11 minute read
Indication for extraction of impacted third molars: Cross-sectional study
CAIO GONÇALVES SILVA 1 | VICTOR HUGO FERREIRA 2 | EVERALDO PINHEIRO LIMA 3 | SUZANA CELIA CARNEIRO 2 | JEFFERSON FIGUEIREDO LEAL 1 | BELMIRO CAVALCANTI VASCONCELOS 1
Advertisement
ABSTRACT
Introduction: Removal of third impacted asymptomatic molars has been the subject of considerable controversy. Therefore, this study aims to verify the indication of removal of lower third molars by oral and maxillofacial surgeons after evaluating radiographic images. Methods: This was an observational cross-sectional study developed with professionals participating in the XXIII Brazilian Conference on Oral and Maxillofacial Surgery (COBRAC-2015) held in Salvador, Bahia, Brazil, in which the participants were divided into groups according to the level of training. Results: The results show that most oral and maxillofacial surgeons tend to indicate the removal of asymptomatic impacted third molars (ITMs), and this decision-making is independent of the level of training, and the number of years of experience does not influence it. Conclusions: It can be concluded that there is insufficient evidence in the current literature to determine routine prophylactic removal of asymptomatic ITMs. The indication or not of removal of asymptomatic ITMs should take into account the patients acceptance as well as the clinical knowledge of the professional to guide the decision making.
Keywords: Molar, third. Tooth, impacted. Surgery, oral.
1 Universidade do Pernambuco, Faculdade de Odontologia, Setor de Cirurgia e Traumatologia
Bucomaxilofacial (Camaragibe/PE, Brazil). 2 Hospital da Restauração, Departamento Cirurgia e Traumatologia Bucomaxilofacial (Recife/PE, Brazil). 3 Sindicato dos Odontologistas de Pernambuco, Curso de Especialização em Implantodontia (Recife/PE, Brazil).
How to cite: Silva CG, Ferreira VH, Lima EP, Carneiro SC, Leal JF, Vasconcelos BC. Indication for extraction of impacted third molars: Cross-sectional study. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):24-8. DOI: https://doi.org/10.14436/2358-2782.5.3.024-028.oar
Submitted: February 17, 2019 - Revised and accepted: May 26, 2019
» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.
» Patients displayed in this article previously approved the use of their facial and intraoral photo graphs.
Contact address: Caio Gonçalves Silva Av. Gal. Newton Cavalcanti, 1.650, Tabatinga – Camaragibe/PE CEP: 54.753-220 – E-mail: caiocgsilva@gmail.com
INTRODUCTION
The surgical removal of an impacted tooth is one of the most common procedures performed by a maxillofacial surgeon in the dental office. 1,2 The third molars are the most commonly impacted teeth, with a mean global rate of impaction of 24%. 3
Impacted third molars (ITM) may be associated with pathological disorders as pericoronitis, root resorption, gingivitis, periodontitis, caries and development of cysts and tumors. 4 The prophylactic removal proposed by some authors 5,6 aims to prevent the development of these lesions and avoid this procedure at a more advanced stage of life, when the risk of postoperative complications is higher. 4
ITM removal surgery is usually a simple procedure performed under local anesthesia in an outpatient setting. However, for a variety of reasons, some patients require hospital care under general anesthesia or intravenous sedation to perform these extractions. 1,4,5
Every procedure for the removal of ITM presents risks for the patient, including temporary or permanent nerve damage, alveolitis, infection, bleeding, swelling, pain and trismus. Moreover, this surgery is often perceived by the patient as an intensely frightening situation, and in some cases an unnecessary surgical procedure, since the tooth is shown as fully erupted in the mouth and does not have clinical and radiographic signs of associated injury. 1,7 8
The removal of asymptomatic ITM has been subject of considerable controversy. Some authors advocate the removal as beneficial for patients to prevent the risk of future bone injury. 5,6 Conversely, the removal of third molar may result in various types of morbidities, thus clinical monitoring of ITM is recommended. 7
Thus, the objective of this study is to verify the indication of removal of third molars by the maxillofacial surgeons after evaluating radiographic images.
METHODS
This observational cross-sectional study was carried out during the XXIII Brazilian Congress of Oral and Maxillofacial Surgery (COBRAC 2015) in Salvador/BA, in the period from August 25 to 29 2015, in which some professionals of Oral and Maxillofacial Surgery and Traumatology who were present were addressed during the event and answered a questionnaire indicating the removal of third molars, after evaluating radiographic images.
The study was conducted in accordance with Resolution 466/2012 of the National Health Council, Ministry of Health, related to ethics in research involving human subjects, and was approved by the Institutional Review Board of Hospital da Restauração (report n. 2.753.179).
For data collection, a questionnaire was designed including age, gender, title (resident/specialized, specialist, master, doctor), training time in the field and a series of four hypothetical clinical cases on which each professional evaluated radiographic images with different types of dental impactions in the mandible and expressed indication or not for extraction (Fig 1). The radiographic images were obtained from the database of a radiology clinic in Recife/PE.
For data collection, the team was calibrated for application of the questionnaire and for acquisition of a random sample of participants during the event. After data collection, the Microsoft Excel was used to tabulate the data and for statistical calculations.
RESULTS
The study analyzed 170 questionnaires that met the inclusion criteria of the research. Among professionals participating in the study, 71.1% were males and mostly specialists. The percentage of participants in relation to the training course in the specialty of Oral and Maxillofacial Surgery is shown in Figure 2.
Sixty-four percent opted to remove the impacted tooth as a prophylactic measure, since most cases presented were young patients. However, the percentage of indication for extraction varied according to the clinical situation presented. The total of indications per case is observed in Table 1.
The total indications for extraction in each clinical situation did not vary significantly between professionals with different training levels, as shown in Figure 3.
A
B
C
D
Figure 1: Radiographic images to assess the extraction of the impacted lower third molar: A) young patient without comorbidities, asymptomatic (case 1); B) elderly patient without comorbidities, asymptomatic (case 2); C) young patient without comorbidities, asymptomatic (case 3); D) young patient without comorbidities, asymptomatic (case 4).
Level of training
Specialized Specialists Masters Doctors
Figure 2: Percentage of participants, according to the level of training.
Case Case
Case Case Specialized
Specialists
Masters
Doctors
Figure 3: Percentage of indication for removal of impacted third impacted third molars, by level of education in each clinical case.
Table 1: Percentage of indications or contraindications for removal of impacted third molars, per clinical case.
Case 1 Case 2 Case 3 Case 4
Yes
62% 15% 93% 85%
No
38% 85% 7% 15%
DISCUSSION
The management related to removal of symptomatic ITM is well described in several oral and maxillofacial surgery books. However, it remains a dilemma for the surgeon on how to proceed in case of na asymptomatic impacted tooth. 7,8
The ITM can be associated with pathological disorders as pericoronitis, root resorption, periodontal problems, caries and development of cysts and tumors. 1,4,9 Other reasons for the prophylactic removal of asymptomatic ITM include the prevention of lower incisor crowding, preparation for orthognathic surgery or radiotherapy. 4
Many dentists and their patients believe that removing asymptomatic ITM is justified to avoid future complications at a later stage of life in which the therapeutic and surgical management is more complex, and the risk of postoperative complications increases. 4,9
According to studies by Metts et al. 7 and Huang et al. 10 , patients are largely influenced by recommendations of their dentists who indicated removal of ITM for prophylactic reasons. Thus, the indication of prophylactic extraction should be based on literature, both to provide the best treatment for the patient and also for legal support in case of possible complications in the postoperative period, which can lead to lawsuits.
The Brazilian Congress of Oral and Maxillofacial Surgery and Traumatology (COBRAC) is the biggest event of the specialty in Brazil, with participation of great specialists from the country, as well as personalities with worldwide recognition, due to the work they develop within the field of oral and maxillofacial surgery. In this sense, we can infer the relevance of the present study, because it was conducted with high-level professionals with high scientific knowledge and working based on what is best in the literature.
This study included a total of 170 professionals from questionnaires, which were participants in the aforementioned congress. Among these, 49 had PhD (29%), 40 were masters (24%), 60 were specialists (35%) and 21 were residents or trainees (12%).
By data analysis, most professionals surveyed tend to indicate the extraction of asymptomatic ITM. However, when comparing the approach between young and elderly patients, we observed that professionals tend to be more conservative in relation to elderly patients but indicate more often the prophylactic extraction in young patients.
This trend follows the report of the study of Petrosyan and Ameerally, 11 which described a criterion for prophylactic removal of third molars. According to the authors, in young patients, the extraction of ITM and its contralateral should be performed prophylactically, if the latter is present partially erupted. The authors justify their behavior arguing that young patients have minimal chances of postoperative serious complications, in addition to a faster recovery.
Similarly, Talwar et al. 12 mention that young patients submitted to extraction of third molars have low morbidity, low prevalence of postoperative complications and minimal impact on quality of life, concluding that the indication of this type of surgery in patients with that age would bring more benefits than harm.
The indication of ITM removal in the older age group was also decreased in the study Ethunandan et al. 13 Factors as decreased bone elasticity, risk of osteoporosis, bone atrophy and increased potential for tooth ankylosis supported the decision.
The study of Camargo et al. 14 evaluated the decision-making between maxillofacial surgeons in relation to ITM surgery and observed that the group with the shortest experience tended to recommend extractions with increasing frequency. The conclusion of these authors is different from data observed in this study, because there was no significant difference in the management of clinical cases presented in different stages in the specialty.
There is insufficient evidence in the current literature to determine the routine prophylactic removal of asymptomatic ITM. 4,7 The management of asymptomatic and uncomplicated ITM remains controversial. The current approach to deal with the ITM is based on clinical judgment, periodic evaluation by some professionals and early extraction by others, and there is no consensus of surgeons in the management of ITM. 1,4,15,16
Considering the lack of evidence, the indication for removing or not asymptomatic ITM must consider the acceptance of patients and clinical knowledge of the professional to guide the decision-making.
CONCLUSION
The decision-making regarding the surgical removal of asymptomatic impacted third molar is independent of the level of professional training.
There is insufficient evidence to support or refute the removal of asymptomatic impacted third molars.
References:
Balaguer-Martí JC, Aloy-Prósper A, Peñarrocha-Oltra A, Peñarrocha-Diago M. Non surgical predicting factors for patient satisfaction after third molar surgery. Med Oral Patol Oral Cir Bucal. 2016 Mar 1;21(2):e201-5. Kumar KS, Sargunam AED, Ravindran C, Giri G. Intra-alveolar extraction of impacted distoangular mandibular third molars: a novel technique. Indian J Dent Res. 2018 Mar-Apr;29(2):252-3. 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 Apr 4;18(1):58. Ghaeminia H, Perry J, Nienhuijs MEL, Toedtling V, Tummers M, Hoppenreijs TJM, et al. Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth. Cochrane Database Syst Rev. 2016 Aug 31;(8):CD003879. White RP Jr, American Association of Oral and Maxillofacial Surgeons House of Deletates. Progress report on third molar clinical trials. J Oral Maxillofac Surg. 2007 Mar;65(3):377-83. Renton T, Al-Haboubi M, Pau A, Shepherd J, Gallagher JE. What has been the United Kingdom’s experience with retention of third molars? J Oral Maxillofac Surg. 2012 Sept;70(9 Suppl 1):S48-57. 7. Mettes TD, Ghaeminia H, Nienhuijs ME, Perry J, van der Sanden WJ, Plasschaert A. Surgical removal versus retention for the management of asymptomatic impacted wisdom teeth. Cochrane Database Syst Rev. 2012 June 13;(6):CD003879. 8. Rodríguez Sánchez F, Rodríguez Andrés C, Arteagoitia
Calvo I. Does Chlorhexidine Prevent Alveolar Osteitis After Third Molar Extractions? Systematic Review and Meta-Analysis. J Oral Maxillofac Surg. 2017
May;75(5):901-914. 9. Baensch F, Kriwalsky MS, Kleffmann W, Kunkel
M. Third Molar Complications in the Elderly-A Matched-Pairs Analysis. J Oral Maxillofac Surg. 2017
Apr;75(4):680-6. 10. Huang GJ, Cunha-Cruz J, Rothen M, Spiekerman
C, Drangsholt M, Anderson L, et al. A prospective study of clinical outcomes related to third molar removal or retention. Am J Public Health. 2014
Apr;104(4):728-34. 11. Petrosyan V, Ameerally P. Changes in demographics of patients undergoing third molar surgery in a hospital setting between 1994 and 2012 and the influence of the National Institute for Health and Care Excellence guidelines. J Oral Maxillofac Surg. 2014 Feb;72(2):254-8. 12. Talwar R, Haug R, Gonzalez M, Perrott D. The AAOMS age-related third molar study. J Oral Maxillofac Surg. 2004 Aug;62(1):34-35. 13. Ethunandan M, Shanahan D, Patel M. Iatrogenic mandibular fractures following removal of impacted third molars: an analysis of 130 cases. Br Dent J. 2012
Feb 24;212(4):179-84. 14. Camargo IB, Melo AR, Fernandes AV, Cunningham
LL Jr, Laureano Filho JR, Van Sickels JE. Decision making in third molar surgery: a survey of Brazilian oral and maxillofacial surgeons. Int Dent J. 2015
Aug;65(4):169-77. 15. Msagati F, Simon EN, Owibingire S. Pattern of occurrence and treatment of impacted teeth at the Muhimbili National Hospital, Dar es Salaam, Tanzania. BMC Oral
Health. 2013 Aug 6;13:37. 16. Mayrink G, Nicolai B, Aboumrad Júnior JP. Comparative study of dipyrone and paracetamol pain control after third molar extraction. J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):32-7.
