study evaluated the efficacy of an anatomicalradiologic-surgical protocol for the extraction of erupted maxillary third molars (EMTMs). Methods and Materials: 166 EMTMs were extracted according to two different extraction techniques. Group 1 (G1, 97 teeth) was treated with the proposed protocol: multiple roots with forceps DG 117/DG 118; single roots with DG 250; tapered roots with DG 270; curved roots with Apexo 303 elevator. Group 2 (G2, 69 teeth) was treated with straight elevator and forceps DG 250 or DG 270. Extraction time and total number of complications (TNCs) were the main outcomes; TNCs were also divided in complications during the extraction (CDEs) and complications after the extraction (CAEs) as secondary outcomes. Results: Differences
between G1 and G2 were detected for extraction time (146.8 vs 225.6 seconds; P < .05) and for complications (G1, 13.4% vs G2, 47.8%; P < .001). Multivariate analysis showed that extraction time and smoking habit were independent risk factors for TNCs (P < .001); furthermore, “not applying the proposed extraction protocol” increases almost 7 times (6.86; 95% CI, 1.41–33.32; P < .02) the possible onset of CAEs. Conclusion: The proposed protocol can be helpful for the general dental practitioner in planning the extraction of EMTMs, shortening the extraction time, and diminishing the complications, especially those occurring after the extraction. (Quintessence Int 2015;46:237–245; doi: 10.3290/j.qi.a32987)
Key words: complications, extraction, extraction time, maxillary third molar
The extraction of erupted maxillary third molars (EMTMs) is a frequent surgical procedure both in private practice as well as in oral surgery departments. The recommendations for the extractions are made for multiple reasons: orthodontic treatment, soft tissue 1
Assistant Professor, Department of Oral Surgery, Catholic University, Rome, Italy.
2
Clinician, Department of Oral Surgery, Catholic University, Rome, Italy.
3
Full Professor, Department of Oral Surgery, Catholic University, Rome, Italy.
4
Clinician, Private Practice, Palo Alto, CA 94304, USA.
5
Assistant Professor, Department of Dentistry and Surgery, University of Bari, Italy.
Correspondence: Dr Carlo Lajolo, School of Dentistry, Catholic University, Largo A Gemelli 8, 00168, Rome, Italy. Email: [email protected]
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trauma, difficult hygiene, decay, periodontal disease, occlusal interference, or damage to the maxillary second molar.1-4 The anatomy of the maxillary third molars can be very particular for both the coronal and the root aspect. Roots can be single or multiple, conical or divergent, with different diameters, and straight or curved.5 A radiologic exam must be carefully performed in order to predict the correct and most successful extraction procedure. Even though it is a known fact that extractions of EMTMs are usually less troublesome than mandibular wisdom teeth, complications during extraction (CDE) and complications after extraction (CAE) can
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Table 1
Anatomy
Proposed anatomical-radiologic-surgical classification: four radiologic and anatomical classes of roots were mainly identified for the EMTMs Root type
Class
Radiology
Surgical instrument*
Maxillary molar forcep DG 117/DG 118 Multiple
M
DG 250
Simple
S
DG 270
Tapered
T
Elevator (Apexo 303)
Curved
C
C, distally curved roots; M, separate roots similar to other maxillary molars (first and second); S, simple or fused roots; T, tapered roots. *Each class was treated with a single specific instrument.
occur: oro-antral communication, fracture of the maxillary tuberosity, crown or root fracture (which can happen at different levels), displacement of the tooth or of the root into the sinus or into the pharyngeal space, ingestion, inhalation of the tooth or a root, damage to the second maxillary molar, dry sockets, infection, hemorrhage, difficult pain management, severe trismus, swelling, fever etc.6-8 To our knowledge, no studies have tried to develop an extraction protocol to facilitate the removal of
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EMTMs (diminishing CDE, CAE, and extraction time); furthermore no anatomical-radiologic classification can be found in the literature that can guide the oral surgeon towards a specific surgical protocol. For this reason, knowing that the anatomy of the maxillary third molar can be variable and owing to the previous clinical experience of the authors, four different radiologic and anatomical classes of EMTMs were identified (Table 1): • separate roots similar to other maxillary molars (first and second), class M
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• • •
simple or fused roots, class S tapered roots, class T distally curved roots, class C.
The aim of the present clinical study was to evaluate whether this classification can be helpful for the extraction of EMTMs in terms of extraction time and number of complications during and after surgery.
METHOD AND MATERIALS Study design, study population, and setting One hundred thirty subjects (mean age ± standard deviation [SD], 43.8 ± 12.8 years; min–max, 16–67; 90 males and 40 females; 56 smokers) were consecutively recruited for the extraction of EMTMs within a 12-month period of time in a single center, open-label, quasi-random clinical trial, beginning August 2012. The inclusion criteria were: • the need for an EMTM extraction • fully erupted third molar (nonimpacted, soft or hard tissue) • no severe periodontal disease affecting the tooth (no mobility) • no deep decay which could impair the integrity of the crown • fully mature roots • no systemic diseases (ie, diabetes, adreno-cortical diseases, coagulopathy, and bleeding time disorders). Patients were divided into two groups with a quasirandom modality, using the hospital admission identification number. Group 1 (pair numbers): 72 subjects (mean age ± SD, 44.8 ± 13.1 years; min–max, 18–67; 55 males, 17 females; 30 smokers) were treated with the proposed protocol (Table 1). Group 2 (odd numbers): 58 subjects (mean age ± SD, 42.8 ± 12.25 years; min– max, 16–66; 35 males, 23 females; 26 smokers) were treated, according to the experience of the oral surgeon, with straight elevator and DG 250 or Ogden Felsch DG 270 forceps (International Catalogue Aesculap, Braun).
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All the patients were treated by four oral surgeons, two for each group, with at least 3 years of clinical experience in oral surgery. All patients had a panoramic radiograph within the previous 6 months or were asked to obtain a new one. The following parameters were recorded: • smoking habit • reason for the extraction • tooth number • radiologic class according to the proposed classification (Table 1) • CDE • CAE • extraction time (the extraction time was measured from the moment of the beginning of the extraction procedure, once the anesthesia was achieved, up to the complete removal of the tooth from the alveolus, whereas time to resolve complications during or after the extraction was not considered). Extraction time and complications were the main outcomes. Total number of complications (TNC) indicates the number of subjects presenting complications during and/or after extraction: TNCs were also divided into CDE and CAE as secondary outcomes. Informed consents were obtained from all participants before the beginning of the extraction. This study was approved by the Ethics Committee (Ref. no. 14600/13) and all patients signed an informed consent agreement.
Extraction procedure Under local anesthesia (2% mepivacaine with epinephrine 1:100,000) and after the separation of the attached gingiva, the extraction procedure was carried out either according to the proposed protocol (group 1; Table 1) or to the clinical experience of the surgeon (straight elevator and DG 250 or Ogden Felsch DG 270). The proposed extraction protocol is summarized in Table 1 and further addressed in the discussion; briefly, four different radiologic and anatomical classes of EMTM (M, multiple roots; S, simple or single roots; T, tapered roots; C, curved roots) were identified, and a
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Table 2
Demographic and clinical data of the sample Total sample
No. of extracted teeth
166
69 (41.6%)
49 (50.5%) / 48 (49.5%)
30 (43.5%) / 39 (56.5%)
168.67 ± 62.80; 60–400
146.82 ± 44.31; 60–290
225.67 ± 68.37; 120–400
Male
118 (71.1%)
77 (65.2%)
41 (34.8%)
Female
48 (28.9%)
Extraction time (seconds: mean ± SD; Min–Max)*
No. of teeth extracted in smokers‡
Reason for extraction§
Radiologic class
Anatomical class§
Total complications¶
Group 2
97 (58.4%)
Tooth number: maxillary right third molar (%)/maxillary left third molar (%)
No. of extracted teeth stratified by sex†
Group 1
20 (41.7%)
28 (58.3%)
32
28
Soft tissue trauma
15 (9.0%)
14 (14.4%)
1 (1.4%)
Decay
50 (30.1%)
32 (33.0%)
18 (26.1%)
Tooth position (occlusal interference, difficult hygiene, extrusion)
29 (17.5%)
19 (19.6%)
10 (14.5%)
Orthodontic treatment
36 (21.7%)
19 (19.6%)
17 (24.6%)
Absence of an opposing tooth
36 (21.7%)
13 (13.4%)
23 (33.3%)
M
58 (59.8%)
21 (30.4%)
S
14 (14.4%)
19 (27.5%)
T
13 (13.4%)
16 (23.2%)
C
12 (12.4%)
13 (18.8%)
M
64 (66.0%)
23 (33.4%)
S
14 (14.4%)
19 (27.5%)
T
9 (9.3%)
14 (20.3%)
C
10 (10.3%)
13 (18.8%)
Yes
13 (13.4%)
33 (47.8%)
No
84 (86.6%)
36 (52.2%)
Yes
11 (11.3%)
29 (42.0%)
No
86 (88.7%)
40 (58.0%)
CDE# Oro-antral communication Details of CDE**
4
6
Hemorrhaging
1
1
Damage to the second maxillary molar (luxation, pain, periodontal damage)
4
9
Crown fracture
1
1
Root apical fracture
1
12
Yes
4 (4.1%)
24 (34.8%)
No
93 (95.9%)
45 (65.2%)
CAE†† Swelling – edema Details of CAE**
2
3
Pain management
2
8
Socket infection
1
13
C, distally curved root; CAE, complication after extraction; CDE, complication during extraction; M, separate roots similar to other maxillary molars (first and second); S, simple or fused roots; SD, standard deviation; T, tapered root. Correlation between radiologic class and anatomical class: Spearman’s rho 0.89; P < .001. *ANOVA between groups P < .001. †χ2 P < .01. ‡χ2 P < .03. §χ2 P < .001. χ2 P < .003. ¶Odds ratio, 5.92; 95% CI, 2.79–12.55; P < .001. #Odds ratio, 5.67; 95% CI, 2.57–12.47; P < .001. **Fisher exact test P < .001. ††Odds ratio, 12.40; 95% CI, 4.06–37.88; P < .001.
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specific instrument was used according to the tooth classification. Four instruments, one for each radiologic class (molar forceps, International Catalogue Aesculap, Braun: DG 117/DG 118 for M; DG 250 for S; Ogden Felsch DG 270 for T; and elevator Apexo 303, Hu-Friedy, for C) were used; so only one instrument was used for each class. After the extraction, the anatomical class of the molar was recorded in order to compare it with the radiologic class. All patients were followed up after a week to examine the wound and to evaluate the onset of complications after the extraction procedure.
Quantitative variables were tested for normal distribution by a Shapiro-Wilk test. Parametric variables were compared by means of two-tailed analysis of variance (ANOVA). Binomial variables were assessed by means of the chi-square test and Fisher’s exact test, to determine the differences between the two groups. Pearson correlation test was used to verify the correlation between radiologic and anatomical classification. Odds ratios (ORs) and 95% confidence intervals (95% CI) were calculated to identify the association between complications and binomial variables. Variables that were shown to be risk factors for complication at the univariate analysis were introduced in a multiple regression model, to assess whether risk factors were reciprocally independent (stepwise logistic regression). The statistical significance level was set at P < .05. The statistical analysis was carried out on the basis of the Intercooled Stata 8.0 computerized program (StataCorp).
this group. To this regard, even if EMTMs with M anatomy, which are supposed to be more difficult, were more numerous in group 1, a lower number of complications was found in this group, owing to an appropriate extraction protocol. Although not the aim of the present study, a good correlation between radiologic and anatomical classes was found (rho 0.89, P < .001), thus panoramic radiography seems to be reliable in predicting the anatomy of EMTMs. Smoking habit, extraction time, and the extraction protocol were statistically associated, at the univariate analysis, with the onset of complications (total complications, CDEs, and CAEs; Table 3). Radiologic and anatomical classes were associated with a higher level of CAEs; the need of orthodontic treatment was also associated with a higher level of CAEs (Table 3). The variable “not having used the proposed protocol” was a statistically significant risk factor at the univariate analysis, in group 2, for the onset of total complications (OR, 5.92; 95% CI, 2.79–12.55; P < .001), CDEs (OR, 5.67; 95% CI, 2.57–12.47; P < .001), and CAEs (Fisher exact test P < .001; Table 2). Damages to the second maxillary molar and apical fractures were the most frequent CDE, especially in group 2; infections of the sockets were the most frequent CAE, especially in group 2 (Table 2). Multiple logistic regression showing risk factors for the onset of total complications, CDEs, and CAEs are summarized in Table 4. Smoke and extraction time are independent risk factors for total complications and CDEs, whereas the onset of CDEs and extraction protocol are independent risk factors for the onset of CAEs.
RESULTS
DISCUSSION
One hundred sixty six EMTMs were extracted, 97 in group 1 (experimental group) and 69 in group 2 (control group); details of the sample and of the clinical procedures are summarized in Table 2 (extraction time, reason for extraction, radiologic and anatomical class, total complications, CDEs, and CAEs). A faster extraction time was measured in group 1 (P < .05) even if radiologic and anatomical class M was more frequent in
Many studies describe the frequencies and the type of complications arising during and after extraction of third molars, the majority of which evaluated mandibular or maxillary impacted third molar extraction.6,9 Even though the extraction of EMTMs is a common surgical procedure in private practice or oral surgery departments, no studies attempted to develop extraction protocols to facilitate the procedure, and no anatomi-
Statistical analysis
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Table 3
Variables associated with complications onset (univariate analysis)
Complications (49 subjects)
Yes
No
Yes
35
17
No
14
100
Extraction time (seconds: mean ± SD; Min–Max)†
224.77 ± 65.80; 120–390
150.86 ± 50.28; 60–400
CDE (40 subjects)
Yes
No
Smoke*
Yes
33
19
No
7
107
Smoke‡ Extraction time (seconds: mean ± SD; Min–Max)†
CAE (28 subjects)
224.77 ± 65.80; 120–390
150.86 ± 50.28; 60–400
Yes
No
M
12
67
S
11
22
T
5
24
C
0
25
Radiologic class§
M
14
73
S
11
22
T
3
20
C
0
23
Soft tissue trauma
2
13
Decay
1
49
Tooth position (occlusal interference, difficult hygiene)
7
22
12
24
6
30
Anatomical class§
Reason for extraction
Orthodontic treatment Absence of an opposing tooth Yes
21
31
No
7
107
Yes
22
18
6
120
Smoke¶
CDE# No Extraction time (seconds: mean ± SD; Min–Max)†
248.42 ± 76.32; 150–400
152.49 ± 45.14; 60–290
C, distally curved roots; CAE, complication after extraction; CDE, complication during extraction; M, separate roots similar to other maxillary molars (first and second); S, simple or fused roots; SD, standard deviation; T, tapered root. *Odds ratio, 14.7; 95% CI, 6.57–32.9; P < .001. †Anova between groups P < .001. ‡Odds ratio, 26.54; 95% CI, 10.26–68.67; P < .001. §Fisher exact test P = .006. Fisher exact test P = .03. ¶Odds ratio, 10.35; 95% CI, 4.02–26.62; P < .001. #Odds ratio, 24.44; 95% CI, 8.73–68.45; P < .001.
cal-radiologic classification can be found in the literature that can direct the surgeon toward a specific extraction protocol.10 The aim of the present clinical study was to evaluate if an anatomical-radiologic-surgical classification of EMTMs might be useful for the general dental practi-
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tioner during extraction, and if defining a new protocol could shorten the extraction time and reduce the number of complications during and after surgery. The multivariate analysis highlights that smoking habit and extraction time are independent risk factors for the onset of total complications (Table 4). Smoking
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Table 4
Risk factors for complications (multivariate analysis) OR
CI 95%
P value
Total complications (CDE + CAE) Smoking habit (yes)
31.27
9.38–104.33
.001
Extraction time
1.04
1.02–1.05
.001
Not applying the proposed extraction protocol
2.67
0.85–8.42
.091
CDE Smoking habit (yes)
223.88
26.39–1899.30
.001
Extraction time
1.02
1.01–1.04
.001
Not applying the proposed extraction protocol
3.15
0.83–11.88
.089
CAE 33.70
1.18–962.52
.05
Not applying the proposed extraction protocol
CDE
6.86
1.41–33.32
.02
Extraction time
1.02
1.01–1.04
.005
CAE, complication after extraction; CDE, complication during extraction.
habit is a well-known risk factor for the onset of complication for both general11 and oral surgical procedures (periodontal surgery, implant surgery) and for oral wound repair.12-14 Furthermore, in the present study, smoking habit is a strong risk factor for the onset of CDE (OR, 223.88; 95% CI, 26.39–1899.30; P < .001; Table 4), whereas it is a risk factor for CAE only in the univariate analysis (OR, 10.35; 95% CI, 4.02–26.62; P < .001; Table 3), and it is close to statistical significance in the multivariate analysis. It is possible that, during extraction procedures, the impaired breathing function (ie, increased cough, increased number of breaths, impaired oxygen level) could negatively interfere with the surgical procedure.15 Many other diseases can affect wound healing and can interfere with recovery (ie, diabetes, coagulopathy, steroid hormone imbalance), but in the present study, no subjects with these risk factors were included. When the extraction time increased, the risk of total complications and of CDEs increased by a minimal amount. However, extraction time is an independent risk factor in the multivariate analysis for both types of outcome; it is close to statistical significance for CAE. These data, in accordance with the literature, highlight that a shorter surgical time is associated with a lower number of complications, mainly due the reduced surgical stress.9,16,17
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The proposed protocol seems to be a very important variable in preventing the onset of complications; the multivariate analysis highlights that not using the protocol, the possible onset of CAEs increases almost 7 times (6.86; 95% CI, 1.41–33.32; P < .02). The use of the experimental protocol, highly associated at the univariate analysis with the reduction of total complications and CDEs, decreases its statistical power in the multivariate analysis. On the other hand, the use of the proposed extraction protocol is statistically associated with a shorter extraction time, which is itself an independent protective factor for the onset of complications. A more appropriate extraction technique can decrease the surgical time and can promote better handling of the soft and hard tissues, thus favoring the quality and the length of the recovery time. Considering the proposed extraction protocol, the choice of a specific tool was driven by anatomicalradiologic-clinical considerations mostly regarding the roots (Table 1): it seems the shape and the clinical position of the crown are not as important for the choice of the surgical tools as the root. Following proper anesthesia and separation of the attached gingiva, each anatomical root class requires therefore a particular extraction technique.
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DG 117 (right) or DG 118 (left) forceps were used for class M: the buccal tip of the beak can be engaged in the furcation and helps in holding the coronal portion of the tooth. Becoming a single unit, these forceps can transmit the force down the tooth, allowing greater control and sensitivity during extraction. DG 250 forceps was used for class S: in these cases a buccal tip is not recommended but the contra-angular shape of the beak helps in reaching the posterior region of the maxilla. Even though the distance between the working end and the hinge pivot does not favor the transmission of the extraction force in an efficient way, the high cutting edges of the working end can easily penetrate between the tooth and the gingiva toward the cementoenamel junction, allowing a good vestibular and palatal hold and helping the luxation maneuver. Furthermore, a single root, even if long, does not generally need a high extraction force when compared with three separate roots. DG 270 forceps was used for class T. This forceps has a retentive working end that can be useful during the extraction of tapered teeth: once the tooth is luxated, it can be slippery and can slip out from the instrument and be lost in the pharyngeal area. Furthermore, the high retentive capability of the working end of this forceps allows precise engagement with the crown of the tapered molar, which is usually prominent, thus transferring the extraction force. The Apexo 303 elevator was used for class C, which had a distally curved root. Using this elevator, a distal rotation movement favors the elevation of the tooth from the socket, respecting the anatomy of the root: the use of a forceps during the extraction movement of class C EMTMs can result in impaction of the beak on the mandibular ramus (the vestibular part of the beak can impact distally the mandibular ramus thus making the extraction uncomfortable and unsafe – the surgeon has to reposition himself and the patient has to close the mouth to reduce the impaction). Furthermore, since mainly downwards and lateral movements can be performed with the forceps, it is possible that the apex of class C EMTMs can be fractured off during the extraction procedure. It is important to note that the contra-
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angular shape of the tip of the elevator helps in reaching the posterior part of the maxilla and engaging with the anatomy of the root. It is recommended that the elevator should be positioned between the root and the alveolar bone more than between the apical third of the interproximal space (between the third and the second molars), in order to avoid any possible damaging pressure to the second maxillary molar. Considering the frequency and type of CDEs, as in other studies, damage to the maxillary second molar and fracture of the apical root were the most frequent complications, especially in the second group (control group; fracture of the apical root can expose the patient to a further risk of displacement of the apex into the sinus during the surgical extraction procedure, and the surgeon to greater stress. This was probably due to excessive use of the straight elevator, which is not always the most appropriate instrument; applying excessive force in the wrong place and direction could induce micro and macro trauma to the second maxillary molar or favor the fracture of the apex. The frequency of oro-antral communications was the same as in other studies on maxillary third molar extraction.6,18,19 Considering the frequency and type of CAEs, infection and pain management were the most frequent CAEs, especially in the second group, and were in line with results of previous studies. It is possible that, in this second group, the excessive force against the tissues (soft and hard) could have induced micro or macro damage to sensitive structures (micro bone fractures or fractures of the tuberosity), favoring the onset of these complications.7,9 The present study, aimed to develop an extraction protocol for the removal of EMTMs, has some limitations. The recruitment of a larger number of participants could prevent discrepancies for some variables between the two groups at baseline: more males were enrolled in the first group (some authors found more complications among females17), a greater M class was present in group 1, and more smokers were enrolled among participants of group 2. Furthermore, the possible role of other variables (eg, obesity [BMI], visibility of the extraction area, other systemic diseases) that
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could be associated with the onset of complications, was not evaluated.16
CONCLUSION Although the proposed protocol for the extraction of EMTMs needs further evaluation, it seems clinically relevant for the general dental practitioner in planning the extraction of EMTMs, shortening the extraction time, and diminishing the complications, especially those occurring after extraction. An adequate technique is essential to better handle soft and hard tissues, thus giving the patient optimal comfort during and after surgery.
ACKNOWLEDGMENT This study was supported in part by Grant from Ministerodell’Istruzione, dell’Università e della Ricerca (MIUR - 20082KAZKN_003).
REFERENCES 1. Fuster Torres MA, Gargallo Albiol J, Berini Aytés L, Gay Escoda C. Evaluation of the indication for surgical extraction of third molars according to the oral surgeon and the primary care dentist. Experience in the Master of Oral Surgery and Implantology at Barcelona University Dental School. Med Oral Patol Oral Cir Bucal 2008;13:E499–E504. 2. Peterson LJ, Ellis E, Hupp JR, Tucker MR. Principles of Exodontia. In: Contemporary Oral and Maxillofacial Surgery. St. Louis: Mosby, 1998. 3. Artun J, Behbehani F, Thalib L. Prediction of maxillary third molar impaction in adolescent orthodontic patients. Angle Orthod 2005;75:904–911. 4. Rafetto LK. Removal of asymptomatic third molars: a supporting view. J Oral Maxillofac Surg 2006;64:1811–1815.
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5. Berkovitz BKB, Holland GR, Moxham BJ. Maxillary third permanent molar. Chapter 2. Dento-osseous structure. In: Oral Anatomy, Histology and Embryology. New York: Mosby, 2009:22. 6. Rothamel D, Wahl G, d’Hoedt B, Nentwig GH, Schwarz F, Becker J. Incidence of predictive factors for perforation of the maxillary antrum in operations to remove upper wisdom teeth: prospective multicentre study. Br J Oral Maxillofac Surg 2007;45:387–391. 7. Contar CM, de Oliveira P, Kanegusuku K, Berticelli RD, Azevedo-Alanis LR, Machado MA. Complications in third molar removal: a retrospective study of 588 patients. Med Oral Patol Oral Cir Bucal 2010;15:e74–e78. 8. Dimitrakopoulos I, Papadaki M. Displacement of a maxillary third molar into the infratemporal fossa: a case report. Quintessence Int 2007;38:607–610. 9. Baqain ZH, Karaky AA, Sawair F, Khraisat A, Duaibis R, Rajab LD. Frequency estimates and risk factors for postoperative morbidity after third molar removal: a prospective cohort study. J Oral Maxillofac Surg 2008;66:2276– 2283. 10. Coleman M, McCormick A, Laskin DM. The incidence of periodontal defects distal to the maxillary second molar after impacted third molar extraction. J Oral Maxillofac Surg 2011;69:319–321. 11. Lindström D, Sadr Azodi O, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg 2008;248:739–745. 12. Semlali A, Chakir J, Goulet JP, Chmielewski W, Rouabhia M. Whole cigarette smoke promotes human gingival epithelial cell apoptosis and inhibits cell repair processes. J Periodontal Res 2011;46:533–541. 13. Garg A. Pathophysiology of tobacco use and wound healing. Dent Implantol Update 2010;21:1–4. 14. Rivera-Hidalgo F. Smoking and periodontal disease. Periodontol 2000 2003;32:50–58. 15. Sethi JM, Rochester CL. Smoking and chronic obstructive pulmonary disease. Clin Chest Med 2000;21:67–86. 16. Gbotolorun OM, Arotiba GT, Ladeinde AL. Assessment of factors associated with surgical difficulty in impacted mandibular third molar extraction. J Oral Maxillofac Surg 2007;65:1977–1983. 17. Blondeau F, Daniel NG. Extraction of impacted mandibular third molars: postoperative complications and their risk factors. J Can Dent Assoc 2007;73:325a–325e. 18. Barbosa-Rebellato NL, Thomé AC, Costa-Maciel C, Oliveira J, Scariot R. Factors associated with complications of removal of third molars: a transversal study. Med Oral Patol Oral Cir Bucal 2011;16:e376–e380. 19. Huang IY, Chen CM, Chuang FH. Caldwell-Luc procedure for retrieval of displaced root in the maxillary sinus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112(6):e59–e63.
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ORAL SURGERY
Carlo Lajolo
Surgical recommendations for the extraction of erupted maxillary third molars: Landmarks emerging from a clinical study Carlo Lajolo, MD, DDS, PhD1/Domenico Piselli, MD, DDS1/Benedicta Tedeschini, DDS2/Antonio D’Addona, DDS3/ Christian Miranda, DDS 4/Massimo Petruzzi, DDS, PhD5/Michele Giuliani, MD, DDS1 Objective: This study evaluated the efficacy of an anatomicalradiologic-surgical protocol for the extraction of erupted maxillary third molars (EMTMs). Methods and Materials: 166 EMTMs were extracted according to two different extraction techniques. Group 1 (G1, 97 teeth) was treated with the proposed protocol: multiple roots with forceps DG 117/DG 118; single roots with DG 250; tapered roots with DG 270; curved roots with Apexo 303 elevator. Group 2 (G2, 69 teeth) was treated with straight elevator and forceps DG 250 or DG 270. Extraction time and total number of complications (TNCs) were the main outcomes; TNCs were also divided in complications during the extraction (CDEs) and complications after the extraction (CAEs) as secondary outcomes. Results: Differences
between G1 and G2 were detected for extraction time (146.8 vs 225.6 seconds; P < .05) and for complications (G1, 13.4% vs G2, 47.8%; P < .001). Multivariate analysis showed that extraction time and smoking habit were independent risk factors for TNCs (P < .001); furthermore, “not applying the proposed extraction protocol” increases almost 7 times (6.86; 95% CI, 1.41–33.32; P < .02) the possible onset of CAEs. Conclusion: The proposed protocol can be helpful for the general dental practitioner in planning the extraction of EMTMs, shortening the extraction time, and diminishing the complications, especially those occurring after the extraction. (Quintessence Int 2015;46:237–245; doi: 10.3290/j.qi.a32987)
Key words: complications, extraction, extraction time, maxillary third molar
The extraction of erupted maxillary third molars (EMTMs) is a frequent surgical procedure both in private practice as well as in oral surgery departments. The recommendations for the extractions are made for multiple reasons: orthodontic treatment, soft tissue 1
Assistant Professor, Department of Oral Surgery, Catholic University, Rome, Italy.
2
Clinician, Department of Oral Surgery, Catholic University, Rome, Italy.
3
Full Professor, Department of Oral Surgery, Catholic University, Rome, Italy.
4
Clinician, Private Practice, Palo Alto, CA 94304, USA.
5
Assistant Professor, Department of Dentistry and Surgery, University of Bari, Italy.
Correspondence: Dr Carlo Lajolo, School of Dentistry, Catholic University, Largo A Gemelli 8, 00168, Rome, Italy. Email: [email protected]
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trauma, difficult hygiene, decay, periodontal disease, occlusal interference, or damage to the maxillary second molar.1-4 The anatomy of the maxillary third molars can be very particular for both the coronal and the root aspect. Roots can be single or multiple, conical or divergent, with different diameters, and straight or curved.5 A radiologic exam must be carefully performed in order to predict the correct and most successful extraction procedure. Even though it is a known fact that extractions of EMTMs are usually less troublesome than mandibular wisdom teeth, complications during extraction (CDE) and complications after extraction (CAE) can
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Table 1
Anatomy
Proposed anatomical-radiologic-surgical classification: four radiologic and anatomical classes of roots were mainly identified for the EMTMs Root type
Class
Radiology
Surgical instrument*
Maxillary molar forcep DG 117/DG 118 Multiple
M
DG 250
Simple
S
DG 270
Tapered
T
Elevator (Apexo 303)
Curved
C
C, distally curved roots; M, separate roots similar to other maxillary molars (first and second); S, simple or fused roots; T, tapered roots. *Each class was treated with a single specific instrument.
occur: oro-antral communication, fracture of the maxillary tuberosity, crown or root fracture (which can happen at different levels), displacement of the tooth or of the root into the sinus or into the pharyngeal space, ingestion, inhalation of the tooth or a root, damage to the second maxillary molar, dry sockets, infection, hemorrhage, difficult pain management, severe trismus, swelling, fever etc.6-8 To our knowledge, no studies have tried to develop an extraction protocol to facilitate the removal of
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EMTMs (diminishing CDE, CAE, and extraction time); furthermore no anatomical-radiologic classification can be found in the literature that can guide the oral surgeon towards a specific surgical protocol. For this reason, knowing that the anatomy of the maxillary third molar can be variable and owing to the previous clinical experience of the authors, four different radiologic and anatomical classes of EMTMs were identified (Table 1): • separate roots similar to other maxillary molars (first and second), class M
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• • •
simple or fused roots, class S tapered roots, class T distally curved roots, class C.
The aim of the present clinical study was to evaluate whether this classification can be helpful for the extraction of EMTMs in terms of extraction time and number of complications during and after surgery.
METHOD AND MATERIALS Study design, study population, and setting One hundred thirty subjects (mean age ± standard deviation [SD], 43.8 ± 12.8 years; min–max, 16–67; 90 males and 40 females; 56 smokers) were consecutively recruited for the extraction of EMTMs within a 12-month period of time in a single center, open-label, quasi-random clinical trial, beginning August 2012. The inclusion criteria were: • the need for an EMTM extraction • fully erupted third molar (nonimpacted, soft or hard tissue) • no severe periodontal disease affecting the tooth (no mobility) • no deep decay which could impair the integrity of the crown • fully mature roots • no systemic diseases (ie, diabetes, adreno-cortical diseases, coagulopathy, and bleeding time disorders). Patients were divided into two groups with a quasirandom modality, using the hospital admission identification number. Group 1 (pair numbers): 72 subjects (mean age ± SD, 44.8 ± 13.1 years; min–max, 18–67; 55 males, 17 females; 30 smokers) were treated with the proposed protocol (Table 1). Group 2 (odd numbers): 58 subjects (mean age ± SD, 42.8 ± 12.25 years; min– max, 16–66; 35 males, 23 females; 26 smokers) were treated, according to the experience of the oral surgeon, with straight elevator and DG 250 or Ogden Felsch DG 270 forceps (International Catalogue Aesculap, Braun).
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All the patients were treated by four oral surgeons, two for each group, with at least 3 years of clinical experience in oral surgery. All patients had a panoramic radiograph within the previous 6 months or were asked to obtain a new one. The following parameters were recorded: • smoking habit • reason for the extraction • tooth number • radiologic class according to the proposed classification (Table 1) • CDE • CAE • extraction time (the extraction time was measured from the moment of the beginning of the extraction procedure, once the anesthesia was achieved, up to the complete removal of the tooth from the alveolus, whereas time to resolve complications during or after the extraction was not considered). Extraction time and complications were the main outcomes. Total number of complications (TNC) indicates the number of subjects presenting complications during and/or after extraction: TNCs were also divided into CDE and CAE as secondary outcomes. Informed consents were obtained from all participants before the beginning of the extraction. This study was approved by the Ethics Committee (Ref. no. 14600/13) and all patients signed an informed consent agreement.
Extraction procedure Under local anesthesia (2% mepivacaine with epinephrine 1:100,000) and after the separation of the attached gingiva, the extraction procedure was carried out either according to the proposed protocol (group 1; Table 1) or to the clinical experience of the surgeon (straight elevator and DG 250 or Ogden Felsch DG 270). The proposed extraction protocol is summarized in Table 1 and further addressed in the discussion; briefly, four different radiologic and anatomical classes of EMTM (M, multiple roots; S, simple or single roots; T, tapered roots; C, curved roots) were identified, and a
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Table 2
Demographic and clinical data of the sample Total sample
No. of extracted teeth
166
69 (41.6%)
49 (50.5%) / 48 (49.5%)
30 (43.5%) / 39 (56.5%)
168.67 ± 62.80; 60–400
146.82 ± 44.31; 60–290
225.67 ± 68.37; 120–400
Male
118 (71.1%)
77 (65.2%)
41 (34.8%)
Female
48 (28.9%)
Extraction time (seconds: mean ± SD; Min–Max)*
No. of teeth extracted in smokers‡
Reason for extraction§
Radiologic class
Anatomical class§
Total complications¶
Group 2
97 (58.4%)
Tooth number: maxillary right third molar (%)/maxillary left third molar (%)
No. of extracted teeth stratified by sex†
Group 1
20 (41.7%)
28 (58.3%)
32
28
Soft tissue trauma
15 (9.0%)
14 (14.4%)
1 (1.4%)
Decay
50 (30.1%)
32 (33.0%)
18 (26.1%)
Tooth position (occlusal interference, difficult hygiene, extrusion)
29 (17.5%)
19 (19.6%)
10 (14.5%)
Orthodontic treatment
36 (21.7%)
19 (19.6%)
17 (24.6%)
Absence of an opposing tooth
36 (21.7%)
13 (13.4%)
23 (33.3%)
M
58 (59.8%)
21 (30.4%)
S
14 (14.4%)
19 (27.5%)
T
13 (13.4%)
16 (23.2%)
C
12 (12.4%)
13 (18.8%)
M
64 (66.0%)
23 (33.4%)
S
14 (14.4%)
19 (27.5%)
T
9 (9.3%)
14 (20.3%)
C
10 (10.3%)
13 (18.8%)
Yes
13 (13.4%)
33 (47.8%)
No
84 (86.6%)
36 (52.2%)
Yes
11 (11.3%)
29 (42.0%)
No
86 (88.7%)
40 (58.0%)
CDE# Oro-antral communication Details of CDE**
4
6
Hemorrhaging
1
1
Damage to the second maxillary molar (luxation, pain, periodontal damage)
4
9
Crown fracture
1
1
Root apical fracture
1
12
Yes
4 (4.1%)
24 (34.8%)
No
93 (95.9%)
45 (65.2%)
CAE†† Swelling – edema Details of CAE**
2
3
Pain management
2
8
Socket infection
1
13
C, distally curved root; CAE, complication after extraction; CDE, complication during extraction; M, separate roots similar to other maxillary molars (first and second); S, simple or fused roots; SD, standard deviation; T, tapered root. Correlation between radiologic class and anatomical class: Spearman’s rho 0.89; P < .001. *ANOVA between groups P < .001. †χ2 P < .01. ‡χ2 P < .03. §χ2 P < .001. χ2 P < .003. ¶Odds ratio, 5.92; 95% CI, 2.79–12.55; P < .001. #Odds ratio, 5.67; 95% CI, 2.57–12.47; P < .001. **Fisher exact test P < .001. ††Odds ratio, 12.40; 95% CI, 4.06–37.88; P < .001.
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specific instrument was used according to the tooth classification. Four instruments, one for each radiologic class (molar forceps, International Catalogue Aesculap, Braun: DG 117/DG 118 for M; DG 250 for S; Ogden Felsch DG 270 for T; and elevator Apexo 303, Hu-Friedy, for C) were used; so only one instrument was used for each class. After the extraction, the anatomical class of the molar was recorded in order to compare it with the radiologic class. All patients were followed up after a week to examine the wound and to evaluate the onset of complications after the extraction procedure.
Quantitative variables were tested for normal distribution by a Shapiro-Wilk test. Parametric variables were compared by means of two-tailed analysis of variance (ANOVA). Binomial variables were assessed by means of the chi-square test and Fisher’s exact test, to determine the differences between the two groups. Pearson correlation test was used to verify the correlation between radiologic and anatomical classification. Odds ratios (ORs) and 95% confidence intervals (95% CI) were calculated to identify the association between complications and binomial variables. Variables that were shown to be risk factors for complication at the univariate analysis were introduced in a multiple regression model, to assess whether risk factors were reciprocally independent (stepwise logistic regression). The statistical significance level was set at P < .05. The statistical analysis was carried out on the basis of the Intercooled Stata 8.0 computerized program (StataCorp).
this group. To this regard, even if EMTMs with M anatomy, which are supposed to be more difficult, were more numerous in group 1, a lower number of complications was found in this group, owing to an appropriate extraction protocol. Although not the aim of the present study, a good correlation between radiologic and anatomical classes was found (rho 0.89, P < .001), thus panoramic radiography seems to be reliable in predicting the anatomy of EMTMs. Smoking habit, extraction time, and the extraction protocol were statistically associated, at the univariate analysis, with the onset of complications (total complications, CDEs, and CAEs; Table 3). Radiologic and anatomical classes were associated with a higher level of CAEs; the need of orthodontic treatment was also associated with a higher level of CAEs (Table 3). The variable “not having used the proposed protocol” was a statistically significant risk factor at the univariate analysis, in group 2, for the onset of total complications (OR, 5.92; 95% CI, 2.79–12.55; P < .001), CDEs (OR, 5.67; 95% CI, 2.57–12.47; P < .001), and CAEs (Fisher exact test P < .001; Table 2). Damages to the second maxillary molar and apical fractures were the most frequent CDE, especially in group 2; infections of the sockets were the most frequent CAE, especially in group 2 (Table 2). Multiple logistic regression showing risk factors for the onset of total complications, CDEs, and CAEs are summarized in Table 4. Smoke and extraction time are independent risk factors for total complications and CDEs, whereas the onset of CDEs and extraction protocol are independent risk factors for the onset of CAEs.
RESULTS
DISCUSSION
One hundred sixty six EMTMs were extracted, 97 in group 1 (experimental group) and 69 in group 2 (control group); details of the sample and of the clinical procedures are summarized in Table 2 (extraction time, reason for extraction, radiologic and anatomical class, total complications, CDEs, and CAEs). A faster extraction time was measured in group 1 (P < .05) even if radiologic and anatomical class M was more frequent in
Many studies describe the frequencies and the type of complications arising during and after extraction of third molars, the majority of which evaluated mandibular or maxillary impacted third molar extraction.6,9 Even though the extraction of EMTMs is a common surgical procedure in private practice or oral surgery departments, no studies attempted to develop extraction protocols to facilitate the procedure, and no anatomi-
Statistical analysis
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Table 3
Variables associated with complications onset (univariate analysis)
Complications (49 subjects)
Yes
No
Yes
35
17
No
14
100
Extraction time (seconds: mean ± SD; Min–Max)†
224.77 ± 65.80; 120–390
150.86 ± 50.28; 60–400
CDE (40 subjects)
Yes
No
Smoke*
Yes
33
19
No
7
107
Smoke‡ Extraction time (seconds: mean ± SD; Min–Max)†
CAE (28 subjects)
224.77 ± 65.80; 120–390
150.86 ± 50.28; 60–400
Yes
No
M
12
67
S
11
22
T
5
24
C
0
25
Radiologic class§
M
14
73
S
11
22
T
3
20
C
0
23
Soft tissue trauma
2
13
Decay
1
49
Tooth position (occlusal interference, difficult hygiene)
7
22
12
24
6
30
Anatomical class§
Reason for extraction
Orthodontic treatment Absence of an opposing tooth Yes
21
31
No
7
107
Yes
22
18
6
120
Smoke¶
CDE# No Extraction time (seconds: mean ± SD; Min–Max)†
248.42 ± 76.32; 150–400
152.49 ± 45.14; 60–290
C, distally curved roots; CAE, complication after extraction; CDE, complication during extraction; M, separate roots similar to other maxillary molars (first and second); S, simple or fused roots; SD, standard deviation; T, tapered root. *Odds ratio, 14.7; 95% CI, 6.57–32.9; P < .001. †Anova between groups P < .001. ‡Odds ratio, 26.54; 95% CI, 10.26–68.67; P < .001. §Fisher exact test P = .006. Fisher exact test P = .03. ¶Odds ratio, 10.35; 95% CI, 4.02–26.62; P < .001. #Odds ratio, 24.44; 95% CI, 8.73–68.45; P < .001.
cal-radiologic classification can be found in the literature that can direct the surgeon toward a specific extraction protocol.10 The aim of the present clinical study was to evaluate if an anatomical-radiologic-surgical classification of EMTMs might be useful for the general dental practi-
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tioner during extraction, and if defining a new protocol could shorten the extraction time and reduce the number of complications during and after surgery. The multivariate analysis highlights that smoking habit and extraction time are independent risk factors for the onset of total complications (Table 4). Smoking
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Table 4
Risk factors for complications (multivariate analysis) OR
CI 95%
P value
Total complications (CDE + CAE) Smoking habit (yes)
31.27
9.38–104.33
.001
Extraction time
1.04
1.02–1.05
.001
Not applying the proposed extraction protocol
2.67
0.85–8.42
.091
CDE Smoking habit (yes)
223.88
26.39–1899.30
.001
Extraction time
1.02
1.01–1.04
.001
Not applying the proposed extraction protocol
3.15
0.83–11.88
.089
CAE 33.70
1.18–962.52
.05
Not applying the proposed extraction protocol
CDE
6.86
1.41–33.32
.02
Extraction time
1.02
1.01–1.04
.005
CAE, complication after extraction; CDE, complication during extraction.
habit is a well-known risk factor for the onset of complication for both general11 and oral surgical procedures (periodontal surgery, implant surgery) and for oral wound repair.12-14 Furthermore, in the present study, smoking habit is a strong risk factor for the onset of CDE (OR, 223.88; 95% CI, 26.39–1899.30; P < .001; Table 4), whereas it is a risk factor for CAE only in the univariate analysis (OR, 10.35; 95% CI, 4.02–26.62; P < .001; Table 3), and it is close to statistical significance in the multivariate analysis. It is possible that, during extraction procedures, the impaired breathing function (ie, increased cough, increased number of breaths, impaired oxygen level) could negatively interfere with the surgical procedure.15 Many other diseases can affect wound healing and can interfere with recovery (ie, diabetes, coagulopathy, steroid hormone imbalance), but in the present study, no subjects with these risk factors were included. When the extraction time increased, the risk of total complications and of CDEs increased by a minimal amount. However, extraction time is an independent risk factor in the multivariate analysis for both types of outcome; it is close to statistical significance for CAE. These data, in accordance with the literature, highlight that a shorter surgical time is associated with a lower number of complications, mainly due the reduced surgical stress.9,16,17
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The proposed protocol seems to be a very important variable in preventing the onset of complications; the multivariate analysis highlights that not using the protocol, the possible onset of CAEs increases almost 7 times (6.86; 95% CI, 1.41–33.32; P < .02). The use of the experimental protocol, highly associated at the univariate analysis with the reduction of total complications and CDEs, decreases its statistical power in the multivariate analysis. On the other hand, the use of the proposed extraction protocol is statistically associated with a shorter extraction time, which is itself an independent protective factor for the onset of complications. A more appropriate extraction technique can decrease the surgical time and can promote better handling of the soft and hard tissues, thus favoring the quality and the length of the recovery time. Considering the proposed extraction protocol, the choice of a specific tool was driven by anatomicalradiologic-clinical considerations mostly regarding the roots (Table 1): it seems the shape and the clinical position of the crown are not as important for the choice of the surgical tools as the root. Following proper anesthesia and separation of the attached gingiva, each anatomical root class requires therefore a particular extraction technique.
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DG 117 (right) or DG 118 (left) forceps were used for class M: the buccal tip of the beak can be engaged in the furcation and helps in holding the coronal portion of the tooth. Becoming a single unit, these forceps can transmit the force down the tooth, allowing greater control and sensitivity during extraction. DG 250 forceps was used for class S: in these cases a buccal tip is not recommended but the contra-angular shape of the beak helps in reaching the posterior region of the maxilla. Even though the distance between the working end and the hinge pivot does not favor the transmission of the extraction force in an efficient way, the high cutting edges of the working end can easily penetrate between the tooth and the gingiva toward the cementoenamel junction, allowing a good vestibular and palatal hold and helping the luxation maneuver. Furthermore, a single root, even if long, does not generally need a high extraction force when compared with three separate roots. DG 270 forceps was used for class T. This forceps has a retentive working end that can be useful during the extraction of tapered teeth: once the tooth is luxated, it can be slippery and can slip out from the instrument and be lost in the pharyngeal area. Furthermore, the high retentive capability of the working end of this forceps allows precise engagement with the crown of the tapered molar, which is usually prominent, thus transferring the extraction force. The Apexo 303 elevator was used for class C, which had a distally curved root. Using this elevator, a distal rotation movement favors the elevation of the tooth from the socket, respecting the anatomy of the root: the use of a forceps during the extraction movement of class C EMTMs can result in impaction of the beak on the mandibular ramus (the vestibular part of the beak can impact distally the mandibular ramus thus making the extraction uncomfortable and unsafe – the surgeon has to reposition himself and the patient has to close the mouth to reduce the impaction). Furthermore, since mainly downwards and lateral movements can be performed with the forceps, it is possible that the apex of class C EMTMs can be fractured off during the extraction procedure. It is important to note that the contra-
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angular shape of the tip of the elevator helps in reaching the posterior part of the maxilla and engaging with the anatomy of the root. It is recommended that the elevator should be positioned between the root and the alveolar bone more than between the apical third of the interproximal space (between the third and the second molars), in order to avoid any possible damaging pressure to the second maxillary molar. Considering the frequency and type of CDEs, as in other studies, damage to the maxillary second molar and fracture of the apical root were the most frequent complications, especially in the second group (control group; fracture of the apical root can expose the patient to a further risk of displacement of the apex into the sinus during the surgical extraction procedure, and the surgeon to greater stress. This was probably due to excessive use of the straight elevator, which is not always the most appropriate instrument; applying excessive force in the wrong place and direction could induce micro and macro trauma to the second maxillary molar or favor the fracture of the apex. The frequency of oro-antral communications was the same as in other studies on maxillary third molar extraction.6,18,19 Considering the frequency and type of CAEs, infection and pain management were the most frequent CAEs, especially in the second group, and were in line with results of previous studies. It is possible that, in this second group, the excessive force against the tissues (soft and hard) could have induced micro or macro damage to sensitive structures (micro bone fractures or fractures of the tuberosity), favoring the onset of these complications.7,9 The present study, aimed to develop an extraction protocol for the removal of EMTMs, has some limitations. The recruitment of a larger number of participants could prevent discrepancies for some variables between the two groups at baseline: more males were enrolled in the first group (some authors found more complications among females17), a greater M class was present in group 1, and more smokers were enrolled among participants of group 2. Furthermore, the possible role of other variables (eg, obesity [BMI], visibility of the extraction area, other systemic diseases) that
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could be associated with the onset of complications, was not evaluated.16
CONCLUSION Although the proposed protocol for the extraction of EMTMs needs further evaluation, it seems clinically relevant for the general dental practitioner in planning the extraction of EMTMs, shortening the extraction time, and diminishing the complications, especially those occurring after extraction. An adequate technique is essential to better handle soft and hard tissues, thus giving the patient optimal comfort during and after surgery.
ACKNOWLEDGMENT This study was supported in part by Grant from Ministerodell’Istruzione, dell’Università e della Ricerca (MIUR - 20082KAZKN_003).
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5. Berkovitz BKB, Holland GR, Moxham BJ. Maxillary third permanent molar. Chapter 2. Dento-osseous structure. In: Oral Anatomy, Histology and Embryology. New York: Mosby, 2009:22. 6. Rothamel D, Wahl G, d’Hoedt B, Nentwig GH, Schwarz F, Becker J. Incidence of predictive factors for perforation of the maxillary antrum in operations to remove upper wisdom teeth: prospective multicentre study. Br J Oral Maxillofac Surg 2007;45:387–391. 7. Contar CM, de Oliveira P, Kanegusuku K, Berticelli RD, Azevedo-Alanis LR, Machado MA. Complications in third molar removal: a retrospective study of 588 patients. Med Oral Patol Oral Cir Bucal 2010;15:e74–e78. 8. Dimitrakopoulos I, Papadaki M. Displacement of a maxillary third molar into the infratemporal fossa: a case report. Quintessence Int 2007;38:607–610. 9. Baqain ZH, Karaky AA, Sawair F, Khraisat A, Duaibis R, Rajab LD. Frequency estimates and risk factors for postoperative morbidity after third molar removal: a prospective cohort study. J Oral Maxillofac Surg 2008;66:2276– 2283. 10. Coleman M, McCormick A, Laskin DM. The incidence of periodontal defects distal to the maxillary second molar after impacted third molar extraction. J Oral Maxillofac Surg 2011;69:319–321. 11. Lindström D, Sadr Azodi O, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg 2008;248:739–745. 12. Semlali A, Chakir J, Goulet JP, Chmielewski W, Rouabhia M. Whole cigarette smoke promotes human gingival epithelial cell apoptosis and inhibits cell repair processes. J Periodontal Res 2011;46:533–541. 13. Garg A. Pathophysiology of tobacco use and wound healing. Dent Implantol Update 2010;21:1–4. 14. Rivera-Hidalgo F. Smoking and periodontal disease. Periodontol 2000 2003;32:50–58. 15. Sethi JM, Rochester CL. Smoking and chronic obstructive pulmonary disease. Clin Chest Med 2000;21:67–86. 16. Gbotolorun OM, Arotiba GT, Ladeinde AL. Assessment of factors associated with surgical difficulty in impacted mandibular third molar extraction. J Oral Maxillofac Surg 2007;65:1977–1983. 17. Blondeau F, Daniel NG. Extraction of impacted mandibular third molars: postoperative complications and their risk factors. J Can Dent Assoc 2007;73:325a–325e. 18. Barbosa-Rebellato NL, Thomé AC, Costa-Maciel C, Oliveira J, Scariot R. Factors associated with complications of removal of third molars: a transversal study. Med Oral Patol Oral Cir Bucal 2011;16:e376–e380. 19. Huang IY, Chen CM, Chuang FH. Caldwell-Luc procedure for retrieval of displaced root in the maxillary sinus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112(6):e59–e63.
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