Evaluation of difficulty index of impacted mandibular third molar extractions

Autologous platelet concentrates after third molar extraction: A systematic review

Surgical removal of impacted mandibular third molars is often followed by postoperative sequelae like pain, swelling, trismus, etc. This systematic review explored the benefits of applying different autologous platelet concentrates (APCs) in the extraction socket of third molars. For this systematic review, PubMed, EMBASE, Web of Science, and Scopus have been utilized, initially yielding 544 papers. The search was narrowed to randomized controlled trials (RCTs, n = 59) published before 2024, all comparing the outcome of applying APCs in the extraction socket of surgically removed impacted mandibular third molars with unassisted healing (blood clot). Most RCTs primarily assessed the impact of APCs on postoperative sequelae. Some RCTs looked at soft- and hard-tissue healing. Eleven studies used PRP, three PRGF, and 45 L-PRF. A detailed analysis revealed a large heterogeneity between studies rendering a meta-analysis impossible. Moreover, the risk of bias was considered high. In the majority of RCTs, the application of an APC resulted in statistically significant reductions of postoperative sequelae (lower pain intensity, lower consumption of analgesics, less postoperative edema, and a lower incidence of trismus and alveolar osteitis), as well as a faster soft tissue healing, and qualitatively and quantitatively better bone healing. A minority of studies reported significant differences in periodontal parameters distally from the second molar.

A 3D-Planned Inward Fragmentation Technique for the Removal of Impacted Mandibular Third Molars: A Case Series

Background/Objectives: The extraction of impacted mandibular third molars (M3Ms) carries significant risks, especially regarding the inferior alveolar nerve (IAN). This study aimed to evaluate the effectiveness of a 3D-planned inward fragmentation technique (3Dp-IFT) to improve surgical outcomes, reduce complications, and preserve bone structure in cases involving complex M3M impactions. Methods: Twenty-three patients aged between 18 and 36 years requiring M3M removal were included. Preoperative planning involved the use of cone-beam computed tomography (CBCT) for precise localization of the furcation area, followed by the creation of a 3D navigation template using PlastyCAD software version 1.7. The surgical procedure was performed under local anesthesia, with meticulous endoscopic assistance to ensure accurate access and minimize trauma. Postoperative outcomes, such as bone loss, pain, swelling, and mouth opening range, were carefully measured. The data were systematically organized and analyzed descriptively using Microsoft Excel. Results: No disturbances to the IAN or lingual nerve were observed. The mean buccal bone loss was 2.2 mm, with a standard deviation of 1.2 mm. Postoperative pain and swelling were generally low, with significant reductions within the first week. The use of the 3D navigation template significantly improved surgical access, enhancing safety and minimizing complications. Conclusions: The 3Dp-IFT technique represents a significant advancement in the minimally invasive removal of M3M by allowing precise access to critical anatomical areas while minimizing bone loss and postoperative complications. This approach is particularly beneficial for complex cases involving M3M near the IAN, thereby improving surgical safety and patient outcomes.

Comparative Evaluation of Surgical Difficulty of Impacted Maxillary and Mandibular Third Molars: An Observational Study

Introduction Extraction of the third molar is the surgical intervention most frequently performed by dental professionals. Notwithstanding a meticulously designed surgical strategy, complications may arise during extraction of the lower third molars. The primary objective of this study was to evaluate and compare the surgical difficulties encountered when managing impacted maxillary and mandibular third molars. The secondary objective was identifying the predictors of surgical difficulty in extracting the third molars from both arches. Materials and methods This study included 30 systemically healthy patients requiring upper and lower third molar extractions on the same side. The Pederson index was used to assess surgical difficulty in such patients on pre-treatment orthopantomograms. The time interval between upper and lower extraction was one week for all patients, and all extractions were performed by an experienced oral and maxillofacial surgeon. An independent t-test was performed to determine the significance of the differences between group variables. Predictors of surgical difficulty, such as sex, type of impaction, duration of surgical procedure, type of surgical procedure, fused roots, and root curvature, were assessed using multivariate analysis. Results The mean patient age was 29.93 ± 2.81 years. The mean mouth opening was 41.25 ± 3.5 mm. Chi-square test results revealed no significant differences between the maxillary and mandibular groups across all variables (p > 0.05). The independent t-test results revealed significant differences between the maxillary and mandibular groups in procedure duration (p < 0.05). The duration of the procedure was significantly longer in the mandibular group (44.13 ± 15.20 minutes) than in the maxillary group (33.33 ± 13.96 minutes). Root curvature, duration of the surgical procedure, type of surgical technique employed, and patient sex were all identified as significant predictors. Conclusion The surgical difficulty for impacted third molars was similar in both arches. The duration of the surgical procedure was longer in the mandibular arch.

Estimating the Extraction Time of an Upper Third Molar: Proposal and Validation of Results

Background: Numerous studies in the literature have aimed to evaluate the difficulty level of removing third molars. However, most of these studies have focused on the lower third molars, which can lead to complications. There is a lack of a method to determine the complexity of upper third molar extraction. Therefore, this study's objective was to develop an equation using multiple linear regression to estimate the extraction time of an upper third molar based on its complexity. Methods: This study involved patients enrolled in the Master of Oral Surgery program at the University of Seville. To determine their relationship with surgical time, the researchers analyzed various factors, such as depth, root morphology, and the need for odontosection. They then validated their findings by studying patients treated at Palmaplanas Hospital in Mallorca. Results: The cohort analysis from the University of Seville revealed significant associations between surgical time and the identified factors. A regression equation design was performed to predict the total duration of surgical intervention for wisdom teeth extraction. This equation incorporates several independent variables, represented by Xi, together with a constant term, C, and the corresponding coefficients, Bi, which weight the impact of each variable on the intervention time. The results are as follows: -0.312 (spatial relationship), 0.651 (depth), -0.443 (bone and mucosa integrity), 0.214 (roots), -0.745 (ostectomy), 0.713 (odontosection), and -0.426 (suture). Upon application of the statistical methodology to the Palmaplanas Hospital cohort, a regression coefficient of 0.770 was determined. This indicates a strong correlation between the input data and the estimated surgical time. Conclusions: In conclusion, the proposed formula demonstrates notable validity in predicting the surgical time required to extract upper third molars.

Effect of Hyaluronic Acid on Socket Healing After Lower Impacted Third Molar Tooth Extraction in 40 Dental Patients

BACKGROUND Surgical extraction of impacted mandibular third molars is the most commonly performed procedure in oral surgery; its associated complications include sensory nerve damage, swelling, and trismus. This study aimed to evaluate the effects of hyaluronic acid (HA) on healing of the socket following extraction of the lower impacted third molar tooth in 40 dental patients. MATERIAL AND METHODS This prospective, double-blind, randomized, controlled study was carried out on 40 adult healthy patients indicated for surgical removal of bilateral impacted mandibular third molars with equal surgical difficulty (moderate surgical difficulty according to the Koerner index. Patients with right mandibular third molars were included into the study (HA) group and those with left mandibular third molars were included into the control group. Surgical removal of impacted teeth was performed at different times for each patient for proper measurement of postoperative clinical variables, including pain, swelling, and mouth opening. RESULTS Postoperative pain evaluation results using the visual analog scale (VAS) showed reduced pain levels at all observation periods. Postoperative swelling peaked in intensity within 12-48 hours, resolving between the 5th and 7th days, and there was no significant difference in pre- and postoperative measurements of interincisal opening between both groups (P>0.05). CONCLUSIONS We found that intra-socket application of hyaluronic acid after surgical extraction of impacted mandibular third molars promoted normal wound healing, and there was a clinical benefit of reduced postoperative pain and swelling.

Effectiveness of Advanced Platelet-Rich Fibrin on Postoperative Sequelae for Impacted Mandibular Third Molar Surgery: A Prospective Study

Introduction Impacted third molar extraction is frequently removed surgically by maxillofacial surgeons, which is mostly associated with postoperative sequelae like pain and swelling. It is essential to minimize the complications and enhance wound healing in the extracted socket of the third molar. Hence, this study aimed to assess the efficiency of advanced platelet-rich fibrin (A-PRF) in wound healing and reducing pain after surgical extraction of the impacted mandibular third molar (IMTM). Materials and methods Thirty healthy patients who have been diagnosed with Pell and Gregory class II IMTM were included in this study. In the study group, which comprises 15 patients, extraction sockets were filled with A-PRF extract. In the control group, no material was placed in the extraction sockets. The pain was assessed preoperative and on the third and seventh postoperative days using a visual analog scale (VAS). Wound healing was assessed on the third and seventh postoperative days using a modified laundry scale. SPSS for Windows was used for data analysis. Categorical data was compared between the groups using the Chi-square test. P-value less than 0.05 was considered as statistically significant. Results The study population's mean age was 25.67 ± 2.4 years. Nineteen patients were male, and 11 patients were female. Differences in mean pain scores between the groups were not statistically significant both on the third postoperative day (p=0.59) and the seventh postoperative day (p=0.33). During the seventh day postoperative day, the study group exhibited better wound healing compared to the control group and the results were statistically significant (p=0.01). Conclusion A-PRF is a simple and effective method of reducing postoperative sequela by promoting wound healing after surgical extraction of IMTM. It has the advantage of less chance of allergic and anaphylactic reactions, unlike their predecessor platelet concentrates.

Efficacy of Oxytetracycline Hydrocortisone-Soaked Gauze Pack on Postoperative Sequelae in Lower Third Molar Surgery: A Prospective Study

Background Though various advancements came into the field of surgery to do the atraumatic procedure, post-operative pain, and swelling are unavoidable complications. Hence, various medicaments are packed in the extracted third molar sockets to prevent these post-operative complications. Aim The study aimed to evaluate the efficacy of oxytetracycline hydrocortisone-soaked gauze in reducing post-operative pain and swelling compared to conventional surgical procedures without any packing in patients undergoing surgical extraction of the impacted mandibular third molars. Materials and methods The study was conducted in the Department of Oral and Maxillofacial Surgery at Saveetha Dental College and Hospitals, Chennai. In this study, 50 patients were randomly included in two groups of 25 participants each. In group A, oxytetracycline hydrocortisone-soaked gauze was placed, and in group B, conventional closure was done without any pack after surgical removal of impacted mandibular third molars. Post-operative pain was assessed on days one, three, and five using a 10-point visual analog scale. Post-operative swelling was assessed on the third and seventh days using a four-point swelling measurement. Data analysis was done using SPSS (IBM Corp. Armonk, NY). A p-value less than 0.05 was considered statistically significant. Independent sample t-test was done to compare the outcomes between the two groups. Results The results demonstrated that group A (Oxytetracycline Hydrocortisone-soaked gauze) showed superior pain reduction compared to group B (conventional closure) at all post-operative intervals (P=0.001). Moreover, group A exhibited reduced swelling, resulting in higher patient satisfaction levels compared to group B on the third post-operative day (P=0.001). Conclusion It can be concluded from the study that there was a significant reduction in post-operative pain and swelling with the use of oxytetracycline hydrocortisone-soaked gauze, as it acts like a local drug delivery system in patients undergoing impacted mandibular third molar surgeries.

Comparison of Efficacy of Coumarin and Chymotrypsin/Trypsin in Patients Undergoing Surgical Removal of Lower Third Molars: A Prospective Study

Background Third-molar surgeries are very commonly done by oral and maxillofacial surgeons. Pain and swelling that is associated with this procedure is a frequent reason for the patient's discomfort and apprehension. There is a need to look for a drug that can substantially reduce postoperative swelling amongst the patients. Pain, swelling, and trismus are common complications that are encountered after third molar surgery. These complications have a major impact on the quality of life of patients undergoing minor surgical procedures. Aim The aim of this study was to compare the effectiveness of coumarin and trypsin/chymotrypsin in the reduction of postoperative sequelae for mandibular third molar surgeries. Materials and methods The research was carried out at Saveetha Dental College and Hospital in the Department of Oral and Maxillofacial Surgery. The study consisted of 50 individuals, 25 individuals received tablets of coumarin, and 25 individuals received tablets containing a combination of trypsin/chymotrypsin postoperatively. Patients were evaluated postoperatively for pain and swelling. Postoperative pain was measured on days one, three, and seven after surgery using a visual analog scale. The postoperative swelling was measured on postoperative days three and day seven via a four-point technique. Data were analyzed using IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York, United States). P-values less than 0.05 were considered statistically significant. The independent samples t-test was used to compare the outcomes between the two groups. Results It was found that study participants in the trypsin/chymotrypsin group reported statistically significantly less pain postoperatively than participants receiving coumarin (p=0.001). There was more reduction in swelling postoperatively in patients who were given trypsin/chymotrypsin as compared to the participants who were given coumarin, and the results were statistically significant. Conclusion Based on the data obtained, it can be inferred that the trypsin/chymotrypsin combination was more effective in reducing postoperative sequelae like pain and swelling than coumarin in the mandibular third molar surgeries.

Comparison of the Effectiveness of Four Different Irrigation Solutions on Postoperative Sequelae in Patients Undergoing Lower Third Molar Surgery: A Prospective Study

Introduction Oral and maxillofacial surgeons frequently perform the removal of impacted mandibular third molars. The success of this surgical intervention depends on meticulous surgical technique and the use of appropriate irrigants to minimize complications in the postoperative period.  Aim The aim of this study was to evaluate the efficacy of four different irrigation solutions (povidone-iodine, metronidazole, chlorhexidine gluconate (CHX), and normal saline) on postoperative sequelae like pain, trismus, swelling, and alveolar osteitis following surgical extraction of the impacted mandibular third molars. Materials and methods The current research was a randomized study carried out at Saveetha Dental College and Hospital in Chennai, India, from December 2022 to March 2023. The study population consisted of 112 participants who were referred to the Oral and Maxillofacial Surgery for the surgical removal of impacted mandibular third molars. The population was divided into four groups, with 28 in each group. They were categorized as A, B, C, and D based on the final irrigation solution used after surgical removal of the impacted teeth. In group A, patients received 0.5% povidone-iodine as the final irrigation solution; group B received 1% metronidazole; group C received 0.12% chlorhexidine gluconate (CHX); and group D received 0.9% normal saline. Patients were examined on the first and seventh postoperative days to assess pain, swelling, trismus, and alveolar osteitis. The results were analyzed with SPSS Statistics for Windows, Version 23.0 (Released 2015; IBM Corp., Armonk, New York, United States) software for Windows (Microsoft Corporation, Redmond, Washington, United States). A p-value less than 0.05 was considered statistically significant.  Results Group B experienced significantly less pain than groups A, C, and D on the first and seventh postoperative days (p<0.05). The facial swelling was significantly less on the first and seventh postoperative day in group B compared to groups A, B, and D (p<0.05). There was no statistically significant variation observed in trismus (mouth opening) across the groups on both the first postoperative and seventh postoperative days. The presence of alveolar osteitis was seen in groups A, C, and D, but no instances were reported in group B. Conclusion It can be concluded that among the four irrigation solutions used in the lower third molar surgery, metronidazole irrigation solution yielded the best results in terms of less pain, swelling, and alveolar osteitis followed by chlorhexidine. There was no difference between povidone-iodine irrigation and normal saline irrigation on the postoperative sequelae. Postoperative trismus does not depend on the irrigation solution used in the third molar surgery.

Comparison of the Efficacy Between Articaine and Lignocaine in Simultaneous Bilateral Orthodontic Maxillary Premolar Extractions: A Split-Mouth Comparative Study

Introduction Local anesthesia plays a crucial role in ensuring patient comfort during orthodontic extractions. Among the various local anesthetic agents commonly used in the field of oral surgery are articaine and lidocaine, which differ in their duration of action and pain effectiveness (pain control) during surgical procedures. This article aimed to analyze the characteristics of 2% lignocaine with 1:80000 adrenaline and 4% articaine with 1:100000 adrenaline regarding duration of action and pain control in patients undergoing bilateral orthodontic maxillary premolar extractions. Materials and methods A split-mouth comparative study was conducted at Saveetha Dental College and Hospitals, Chennai, for which 50 patients of age less than 30 years and who required bilateral orthodontic premolar extractions were selected. Approximately 4% articaine hydrochloride solution was administered on one side, and 2% lignocaine hydrochloride was administered on the contralateral side. Palatal infiltration was not given in the articaine group. The degree of extraction difficulty was similar in both groups, with no discernible variation. In each patient, the duration of anesthesia and pain control were assessed. The IBM Statistical Package for Social Sciences (SPSS version 24.0, IBM SPSS Statistics for Windows, Armonk, NY) was used to perform the student's paired t-test for detecting the difference in outcome parameters between the two groups. Results Upon comparing both groups, it was concluded that the articaine group had a longer mean anesthetic duration of action of 217 minutes, whereas for the lignocaine group, it was 169 minutes, and greater pain reduction was present with the articaine group. The articaine group exhibited less pain (superior pain control) with a mean visual analogue scale (VAS) score of 1.07 compared to that of the lignocaine group with a mean VAS score of 1.53 during orthodontic premolar extractions. Both the results were statistically significant (P=0.001). Conclusion This split-mouth comparative study concludes that articaine is a more effective local anesthetic in terms of duration of action and pain reduction than that of lignocaine, and it can be used as a local anesthetic of choice for orthodontic maxillary premolar extractions.

Comparison of Pain Perception Between Local Infiltration and Inferior Alveolar Nerve Block Injection Techniques in Patients Undergoing Orthodontic Lower Premolar Extractions

Introduction The most frequently used local anesthesia administration techniques for extraction of lower teeth in dentistry are local infiltration and inferior alveolar nerve block. Therapeutic extraction of premolars is the most common procedure done for patients undergoing orthodontic treatment. Inferior alveolar nerve block has been used most commonly for extraction of mandibular posterior teeth; however, it is a technique-sensitive procedure and has complications such as facial nerve palsy, trismus, and long duration of anesthesia. Local infiltration is a simple and effective technique for anesthetizing teeth prior to extraction. Aim This study aims to compare the efficacy of local anesthesia administered through inferior alveolar nerve block and local infiltration techniques for extraction of lower premolar teeth for orthodontic purposes. Materials and methods A prospective comparative study was conducted for a period of six months in which a total of 100 patients who were referred for extraction of lower premolar teeth for orthodontic purposes were included. Among 100 patients, 60 patients were males, and 40 patients were females with a mean age of 16.5 ± 1.25 years. The patients were equally divided into two groups, in which Group 1 received local infiltration and Group 2 received an inferior alveolar nerve block. The outcome parameters assessed were pain during injection and pain during extraction using the visual analog scale (VAS) score and Wong-Baker Faces Pain Rating Scale score. Statistical analysis was done using an independent sample t-test with SPSS version 23.0 software (IBM Corp., Armonk, NY) at p < 0.05 considered statistically significant. Results The difference in mean pain scores between the two groups during injection as assessed using the Faces Pain Rating Scale (p = 0.001) and VAS (p = 0.001) was statistically significant, with the infiltration group exhibiting less pain than the inferior alveolar nerve block group. The difference in mean pain scores between the two groups during extraction as assessed using the Faces Pain Rating Scale (p = 0.308) and VAS (p = 0.350) was statistically not significant, with the infiltration group not significantly differing from the inferior alveolar nerve block group. Thus, the pain during local infiltration was significantly lesser when compared to the inferior alveolar nerve block during injection, whereas pain perception during extraction was similar in patients with both injection techniques. Conclusion It can be concluded that local infiltration is less painful for the patient during injection and as efficacious as nerve block for extraction, hence local infiltration can be routinely used for lower premolar orthodontic extractions.

Microbiological Evaluation of Four Different Suture Materials Used for the Surgical Removal of Impacted Lower Third Molars: A Single-Center Prospective Comparative Study

Introduction Sutures play a crucial role in the postoperative healing process, as they help approximate wound edges, promote hemostasis, and support tissue healing. The oral cavity harbors a diverse microbial population, and oral surgical procedures can introduce potential pathogens into the surgical site. Understanding the impact of suture material on wound infection rates and the colonization of potentially harmful microorganisms is vital for improving patient outcomes. This study was aimed to evaluate and compare the microbiological properties of prolene, vicryl plus, monocryl, and silk sutures used after the surgical removal of impacted lower third molars. Materials and methods A total of 40 patients requiring surgical extraction of impacted lower third molars were assigned to four groups: prolene, vicryl plus, monocryl, and silk sutures. Surgical extraction of impacted tooth was done, and wound was sutured with the abovementioned four different materials in four groups, respectively. After seven days, the sutures were removed and sent to the microbiology lab for colony count assessment. Total microbial colony count, streptococcus count, and lactobacillus count were assessed. Data was analyzed using IBM SPSS Statistics for Windows, Version 23.0 (Released 2015; IBM Corp., Armonk, New York, United States) with p-values less than 0.05 considered as statistically significant. The one-way analysis of variance (ANOVA) and post-hoc Tukey test were done to compare intergroup relations. Results The microbiological evaluation of the sutures revealed significant differences in bacterial colonization among the four groups. More bacterial quantities were found in the silk group followed by the monocryl, vicryl plus, and prolene groups in the descending order. Prolene demonstrated the lowest incidence of bacterial growth (p<0.001) compared to vicryl plus, monocryl, and silk sutures. Bacterial colony count was highest in the silk group. The predominant bacterial species found in all groups were Streptococcus viridans, Staphylococcus aureus, and Lactobacillus.  Conclusion It was found that prolene and vicryl plus sutures exhibited superior microbiological properties compared to monocryl and silk sutures when used for the surgical removal of impacted lower third molars. The lower incidence and less quantity of bacterial colonization on prolene sutures suggest their potential for reducing the risk of postoperative infection; hence, these sutures can be preferred for oral surgical procedures.

Comparison of Pain Levels With Postoperative Intramuscular Administration of Single-Dose Ketoprofen Versus Diclofenac Sodium in Patients Undergoing Lower Third Molar Surgery

Background Third molar surgeries are commonly performed in oral and maxillofacial surgery practice. Pain associated with this procedure is usually a frequent reason for patient apprehension and discomfort. Oral analgesics, though effective, do not provide sufficient pain relief in the immediate postoperative period.  Aim To assess the postoperative effect on pain levels of single-dose administration of ketoprofen and diclofenac sodium as an injection in patients undergoing third molar removal surgeries.  Methods This study was conducted among 30 patients divided into two groups (n=15). Patients in Group K received injection ketoprofen 100 mg and Group D included patients receiving injection diclofenac sodium 75 mg, both intramuscularly postoperatively. The intensity of pain was assessed at 30 minutes, two, six, and eight hours post-surgical removal of the impacted tooth using the visual analogue scale (VAS). The statistical data was analyzed using SPSS for Windows version 23.0 (IBM Corp., Armonk, NY, USA). The comparative statistical test adopted to compare pain scores between the two groups was the Independent samples t-test. A p-value of <0.05 was considered to be statistically significant. Results Our study results revealed that Group K patient's VAS scores after two hours, six hours, and eight hours were 3.9 ± 2.7, 4.5 ± 3.23, 2.93 ± 2.27 respectively. In Group D patient's VAS scores after two hours, six hours, and eight hours were 4.83 ± 2.82, 5.03 ± 2.9, 3.73 ± 2.91 respectively. Patients who were administered ketoprofen had lower pain levels when compared to patients who were given diclofenac but the difference was not statistically significant at any time point (p=0.172 after eight hours). Our results depicted that the pain levels uniformly reached their maximal levels six hours after the procedure and thereafter steadily declined in both groups.  Conclusion It can be concluded from the study that both the drugs ketoprofen and diclofenac sodium analyzed in this study can be used interchangeably for the reduction of pain following lower third molar surgery.