British Journal of Oral and Maxillofacial Surgery (2004) 42, 209214

Clinical postoperative ndings after removal

of impacted mandibular third molars: prediction
of postoperative facial swelling and pain based
on preoperative variables
Hidemichi Yuasa
a,b,
*, Masayuki Sugiura
c
a
Department of Oral and Maxillofacial Surgery, Central Hospital of Tokai Medical Institute, 1, Marune,
Arao-tyou, Tokai City 476-8511, Japan
b
The Second Department of Oral and Maxillofacial Surgery, School of Dentistry, Aich-Gakuin University,
2-11, Suemori-dori, Chikusa-ku, Nagoya 464-8651, Japan
c
Department of Oral and Maxillofacial Surgery, Nagoya City Jyohoku Municipal Hospital 2-15,
Kaneda-tyou, Kita-ku, Nagoya 462-0033, Japan
Accepted 9 February 2004
KEYWORDS
Impacted mandibular
third molar;
Surgical removal;
Informed consent;
Postoperative ndings;
Prediction
Summary Purpose: This paper is intended as an investigation of the relationship
between preoperative ndings and short-term outcome in third molar surgery. Ma-
terial and methods: We assessed 153 consecutive surgical extractions of mandibular
third molars performed in 140 patients between April 1998 and March 2001. Results:
Fifty-four (35%) of the 153 extractions were performed in male subjects and 99 (65%)
in female subjects. The median age was 27 years. The amount of facial swelling varied
depending on age and sex. Severe pain was associated with depth and preoperative
index of difculty. Average pain was associated with preoperative index of difculty.
Conclusion: In conclusion, we consider that the short-term outcomes of third molar
operations (swelling and pain) differ depending on patients characteristics (age and
sex) and preoperative index of difculty. Further mega-trial studies of the association
between preoperative ndings and short-term outcome will help to elucidate the true
nature and magnitude of the association.
2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.
Introduction
The removal of lower third molars is the most com-
mon oral operation, and the postoperative course
*Corresponding author. Present address: 8U-102room,
a-banrafure hosigaoka, 1-23-4, Hosigaoka, Chikusa-ku, Nagoya
464-0801, Japan. Tel.: +81-52-781-4045; fax: +81-52-781-4045.
E-mail address: MXE05064@nifty.ne.jp (H. Yuasa).
can be complicated.
16
There have been few at-
tempts to study patients expectations of outcome
although patients perception of recovery after
third molar surgery has been reported.
7,8
Berge and Boe attempted to predict the extent
of postoperative morbidity by multiple regression
analysis.
9
Their study did not, however, correlate
the extent of postoperative facial swelling and
pain with preoperative variables, but with overall
0266-4356/$ see front matter 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2004.02.005
210 H. Yuasa, M. Sugiura
predictive factors. It is more informative from a
patients point of view to relate outcome to factors
that can be measured preoperatively than to rely
on an overall probability. In the present paper we
present the results of an investigation into the cor-
relation between preoperative factors (patients
characteristics, anatomical position of the tooth,
and index of operative difculty) and postoper-
ative morbidity (short-term outcome: pain and
swelling on the rst day) after extraction of third
molars.
Patients and methods
Between April 1998 and March 2001 in the rst oral
surgery clinic of the Nagoya City Jyouhoku Munici-
pal Hospital, Japan, we studied prospectively 140
consecutive patients who had 153 extractions of
mandibular third molars. Thirteen patients who
needed bilateral extractions had their teeth re-
moved on separate occasions. The study was re-
stricted to healthy Japanese people who had no
serious medical disorder or bleeding dyscrasia.
Only one lower third molar was removed at each
operation. All teeth were partially or completely
covered by mucosa and the root was fully formed
in all cases.
Exclusion criteria included patients who required
admission to the hospital or who were pregnant. No
patient had acute pericoronitis or severe periodon-
tal disease at the time of operation. Patients were
not given preoperative antimicrobial drugs or other
medication that might inuence healing. Three pa-
tients with swelling or pain as a result of unusual
events were excluded from the analysis (two sub-
cutaneous emphysema and one haemorrhage).
All operations were done under local anaesthe-
sia by the same oral surgeon (H.Y., who has more
than 10 years experience) in the same operating
room and under similar conditions. Analgesia was
achieved by an inferior alveolar and buccal nerve
block, together with inltration of the mucosa of
the retromolar trigone with two 1.8-ml capsules
of 2% lignocaine containing 1:80,000 adrenaline.
The mucoperiosteal ap extended from the mesial
corner of the rst molar distally to the retromo-
lar region. Bone was removed with a round bur,
and the tooth was sectioned with a ssure bur in
a high-speed handpiece. The wound was irrigated
with cool sterile physiologic saline solution. A 4-0
nylon suture was used to close the wound with-
out tension. One suture was placed interdentally
between the second and rst molars, and three su-
tures were used to close the distal part of the inci-
sion. A small rubber tube drain was inserted in the
distal part of the incision to avoid accumulation of
haematoma that could result in excessive swelling.
For the rst 3 postoperative days all patients
were given antibiotics (amoxycillin or cefaclor
750 mg three times daily), drugs for peptic ul-
cer (ranitidine 300 mg three times daily) and an
anti-inammatory drug (loxoprofen sodium 120 mg
every 6 h). In Japan, medical insurance does not
allow dentists to give prophylactic antibiotics.
The following variables were recorded before the
operation:
Clinical: Age (continuous and categorical vari-
ables: 029, 3039, and over 40 years); sex
(male, female); side operated on (right, left);
maximum interincisal distance (continuous and
categorical: 3039, 4049, and over 50 mm
029 mm is none); history of pericoronitis
(yes, no); degree of eruption (partial eruption,
non-eruption); and facial measurements, hori-
zontal (distance from the corner of the mouth
to the attachment of the ear lobe following
the bulge of the cheek) and vertical (distance
from the outer canthus of the eye to the angle
of the mandible).
Radiographic: Position of tooth
10,11
(position A:
highest portion of the tooth on a level with
or above the occlusal line; position B: highest
portion of the tooth below the occlusal line,
but above the cervical line of the second mo-
lar; position C: highest portion of the tooth
on a level with or below the cervical line of
the second molar); relative depth of tooth;
relation of tooth to the ramus of the mandible
(relation to ramus and space available) (class
1: sufcient space between the ramus and the
distal surface of the second molar for the ac-
commodation of the mesiodistal diameter of
the crown of the third molar; class 2: space
between the ramus and the distal surface of
the second molar is less than the mesiodis-
tal diameter of the crown of the third molar;
class 3: all or most of the third molar is within
the ramus); position of tooth in relation to the
long axis of the second molar (spatial relation)
(angulations were dened as distal or mesial
divergence of the occlusal surface from the oc-
clusal plane established by the rst and second
molars, horizontal, mesioangular, vertical, dis-
toangular); relative horizontal position of the
third molar (centre, lingual deection, buccal
deection); periodontal membrane space (all
ndings, partial ndings, or no ndings); and
preoperative index of difculty using rotational
panoramic tomograms and oral ndings
12
(po-
sition C or class 3 or thick (singular-middle root
Removal of impacted mandibular third molars 211
is wider than the neck and the roots do not
separate), incomplete roots excluded) on ro-
tational panoramic images predicts difculty.
The measures of outcome that we used as sur-
rogate measures of morbidity (Table 2) were facial
swelling dened by the distance from the corner of
the mouth to the ear lobe and the outer canthus of
the eye to the angle of the mandible measured by
a thread which was then transferred to a ruler. Fa-
cial swelling was calculated as horizontal measure
plus vertical measurement divided by 2, and per-
centage of facial swelling as preoperative measure-
ment minus postoperative measurement divided by
preoperative measurement times 100.
These measurements and those of interincisal
opening were made on postoperative days 1 and
7 by the same person. Trismus was calculated as
preoperative measurement minus postoperative
measurement divided by preoperative measure-
ment multiplied by 100. In addition, each patient
was given a questionnaire that included the revised
Table 1 Univariate analysis on postoperative day 1.
Variable Number of patients Swelling (mm) Severe pain (0100 VAS) Average pain (0100 VAS)
Age
029 95 18 51 40
3039 39 18 50 39
Over 40 19 28
*
50 42
Sex
Male 54 24 50 40
Female 99 15
*
50 40
Maximum interincisal distance
3039 23 18 60 45
4049 101 18 46 38
Over 50 29 28 52 42
Degree of eruption
Partial 97 19 48 36
Unerupted 56 19 51 40
Depth
Position A 42 19 44 34
Position B 80 19 51 39
Position C 31 19 62
*
49
*
Relation to ramus, space available
Class 1 23 28 48 49
Class 2 111 19 50 38
Class 3 19 10
*
64 45
Preoperative index of difculty
Easy 99 19 46 36
Difcult 54 19 60
*
45
*
Figures are medians.
*
Signicantly different from others in that group.
Health-Related Quality of Life (HRQL) instrument
to be completed on postoperative days 1 and 7.
7
The amount of pain was assessed by the patients
on visual analogue scales (VAS) that ran from 0 to
100 mm. The amount was arbitrarily divided into
average and severe.
Statistical analysis
The MannWhitney U test was used to calculate the
signicance of continuous preoperative variables.
The variables that were signicant predictors were
used in a logistic regression model with facial
swelling, severe pain, and average pain as the de-
pendent variables. In doing the logistic analysis,
continuous variables and dependent variables were
ranked according to their median value. The post-
operative difculty rank excluded the predictive
model for the self-completed outcome measure-
ment. In addition, variables with correlations of
0.3 or over were excluded from the model. We then
analysed the position of the tooth (depth, relation
212 H. Yuasa, M. Sugiura
to ramus, and space available) and preoperative
index of difculty in two models.
Calculations were made with the statistical soft-
ware package STATISTICA 2000 (Stat Soft Inc. USA,
2000). For all tests a probability of less than 0.05
was considered signicant.
Results
Of the 153 extractions, 54 (35%) were in male and
99 (65%) in female. The median age was 27 years
(range: 1767). The clinical indications for removal
were pericoronitis in 88 (58%), pain in 17 (11%),
caries in second molar in 11 (7%), orthodontic rea-
sons in 8 (5%), impaction in 19 (12%), and request
by the patient in 10 (6%).
Univariate analysis showed that the factors that
predicted swelling on day 1 on were age, sex, and
relation to ramus (space available). Those that pre-
dicted severe pain were depth of impaction and
preoperative index of difculty (Table 1).
On day 7 the factors predictive of continued
swelling were age and horizontal position. Those
Table 2 Univariate analysis on postoperative day 7.
Variable Number of patients Swelling (mm) Severe pain (0100 VAS) Average pain (0100 VAS)
Age
029 95 0 12 10
3039 39 0 15 10
Over 40 19 10
*
14 11
Maximum interincisal distance preoperative
3039 23 0 20 13
4049 101 0 15 10
Over 50 29 0 10 10
Degree of eruption
Partial 97 0 10 10
Unerupted 56 0 20
*
12
Depth
Position A 42 0 9 6
Position B 80 0 12 10
Position C 31 0 20
*
11
Horizontal position
Centre 111 0 12 10
Lingual 1 0 0 0
Buccal 11 15
*
28 11
Preoperative index of difculty
Easy 99 0 10 8
Difcult 54 0 21
*
16
*
Figures are medians.
*
Signicantly different from others in that group.
predictive of persistent severe pain were degree
of eruption, depth of impaction, and preoperative
index of difculty (Table 2).
If the three outcome factors (swelling, severe
pain, and average pain) were considered collec-
tively as a measure of morbidity then on day 1 they
were predicted by these variables: age, sex, depth,
relation to ramus, and preoperative index of dif-
culty.
The independent variables that predicted
swelling were age and sex (P < 0.04 for age and
P = 0.04 for sex). Severe pain was signicantly
correlated with depth (P = 0.03) and preoperative
index of difculty (P = 0.01). Average pain was
signicantly correlated with preoperative index of
difculty (P = 0.02).
Discussion
The amount of facial swelling varied depending on
age and sex. Severe pain was associated with depth
of tooth and preoperative index of difculty. Av-
erage pain was associated with preoperative index
Removal of impacted mandibular third molars 213
of difculty. It is quite likely that facial swelling is
affected by individual characteristics such as age
and sex. Facial swelling was also associated with
the relation to the ramus and space available in
the univariate analysis. Unlike other factors, severe
swelling was seen with easier extractions, which
were associated with a wide relation to ramus and
space available. We think that the relation to the
ramus and space available may show the form of
the patients face.
Severe pain and average pain were related to
the depth of teeth and the difculty of extraction.
Whereas swelling was more common in patients
over 40 years of age, pain did not vary with age.
The preoperative index of difculty described by
Yuasa et al. has been useful in predicting postop-
erative pain.
12
Signicant variables on multivariate analysis are
shown in Fig. 1 (with the exception of depth). For
swelling, this diagram tells us that the strengths of
correlation of age group (40 years or over) and sex
(male) are larger than the rest.
We did not examine the ndings on day 7 because
of the small size of the effects. We did not discuss
oral health, routine activities, overall health, and
other symptoms included in the HRQL report
7
be-
cause they had little connection with swelling or
pain.
Further studies will be required to conrm the
predictive factors described in this paper, and we
cannot assume causal inferences between preoper-
ative ndings and outcome. We consider it unlikely,
Age (year)
S
w
e
l
l
i
n
g
0
2
4
6
8
10
12
14
16
0-29 30-29 over 40
Gender
S
w
e
l
l
i
n
g
0
2
4
6
8
10
12
14
16
Male Female
Preoperative difficulty index
W
o
r
s
t

p
a
i
n

(
V
A
S
)
0
20
40
60
80
100
Easy Difficult
Preoperative difficulty index
A
v
e
r
a
g
e

p
a
i
n

(
V
A
S
)
0
20
40
60
80
100
Easy Difficult
(b) (d)
(a) (c)
Figure 1 Box and whisker plots of signicant variables: (a) swelling and age; (b) swelling and sex; (c) worst pain
and preoperative difculty index; and (d) average pain and preoperative difculty index. The black central symbol
indicates the median, the bars indicate the range, and the horizontal edges of the boxes the interquartile range.
however, that these biases will affect the internal
validity of the main result, particularly because of
the internal consistency in univariate and multi-
variate analysis. Potential problems derived from
somewhat arbitrary assessments of swelling and
pain were addressed by using univariate analysis
and arbitrary cut-off points, in addition to logistic
regression analysis.
We had few complications.
1,3
There were no
cases of dysaesthesia, fracture, secondary infec-
tion, or dry socket (alveolar osteitis). However, two
patients had subcutaneous emphysema and one ex-
cessive bleeding. Compared with other reports, the
postoperative complications that we encountered
were minor.
7,13,14
In conclusion, we consider that the short-term
outcomes of third molar operations (swelling and
pain) differ depending on patients characteristics
(age and sex) and preoperative index of difculty.
It would help to identify a group of patients at high
risk of severe swelling and pain and to design ran-
domised trials to evaluate the effectiveness of new
surgical methods. For instance, subjects who have
extractions should not be viewed as a uniform pop-
ulation when postoperative analgesia is evaluated,
but should be stratied by operating time and pre-
operative index of difculty. However, because of
the observational nature of the study, our results
should be interpreted with caution. Further stud-
ies of the association between preoperative nd-
ings and short-term outcome will help to elucidate
the true nature and magnitude of the association.
214 H. Yuasa, M. Sugiura
References
1. Chiapasco M, De Cicco L, Marrone G. Side effects and com-
plications associated with third molar surgery. Oral Surg
Oral Med Oral Pathol 1993;76:41220.
2. Lopes V, Mumenya R, Feinmann C, Harris M. Third mo-
lar surgery: an audit of the indications for surgery, post-
operative complaints and patient satisfaction. Br J Oral
Maxillofac Surg 1995;33:335.
3. Oikarinen K, Rasanen A. Complications of third molar
surgery among university students. J Am Coll Health
1991;39:2815.
4. Garcia Garcia A, Gude Sampedro F, Gandara Rey J, Gallas
Torreira M. Trismus and pain after removal of impacted
lower third molars. J Oral Maxillofac Surg 1997;55:12236.
5. Renton T, McGurk M. Evaluation of factors predictive of lin-
gual nerve injury in third molar surgery. Br J Oral Maxillofac
Surg 2001;39:4238.
6. Renton T, Smeeton N, McGurk M. Factors predictive of
difculty of mandibular third molar surgery. Br Dent J
2001;190:60710.
7. Shugars DA, Benson K, White Jr RP, et al. Developing a
measure of patient perceptions of short-term outcomes of
third molar surgery. J Oral Maxillofac Surg 1996;54:1402
8.
HISTORICAL CASE
ROBERT JAMES GORLIN (1923)
American oral pathologist and geneticist. Most
famous eponym: Gorlin-Goltz syndrome which
comprises multiple jaw cysts, cutaneous nod-
ules with a propensity to malignant change,
cranial enlargement and skeletal abnormali-
ties.
Robert Gorlin served in the US army during the
Second World War, before studying dentistry
at the University of Washington. After gradua-
tion, he obtained an MS in chemistry. He held
a number of academic posts before he moved
to the University of Minnesota, where he be-
came professor and chairman of the division
of oral pathology in 1958. He became Regents
Professor Emeritus of Oral Pathology and Ge-
netics at the University of Minnesota in 2000.
He additionally served as professor of patho-
logy, dermatology, paediatrics, obstetrics, gy-
naecology and otolaryngology. He is one of
the founders and a diplomate of the American
Board of Medical Genetics, Clinical Genetics.
Gorlin is internationally known for his work in
craniofacial and deafness syndromes. He has
published more than 400 articles about cran-
iofacial syndromes, and his book Syndromes of
the Head and Neck is the denitive work on the
subject. This is nowin its fourth edition. Gorlin
served for 30 years as editor of the oral pathol-
ogy section of Oral Surgery, Oral Medicine and
Oral Pathology. In 1997, he was presented
with the Premio Anni Verdi award in Spo-
leto, Italy and was elected to the Institute of
Medicine.
He has given his name to many syndromes
and signs. One in particular is Gorlins sign
the ability to touch the tip of the nose with
the tongue in patients with Ehlers-Danlos syn-
drome.
1. Gorlin R, et al. Focal facial hypoplasia syn-
drome. Acta Dermatol Venereol (Stockholm)
1963;42:42140.
8. Conrad S, Blakey GH, Shugars DA, Marciani RD, Phillips C,
White Jr R. Patients perception of recovery after third
molar surgery. J Oral Maxillofac Surg 1999;57:128894.
9. Berge TI, Boe OE. Predictor evaluation of postoperative
morbidity after surgical removal of mandibular third molars.
Acta Odontol Scand 1994;52:1629.
10. Pell GJ, Gregory TG. Report on a ten-year study of a tooth
division technique for the removal of impacted teeth. Am
J Orthod 1942;28:6606.
11. Winter GB. Impact mandibular third molar. St. Louis: Amer-
ican Medical Books. p. 19 (quoted by Gargallo-Albol J,
Buenechea-Imaz R, Gay-Escoda C. Lingual nerve protection
during surgical removal of lower third molars. A prospective
randomised study. Int J Oral Maxillofac Surg 2000;29:268
71).
12. Yuasa H, Kawai T, Sugiua M. Classication of surgical dif-
culty in extracting impacted third molars. Br J Oral Max-
illofac Surg 2002;40:2631.
13. Amin MM, Laskin DM. Prophylactic use of indomethacin for
prevention of postsurgical complications after removal of
impacted third molars. Oral Surg Oral Med Oral Pathol
1983;55:44851.
14. Rakprasitkul S, Pairuchvej V. Mandibular third molar surgery
with primary closure and tube drain. Int J Oral Maxillofac
Surg 1997;26:18790.