The New Iraqi Journal of Medicine

Research Article
Oral Surgery

Factors predictive of difficult impacted third molar surgery.

Sundus Anwer M. AL-Hamdani *, Maha M. Al-Sened**, Khawlah Tarteeb Hussein *, Ahmed Samir Al-Naaimi***.

Abstract
Background: Although the removal of third molar is a common procedure, in some cases it can be difficult.

Estimating possible difficulties in the removal of third molars is a constant challenge for dental surgeons. Aim: Study the association of selected factors with difficult third molar surgeries. Method: A total of 256 patients having symptomatic third molars and referred to the oral surgery department for consultation, diagnosis and treatment of partially or completely impacted third molars in the mandible and maxilla were included in the sample. All had surgical extraction of third molar. Results: increased surgical difficulty was associated with horizontal impaction, male gender, above 30 years of age and under 20 years of age, mandibular location in addition to complete impaction type. Conclusion: In the context of difficult surgery predicted by the above factors one should adequately prepare the necessary logistics and proficiency level required for the procedure.
Keywords: third molars, impaction, surgical difficulty.

The N Iraqi J Med, August 2013; 9(2):

Introduction
Although the removal of third molars is a common procedure, in some cases it can be difficult. It is hard to evaluate factors that complicate removal of impacted third molars because of the large variation among patients and the difficulty of creating a study design [1]. The ability to predict the surgical difficulty of impacted third molars is essential when designing a treatment plan and has several advantages. It helps to assess the competence of the dental practitioner for the particular operation, minimize complication, and optimize the preparation of the patient and assist in terms of the postoperative management of inflammation and pain [2].
*Oral Surgery Department, Al-Karama Specialized Dentistry Center. ** The Clinic of Early Detection of Cancer-Medical City. ****Community Medicine, College of Medicine, University of Baghdad Email: Sundus Anwer M. AL-Hamdani: drsondos2000@yahoo.ocm . Maha M. Al-Sened samir7715@yahoo.com Khawlah Tarteeb Hussein k95ta@yahoo.com Ahmed Samir Al-Naaimi: ahmed_ihss22yahoo.com

Objectives: 1. Assess the relative frequency of simple surgeries (flap + tooth elevation) to remove impacted third molars Vs that of difficult surgery {flap+ (bone removal+/- tooth sectioning)}. 2. Assess the role of selected factors in predicting a difficult third molar surgery.

Materials and methods

Study design: Cross-sectional. Study setting: Oral surgery department in AlKarama specialized dentistry center in Baghdad for consultation. Study period: The study spanned a period of 6 years (2004-2009). Study Population: All patients referred to the oral surgery department for consultation, diagnosis and treatment of partially or completely impacted third molars in the mandible and maxilla.

Study sample: The records of all patients available during the 6years study period. A total of 256 subjects were included in the sample, 138 females and 118 males, their ages ranged between 16-49 years. Chief complaint (reason for extraction), clinical examination, combined with radio graphical evaluation and demographic information was obtained for each patient. Definition of study variables: Angulations: The angulations of third molars teeth were classified as vertical, horizontal, mesioangular or distoangular according to winters classification (Winter 1926) [3]. Other positions such as buccoangular, lingoangular, transverse and inverted were classified an aberrant position. The state of eruption: The state of eruption of the tooth was determined according to this criterion; completely impacted: when entirely covered by soft tissue and partially or completely covered by bone within bony alveolus. Partially erupted: when it has failed to erupt into a normal functional position and its partly visible in oral cavity (faculty of dental surgery 1997) [4]. Evaluation of surgical difficulty: All extraction in this study done surgically (reflecting of a mucoperiosteal flap) under local anesthesia. After that the tooth was removed using these surgical procedures: Elevation only (with forceps or elevator). Bone removal + elevation. Tooth sectioning +elevation. Bone removal + tooth sectioning + elevation. According to these procedures, surgical difficulty was evaluated during surgery and rating of difficulty on a 3- class-scale: Class-I (easy): elevation only. Class-II (moderate): tooth sectioning or bone removal + elevation. Class-III (difficult): tooth sectioning + bone removal + elevation. In the subsequent analysis of the data, class-II and class-III grouped together as difficult {tooth sectioning +/- bone removal} and class-I as easy (simple elevation). The scale used in the current study was almost similar to that of Garcia et al [5]. His scale was originally composed of 4 classes, (table 1). The final scale used in Garcia et al study was dichotomous also. Class-I and II was considered Easy surgery, while class-III and IV was classified as difficult surgery.

Statistical analysis: SPSS version 20 computer software was used for statistical analysis. Frequency distribution for selected variables was done first. The statistical significance of difference in average measure of surgical difficulty between 2 groups was assessed by Mann-Whitney test (nonparametric test), while between more than 2 groups Kruskal-Wallis test was used. The mean rank is a by-product of these non-parametric tests as a measure of central tendency for the compared groups. Multiple logistic regression analysis was used to assess the net risk for each of selected explanatory variables on having difficult surgery. P value less than 0.05 was considered statistically significant. Table 1: Surgical difficulty scale, Garcia et al [5].
Type I II III IV Technique Simple extraction Extraction requiring ostectomy Extraction requiring ostectomy and coronal section Complex extraction (root section)

Results The results were based on the analysis of a sample of 256 patients with symptomatic impacted third molars. The age of the subjects ranged from 16-49 years of age with mean of 24.4 years (+/- 5.8 years SD). Young adults (20-24 years of age) constituted the highest proportion of cases (43.4%). Females constituted a slightly higher proportion (53.9%) than males, table 2. Table 2: Frequency distribution of the study sample by age and gender.
N Age group (years) 16-20 38 20-24 111 25-29 65 30-34 23 35-49 19 Total 256 Mean+/-SD (24.4+/-5.8 years) Gender Female 138 Male 118 Total 256 Total 256 % 14.8 43.4 25.4 9 7.4 100

53.9 46.1 100 100

In the present study the difficulty level of surgical extraction of impacted third molars was determined intra-operatively according to the type of surgical intervention into a 3 grade scale. The higher percentage had the simplest surgical procedure (class-I =44.5%), followed by class-II (37.5%), and the lowest percentage was for class-III (the highest difficulty level= 18%), table 3.

Table 3: Frequency distribution of the study sample by type of surgical intervention.

Type of surgical intervention Elevation only Bone removal Tooth sectioning Tooth sectioning+Bone removal Total N 114 77 19 46 256 % 44.5 30.1 7.4 18 100

Uni-variat analysis (table 4) showed that three variables (gender, location and the type of

angulation) had significant association with difficulty level of surgical procedure (p >0.05).Male gender was associated with a higher difficulty level in surgical procedure (mean rank=152.1) compared to females (mean rank=108.3). Mandibular location of the extracted tooth was associated with a higher mean rank for difficulty level (130.9) compared to maxillary location (94.6). Horizontal/transverse angulation of extracted tooth was associated with the highest mean rank of difficulty level (192), while vertical angulation (83.7).

Table 4: Difficulty grading of surgical intervention by age, gender, location and type of tooth impaction .
Elevation only (class-I) N 1. Age group (years) 16-20 20-24 25-29 30-34 35-49 Gender Female Male Mandibular location Vs Maxilla Maxilla Mandible Type of tooth impaction Partially erupted Complete soft tissue impaction Complete bony impaction Type of angulation in tooth Distoangular Mesioangular Vertical Horizontal / transverse (Aberrant) 12 58 29 8 7 80 34 11 103 84 30 0 11 29 72 2 % 31.6 52.3 44.6 34.8 36.8 58 28.8 64.7 43.1 48 40 0 50 26.4 75.8 6.9 Tooth sectioning (or) Bone removal (class-II) Type of surgical intervention Tooth sectioning+ Bone removal (class-III) N % N % 22 35 20 10 9 45 51 6 90 62 28 6 10 52 22 12 57.9 31.5 30.8 43.5 47.4 32.6 43.2 35.3 37.7 35.4 37.3 100 45.5 47.3 23.2 41.4 4 18 16 5 3 13 33 0 46 29 17 0 1 29 1 15 10.5 16.2 24.6 21.7 15.8 9.4 28 0 19.2 16.6 22.7 0 4.5 26.4 1.1 51.7

Total N 38 111 65 23 19 138 118 17 239 175 75 6 22 110 95 29 %

Mean rank

0.42[NS] 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 136.8 119.2 133.1 141.4 135 <0.001 108.3 152.1 0.034 94.6 130.9 0.19[NS] 123.9 136.6 162.5 <0.001 113.2 153.5 83.7 192

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To study the net and independent effect of mandibular location, type of tooth angulation and type of tooth impaction after adjusting for age and gender on the risk of having a difficult surgery (Tooth sectioning +/- Bone removal compared to the simpler tissue elevation only) a multiple logistic regression model was used. With the exception of location all the remaining 4 explanatory variables had a statistically significant impact on the risk of having difficult surgery. Mandibular location was associated with an increase in risk of difficult surgery of 80% compared to maxillary location after adjusting for the remaining independent (explanatory) variables included in the model. The 20-29 years of age group was associated with the lowest risk of having difficult surgery and was therefore used as a reference category for the effect

of age. The < 20 years of age group was associated with 2.6 times increase in the risk of difficult surgery compared to the reference category (20-29 years of age). In addition the 30+ years of age group was associated with 3.8 times increase in the risk of difficult surgery compared to the reference category (20-29 years of age) after controlling for the remaining independent (explanatory) variables included in the model. The vertical type of angulation was associated with the lowest risk of having difficult surgery and was therefore used as a reference category for the effect of angulations type. The horizontal/transverse location increased the risk of difficult surgery 53.8 times compared to reference category (vertical angulations), while distoangular and mesioangular orientation increased the risk by 4.7 and 9.9 times after controlling for the remaining explanatory variables included in the model. Complete soft tissue

impaction and complete bony impaction increased the risk of difficult surgery by 2.4 times compared to partially erupt after controlling for the remaining explanatory variables included in the model

after controlling for the remaining explanatory variables included in the model. The model was statistically significant and had an overall accuracy of 77.4%, table 5.

Male gender significantly increased the risk of difficult surgery by 4.4 times compared to females Table 5: Multiple logistic regression model with risk of having a difficult surgery (Tooth sectioning +/Bone removal compared to the simpler tissue elevation only) as the dependent (response) variable and selected explanatory variables.
OR Type of impaction Complete soft tissue impaction compared to partially erupted male gender compared to female Mandibular location compared to maxilla Type of angulation Mesioangular compared to vertical Distoangular compared to vertical Horizontal / transverse (Aberrant) compared to vertical Age group (years) <20 years of age compared to (20-29) 30+ compared to (20-29) 2.4 4.4 1.8 9.9 4.7 53.8 0.007 2.6 3.8 P 0.09 <0.001 0.43[NS] <0.001

Note: Complete bony impaction increased the risk of having a difficult surgery compared to partially erupted, but the odds ratio can not be calculated. Overall predictive accuracy=77.3% P (model) <0.001

Discussion Preoperative assessment of surgical difficulty is fundamental to the planning of extraction of impacted third molars [6]. Several classification systems have been established to estimate surgical difficulty for removing third molars but they prove to be of little clinical use [5, 7]. These systems are primarily based on the preoperative assessment of panoramic radiographs [1], but other factors such as demographic and operative variables have also been analyzed [6,8]. Chandler et al, 1988 [9], suggested that preoperative assessment of surgical difficulty was unreliable and the best measure was that made during the procedure. In the present study the difficulty level of surgical extraction of impacted third molars was determined intra-operatively according to the type of surgical intervention into three class-scales: class-I (easy), class-II (moderate) and class-III (difficult). Class-I (flap reflection+tooth elevation) was the most frequent procedure used, followed by class-II, while class-III was the least frequent procedure used. This distribution and ranking of difficulty level agrees with many previously published articles [6, 10, 11], Although some of these studies used different types of classification for difficulty level of surgery.

Many articles [1, 2, 6, 8, 11] took into consideration operating time (from the first extraction maneuver to the completion of surgery) and have evaluated surgical difficulty according to increase in operating time. Although time is an objective measure of difficulty, the present study did not evaluate time factor, since the researchers of present study felt that assessment of surgical time may be biased and confounded by level of patients cooperation (gag reflex, fear, anxiety, mouth opening). The current study assessed the effect of selected factors on surgical difficulty, some of these factors are demographic (age and gender) and others are dental factors (impaction, angulation and location of impacted tooth). All these variables had a statistically significant impact on the risk of having difficult surgery when a multivariate analysis was used. Renton et al [8] and Gbotoloran[6] observed that surgical difficulty increased with increment in age of the patient. This was in agreement with our study where <30years of age have more difficult surgeries. Peterson et al [12], also linked increased bone density (measured radiographically) to age and increased surgical difficulty, which could account for positive relationship between increased age and surgical difficulty.

In the present study it was found that surgical difficulty also increased (but to a lesser degree) when the patient was >20 years of age. The possible explanation behind this finding is that younger patients complain from third molar problems early in their lives. The tooth is usually still in deeper position, having unfavorable angulation (horizontal or mesioangular)[13] making the surgery for removal difficult. Younger patients tend to be less cooperative with the surgical procedure. The other two variables that have been studied in our model were gender and location. Male gender and mandibular location are associated with more difficult surgery and this could be attributed to alteration in the properties of bone [8]. In the present study the most important factor that increases the risk of having difficult surgery was the angulation of the tooth, in which greater difficulty occurred with horizontal type of angulations. Wathson et al [14], (2011), in his study of factors associated with surgical difficulty during removal of impacted third molars found that age and gender of the patient was not significant predictors of difficulty but deviation from the vertical alignment of the tooth increased surgical difficulty because of the difficult access to the rotation axis of the tooth. He also found that greater difficulty occurred with horizontal type of angulation. Hupp et al [13] found that teeth at certain inclination have ready-made pathways for removal, whereas pathways for teeth of other inclination require the removal of substantial amount of bone. He considered the distoangular impactions as the teeth with the most difficult angulation for removal followed by horizontal impaction and the vertical type of impaction is the third in difficulty of removal. The mesioangular impaction is generally acknowledged as the least difficult impaction to remove. In the present study, according to the state of eruption, partially erupted molars were easier to remove than complete impacted molars. Renton et al [8], found that hard tissue impaction of third molar was one of the dental factors that increase the surgical difficulty for removal. Yuasa et al [1] and Wathson et al [14] studied additional factors (depth, ramus relationship, proximity to mandibular canal, abnormal root curvature, width of roots, spatial relationship, and periodontal space) that complicate the surgical removal of impacted third molars. Although these factors are important in determination of difficulty but they depend mainly on personal biases in interpretation of 2 dimensional radiographs. It was

therefore omitted from the current study to eliminate a potential source of bias and error. Torres et al (2010) [2] found that the use of panoramic radiograph doesnt allow practitioners to accurately predicate lower third molar extraction difficulty and techniques regardless of their level of experience. Its difficult to predict the difficulty of extraction from these x- ray techniques (two dimension) weather panoramic or periapical views because sometimes its difficult to get some of the precise details like (root curvature, width of roots, proximity to mandibular canal, number of roots.etc.) from them. Instead, if we want to depend on x-rays we may need more sophisticated radiographical techniques like three-dimensional (3D) imaging, such as computed tomography (CT) or cone beam CT (CBCT) may be valuable. Ghaeminia et al [15] evaluated the role of cone beam computed tomography (CBCT) in the treatment of patients with impacted mandibular third molars at increased risk of inferior alveolar nerve (IAN) injury and he found that CBCT contributes to optimal risk assessment and, as a consequence, to more adequate surgical planning, compared with panoramic radiography.

Conclusions
1. Less than half of the cases (44.5%) needed only tooth elevation as a surgical intervention and about one third (30.1%) needed bone removal. 2. The following factors increase the risk of having difficult surgery (Tooth sectioning +/- Bone removal (class-II and III) compared to the simpler tooth elevation only (class-I) : o Horizontal / transverse (Aberrant) orientation. o Mesioangular and distoangular orientation. o Male gender. o Older age (30+ years of age). o Younger age (<20 years of age). o Complete soft tissue and bony impaction.

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