1
Mohamad Badra
5th year, 13 grINVESTIGATION OF
POSTOPERATIVE
COMPLICATIONS
RELATED TO
SURGICAL REMOVAL
OF WISDOM TEETH:A
SYSTEMATIC REVIEW
Master’s Thesis Supervisor DDS, PhD, Marius Leketas Kaunas, 20192
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
INVESTIGATION OF POSTOPERATIVE
COMPLICATIONS RELATED TO SURGICAL REMOVAL OF WISDOM TEETH:A SYSTEMATIC
REVIEW
Master’s Thesis
The thesis was done
by student ... Supervisor ...
(signature) (signature)
... ...
(name surname, year, group) (degree, name surname)
... 20…. ... 20….
(day/month) (day/month)
3
EVALUATION TABLE OF THE MASTER’S THESIS
OF THE TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC LITERATURE Evaluation: ... Reviewer: ...
(scientific degree. name and surname)
Reviewing date: ...
No. MT parts MT evaluation aspects
Compliance with MT requirements and evaluation Yes Partially No 1 Summary (0.5 point)
Is summary informative and in compliance with the
thesis content and requirements? 0.3 0.1 0
2 Are keywords in compliance with the thesis essence? 0.2 0.1 0
3 Introduc-
tion, aim and tasks (1 point)
Are the novelty, relevance and significance of the
work justified in the introduction of the thesis? 0.4 0.2 0 4 Are the problem, hypothesis, aim and tasks formed clearly and properly? 0.4 0.2 0
5 Are the aim and tasks interrelated? 0.2 0.1 0
6 Selection criteria of the studies, search methods and strategy (3.4 points)
Is the protocol of systemic review present? 0.6 0.3 0 7 Were the eligibility criteria of articles for the selected protocol determined (e.g., year, language,
publication condition, etc.)
0.4 0.2 0
8
Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and is the last search day indicated?
0.2 0.1 0
9
Is the electronic search strategy described in such a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to the combinations of keywords)?
0.4 0.1 0
10
Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?
0.4 0.2 0
11 Is the data extraction method from the articles (types of investigations, participants, interventions, analysed factors, indexes) described?
0.4 0.2 0
12 Are all the variables (for which data were sought and any assumptions and simplifications made) listed and defined?
0.4 0.2 0
4
information is to be used in data synthesis, described?
14 Were the principal summary measures (risk ratio, difference in means) stated? 0.4 0.2 0
15 Systemiza- tion and analysis of data (2.2 points)
Is the number of studies screened: included upon assessment for eligibility and excluded upon giving
the reasons in each stage of exclusion presented? 0.6 0.3 0
16
Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?
0.6 0.3 0
17
Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)
0.4 0.2 0
18
Are the extracted and systemized data from studies presented in the tables according to individual
tasks? 0.6 0.3 0
19
Discussion (1.4 points)
Are the main findings summarized and is their
relevance indicated? 0.4 0.2 0
20 Are the limitations of the performed systemic review discussed? 0.4 0.2 0 21 Does author present the interpretation of the results? 0.4 0.2 0 22
Conclusions (0.5 points)
Do the conclusions reflect the topic, aim and tasks
of the Master’s thesis? 0.2 0.1 0
23 Are the conclusions based on the analysed material? 0.2 0.1 0
24 Are the conclusions clear and laconic? 0.1 0.1 0
25
References (1 point)
Is the references list formed according to the
requirements? 0.4 0.2 0
26
Are the links of the references to the text correct? Are the literature sources cited correctly and
precisely? 0.2 0.1 0
27 Is the scientific level of references suitable for
Master’s thesis? 0.2 0.1 0
28
Do the cited sources not older than 10 years old form at least 70% of sources, and the not older than
5 years – at least 40%? 0.2 0.1 0
Additional sections, which may increase the collected number of points
29 Annexes Do the presented annexes help to understand the analysed topic? +0.2 +0.1 0
30
Practical recommen-
dations
Are the practical recommendations suggested and
are they related to the received results? +0.4 +0.2 0
31
Were additional methods of data analysis and their results used and described (sensitivity analyses,
5
*Remark: the amount of collected points may exceed 10 points. Reviewer’s comments:
32
Was meta-analysis applied? Are the selected statistical methods indicated? Are the results of
each meta-analysis presented? +2 +1 0
General requirements, non-compliance with which reduce the number of points
33
General require- ments
Is the thesis volume sufficient (excluding
annexes)? 15-20 pages (-2 points) (-5 points) <15 pages 34 Is the thesis volume increased artificially? -2 points -1 point
35 Does the thesis structure satisfy the requirements of Master’s thesis? -1 point -2 points 36 Is the thesis written in correct language, scientifically, logically and laconically? -0.5 point -1 points 37 Are there any grammatical, style or computer literacy-related mistakes? -2 points -1 points
38 Is text consistent, integral, and are the volumes of its structural parts balanced? -0.2 point -0.5 points 39 Amount of plagiarism in the thesis. (not evaluated) >20%
40
Is the content (names of sections and sub- sections and enumeration of pages) in compliance with the thesis structure and aims?
-0.2 point -0.5 points
41
Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections distinguished logically and correctly?
-0.2 point -0.5 points
42 Are there explanations of the key terms and abbreviations (if needed)? -0.2 point -0.5 points
43 Is the quality of the thesis typography (quality of printing, visual aids, binding) good?
-0.2 point -0.5 points
6 TABLE OF CONTENTS 1. 1.1. 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1,9 2. 2.1 2.2 3. SUMMARY ... INTRODUCTION... SELECTION CRITERIA OF THE STUDIES, SEARCH METHODS AND
STRATEGY………...………..……… Focus questions
Types of publication Types of studies Information Sources Literature search strategy Selection studies
Inclusion and exclusion criteria Data extraction
Risk of bias
SYSTEMISATION AND ANALYSIS OF DATA……….. Study selection Study characteristics DISCUSSION……… CONCLUSION……….. PRACTICAL RECCOMENDATIONS... REFERENCES……… ANNEXES………... 7 9 10 10 10 11 11 11 11 13 13 14 14 14 14 17 20 26 26 27
7
ABSTRACT
Objectives: Extraction of third molars or what is known by wisdom teeth is a frequent surgical procedure.
During the informed consent process, usual complications related to wisdom teeth extractions are well acknowledged and often explained to patients undergoing such procedures. Intra-operative and
postoperative complications must be well recognized by, general dental practitioner, oral and maxillofacial surgeon as well as the oral surgeons. The purpose of the present study was to systematically review the unusual complications of this routine procedure.
Materials and Methods: The study search was performed on MEDLINE and ScienceDirect from 2009
until 2019. Screenings at the titles, abstracts, and full-texts were done. Clinical case reports in the English language that reported patients with a presented uncommon complication due to the extraction of one or more third molar were included PRISMA guidelines accordingly. Key terms included wisdom tooth, third molar, rare, uncommon, and complications.
Results: Commonly detected, usual complications are permanent damage of nerve and mandibular
fractures. Rare and uncommon complications were twelve (12) identified in eleven (11) articles. Among those complications were abscess formation, and displacement of teeth, roots, and burs: subcutaneous cervicofacial, cervicothoracic emphysema, pneumomediastinum, pneumorrhachis. Ear bleed and styloid fracture were also detected.
Conclusions: To obtain perfect patient care, recognizing the probable complication is a must. Uncommon
complications should be acknowledged as early as possible to guarantee a complication free surgery.
8
Abbreviations
o Universal (FDI): 1(18),16(28), 17(38), 32(48) o Gender: (M)Male, (F)Female
o OPG: Orthopantomogram
o MRI: Magnetic Resonance Imaging o CT: Computerized Tomography
o 3DCBCT: Three dimensioned Cone Beam Computerized Tomography o 3DCBVT: Three dimensioned Cone Beam Volumetric Tomography o IV: Intravenously
o IO: Intraorally
o NSAIDs: Non-steroidal anti-inflammatory drugs o WBC: White blood cell
9
INTRODUCTION
The Third Molar Clinical trial research group of the American Association of Oral and Maxillofacial Surgeons launched an idealistic longitudinal study in 1994 that has enriched the scientific data of the complications related to third molar surgeries. The extraction of third molars or what is known as wisdom teeth is considered to be the most ubiquitous procedure carried out by both oral and maxillofacial surgeons.[1] Accurate preoperative planning and high surgical skills are required to sustain a successful surgical procedure with a minimal incidence of adverse effects. Such adverse effects are unintentional outcomes, the possibility of occurrence of such outcomes should be explained and mentioned to patients undergoing a third molar extraction. [1,2]
It is a must to provide the patient with a precise and reliable prediction concerning the risks of adverse effects and the complexity of the surgery. [3]
Assessment of possible adverse events is a constant quandary for dental practitioners generally and fresh graduates specifically. Studies on wisdom teeth extraction concentrated on complications following an extraction or what is known by postoperative complications, with less attention given to complications arising during the extraction process, or what is known by intra-operative complications.[4]
According to literature, complications after wisdom teeth extractions is between 4.6% and 30.9%, occurring intra-operatively or following the surgical procedure, postoperatively. [5,6]
The first is a consequence of soft tissue lesions (lacerations, dislocations, and emphysema), lesions of adjacent teeth and nearby anatomical structures (luxation, fractures, oroantral communications, avulsion), lesion of the vascular region (overheating, compression), or bone fractures (tuberosity, mandibular, maxillary, alveolar). On the other hand, soft tissue lesions (trismus, swelling, pain), infections (alveolitis, osteitis), vascular factors (petechiae, ecchymoses, hematomas) gives rise to postoperative complications. [7] Discrepancies in the findings are related to diverse definitions of complications, variable techniques of evaluating study variables, study designs as well as the absence of patient’s follow-up.[6]
The range of complications varies from asymptomatic to severe symptomatic complications; the most common complications reported in the literature are the following, alveolar osteitis, bleeding, infection and paresthesia [1,2].
Complications cleared up without additional treatment are considered minor, whereas major ones are those that need supplementary treatment and may end up in irreversible outcomes.
Iatrogenic displacement of third molar teeth, severe hemorrhage, and abscess formation fall under the category of major complications, whereas minor complications are swelling, pain and trismus.
10
Despite the fact, that third molars may stay symptom-free, it is extremely apparent that they may be the reason of one or more problems. Minor preoperative complications such as pain, pericoronitis, root resorption of the second molar as well as periodontal disease development on the second molar. Abscess formation and odontogenic cysts or tumors are considered to major preoperative complications.[2]
All possible complications must be recognized by general dental clinicians as well as oral and maxillofacial surgeons to assure suitable management.
Aims: This systematic review aims to recall oral and maxillofacial surgeons generally and fresh dental
graduates specifically, of the rare and uncommon complications related to surgical removal of wisdom teeth. Correspondingly, this review may help clinicians in avoiding such complications.
Tasks: To investigate the uncommon complications occurring after third molar surgery and to analyse what
factors could influence the occurrence of such rare complications.
SELECTION CITERIA OF THE STUDIES, SEARCH METHODS AND STRATEGY Focus Question
The presented focus question was placed according to the population, intervention, comparison and outcome (PICO) study design.
Table 1. PICO Characteristics
Population (P) Patients who underwent surgical removal of a third molar
Intervention (I) Radiological imaging
Comparator or control group
(C) No term was used in the comparator or control group (C)
Outcomes (O) The evaluation of discomfort, and complications after third molar
surgery.
Focus questions What are the unusual complications related to surgical removal of
11
Types of Publications
This review included case reports of humans who had at least a complicated third molar extraction, published in the English language.
Types of Studies
The review included all human studies and clinical case reports published between March 2009 and March 2019, that reported on uncommon complications related to surgical removal of the third molar.
Information sources
The electronic search strategy was based on searching the PubMed MEDLINE database between March 2009 and March 2019, the ScienceDirect database between 2009 and 2019 and manually searching the bibliographies of the included journals and articles dealing with dentistry, and oral surgery between 2009 and 2019: British Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery,
International Journal of Oral and Maxillofacial Surgery. Oral and Maxillofacial Clinics of North America Journal, European Journal of Oral Sciences, Journal of Dental Research, British Dental Journal, Medical Principles and Practice.
Literature Search Strategy
To detect the appropriate studies, a detailed electronic search was carried out according to PRISMA guidelines [8] within a PubMed/Medline and ScienceDirect databases using different combinations of the following keywords: (rare[All Fields] AND complication[All Fields] AND after[All Fields] AND ("molar, third"[MeSH Terms] OR ("molar"[All Fields] AND "third"[All Fields]) OR "third molar"[All Fields] OR ("wisdom"[All Fields] AND "tooth"[All Fields]) OR "wisdom tooth"[All Fields]) AND ("surgery"[Subheading] OR "surgery"[All Fields] OR "surgical procedures, operative"[MeSH Terms] OR ("surgical"[All Fields] AND "procedures"[All Fields] AND "operative"[All Fields]) OR "operative surgical procedures"[All Fields] OR "surgery"[All Fields] OR "general surgery"[MeSH Terms] OR ("general"[All Fields] AND "surgery"[All Fields]) OR "general surgery"[All Fields])) AND ("2009/03/24"[PDat] : "2019/03/21"[PDat] AND "humans"[MeSH Terms] AND English[lang])
12
13
Selection of studies
The derived articles were independently revised to confirm inclusion and exclusion criteria by two reviewers. In the beginning, titles and abstracts were screened, and finally, full reports were obtained for all the studies that were eligible for inclusion in this review.
Population
Patients who underwent at least one complicated surgical removal of a third molar which is considered to be rare.
Inclusion and exclusion criteria
Inclusion criteria for the selection were:
• Human studies dealing with at least a patient who had one uncommon/rare complicated third molar surgery.
• Full text available, in the English language.
• Mentioned imaging methods for diagnosis and further investigation. Exclusion criteria for the selection were:
• Animal studies
• Articles without abstract
• Deficient information regarding the topic
• Studies involving patients with systematic diseases, immunological disorders, and osteoporosis.
Sequential search strategy
The selected articles were screened independently to confirm inclusion and exclusion criteria. Later the initial literature search, all studies were included in the review according to title relevancy, considering the exclusion criteria. Moreover, studies were excluded based on irrelevant data obtained from the abstracts. The final stage of screening demanded reading the full texts and affirming each study’s eligibility based on the inclusion criteria.
14
Data collection process
Data were independently extracted from articles in the form of variables according to the aim and themes of the present review as listed shown below.
Data extraction
Extraction and collection of data were done for studies that accomplished the inclusion criteria; the data were arranged as follows:
• “Author-year”- the author and the year of publication.
• “Tooth number”- which exact third molar was extracted and number according to FDI. • “Age”- age of the patient at the time of surgery.
• “Sex”- the gender of the presented patient.
• “Rx”- the used radiographic imaging to diagnose the complication. • “Findings in Imaging”- radiographical findings in selected imaging. • “Complication”- the presented complication due to third molar surgery. • “Complication Management”- described the treatment protocol.
Risk of bias assessment
The risk of bias assessment was not conducted. Considering the chosen case reports, the risk of bias is high. [9]
Statistical analysis
No meta-analyses could be performed due to the heterogenous case reports.
SYSTEMIZATION AND ANALYSIS OF DATA Study selection
Total of one hundred fifty-five (155) publications were retrieved, and thirty (30) articles were reviewed in full. The initial exclusion was done by duplication and not relevant titles and abstracts. Among them, eleven (11) publications were selected for the systematic review. According to inclusion and exclusion
15
criteria, finally, eleven (11) publications were included, which have had evaluated a total of twelve (12) uncommon complications from eleven (11) patients.
Table 2. Reviewed single-event case reports of rare third molar complications
Study T
o ot h #
Age Sex Rx Findings in Rx Complication Complication
management Casio Edvard Sverzut et al 2009 [10] 28 22 M 3D
CBVT left maxillary third molar was displaced o (3DCBVT) into the infratemporal fossa
Accidentally displaced into the infra-temporal fossa via intramural approach Small incision parallel to the fibers of the buccinator muscle and superficial dissection H. Kocaelli et al 2011 [11] 18 32 F Lateral radiogr aph/CT / 3DCT/ o (L.R)
#18 positioned anterior to the ramus, at the level of the crowns of the #17.
o (CT)
Displaced tooth migrated into the buccal space; it was trapped between the masseter and buccinator muscles.
o (3DCT)
tooth was found anterior and medial to the anterior border of the ramus, crown level distally to #17 and a long axis outspreading in a bucco-palatinal and mediolateral direction
Displaced into buccal space Antibiotic and analgesic/ antipyretic therapy. Submucosal incision underneath the parotid papilla, tooth was reached via blunt dissection. Patrico Jose de Olveira Neto et al 2012 [12]
38 22 M CT Inflammatory area in temporal space without purulent collection.
Temporal Abscess IV cephalosporin, extraoral and intraoral incision and drainage. After discharged IO Clindamycin 600mg Bruno Tochetto Primo et al 2014 [13] 18 14 F Pan-tomogr aphy /CBT
Displacement of the tooth into the infra
temporal space Displaced into infratemporal fossa Watchful waiting for 4 months and surgical removal through an incision made with electrocautery at point of palpation
16 Berkay Tolga Suer et al 2014 [14] 48 26 M OPG/ CT/ 3DCT
Tooth displaced into the pterygomandibular region.
Medial aspect of the mandibular rams, close to mylohyoid ridge
Displaced into pterygomandibular space Hospitalization. Ornidazole and naproxen sodium and jaw physiotherapy. Surgical removal, incision distal to 47 and continued up to ascending ramus + oblique incision from 47 to vestibular sulcus. Buccal and lingual MPF in retromolar area,
pterygomandibular space was reached lingually Emrah Soylu et al 2016 [15] 18 42 M OPG/ CT/3D CBCT o (OPG)
Accumulation of air in the right side of patient’s face.
o (CBCT)
Air accumulation in right infratemporal, submandibular
sublingual, pterygomandibular, buccal, masseteric spaces and the upper part of the para-pharyngeal space. Fractured part of the buccal cortex was displaced towards the vestibular-distal region, and a vertical fracture line was observed on the mesial side of the extraction socket Extensive subcutaneous emphysema/Cervicofac ial subcutaneous emphysema Hospitalization IV antibiotics (1000mg ampicillin sulbactam) IO antibiotics (375mg ampicillin sulbactam q8h for 7days) Maxime Picard et al 2015 [16]
48 27 M CT Extensive bilateral subcutaneous emphysema starting in right mandibular angle and extending into the para-retropharyngeal spaces Extensive cervicothoracic emphysema Oral antibiotics with Pristinamycin. Oral wound was filled with fibrin biological glue. Kishnaku mar Raja et al 2017 [17] 48 23 F OPG/ CT o (OPG)
fracture of right styloid process. o (CT)
no basal skull fracture
Ear bleed and Styloid fracture Soft diet, analgesics and restriction of mouth opening for 2 weeks Jothi Raamahli ngam Rajarn et al 2017 [18] 48 42 M OPG/
CT thin radio opaque material resembling a tip o (OPG) of a bur is seen embedded in the
mandibular bone, distal to the tooth 47
Fractured bur fragment at the right mandibular bone
17 Tamer Y et al 2018 [19] 48 33 M OPG/C BCT
Precise position of the root fragment, located lingual to the mandibular ramus, above the inferior border
Displacement of mandibles third molar roots into the pterygomandibular space
Surgical incision Mucoperiosteal flap was raised and the granulation tissue was curetted. The root fragment was reached at the apical area of the socket and retrieved from the medial pterygoid muscle. Amoxicillin 500 q8h for 5 days Flurbiprofen q12h as necessary Tay and Loh 2018 [20] 18 28 38 48 18 M Lateral neck X-ray/CT o (LX-ray)
Diffused soft tissue emphysema in the neck, as well as soft tissue thickening with gas lucency in the pre-vertebral region
o (Chest x-ray) Pneumo-mediastinum
o (CT)
Subcutaneous gas along the face, right extraconal, and deep neck spaces (masticator, para-pharyngeal, carotid, parotid, prevertebral, para-spinal), with extension into the mediastinum and spinal canal. Extensive subcutaneous emphysema, pneumo-mediastinum, and pneumorrhachis Supplemental oxygen and IV amoxicillin-clavulanic acid Study characteristics
Finally, 11 articles were included in the review [10-20]. The summarized case studies are described in Table 2. A total of 11 patients diagnosed with rare, uncommon complications related to surgical removal of wisdom tooth/teeth were included in the studies using different management methods.
Among these complications, were unusual abscess formations, displacement of teeth, iatrogenic displacement of dental bur, subcutaneous and tissue space emphysema.
Numerous studies concerning complications of the third molar were found, intraoperative and postoperative, many studies were involved in the mandibular fracture and the permanent loss of both lingual and inferior alveolar nerve. Eleven articles were found describing complications unlike the previous mentioned, unusual but widely known accidents. Most notable complications were rare abscess formations, inflammatory processes, and teeth displacement into fascial spaces. A general review is shown in Table 3.
18
Table.3 Overall uncommon complications related to third molar surgery
UNCOMMON COMPLICATIONS RELATED TO THIRD MOLAR SURGERY INTRAOPERATIVE o Tooth displacement
o Root displacement
o Bur displacement
POSTOPERATIVE o Temporal Abscess
o Cervicothoracic Emphysema o Cervicofacial emphysema o Ear bleed o Styloid fracture o Pneumomediastinum o Pneumorrhachis o Subcutaneous Emphysema
Eleven patients (mean age 27.3), eight males (mean age 29 years) and three females (mean age 23 years) were enrolled. Incidence of complications was higher after a mandibular third molar extraction, a second surgical interference was required in almost all cases.
The first surgical procedure was reported as complicated, while the surgical intervention was described as an extensive procedure to eliminate the complication. Clinical findings were matching almost in all case reports; difficulty in mouth opening, eating difficulties and restricted painful mandibular movements. Diagnosis of complications was set using the help of several imaging methods; orthopantomograms (OPG), magnetic resonance imaging (MRI), computerized tomography (CT), three dimensioned cone beam computerized tomography (3DCBCT) in addition to three dimensioned cone beam volumetric tomography (3DCBVT).
Sverzut et al presented third molar displacement into infratemporal fossae. and Primo et al. the first patient had a limited mouth opening and painful movements. Another patient was asymptomatic respectively. [10,13]
Another case report by Kacaelli et al. presenting a patient with displaced maxillary third molar into buccal space, the patient had 39°C; in addition to malaise, pain, and swollen buccal area. [11]
Olviera et al. presented temporal abscess formation. After the extraction attempt of tooth #38 diagnosed with pericoronitis prior extraction, no medication was prescribed after the extraction, the patient
complained about pain four days after the extraction. [12]
Suer et al. presented a case report; the patient had already undergone a surgical procedure two years ago, to extract the right mandibular third molar, during the procedure the third molar disappeared. Due to repetitive infections, the patient had to take antibiotics many times for two years. Clinical examination revealed enlarged lymph nodes, acute infection, in addition to the swollen retromolar area. Patient’s maximal interincisal opening was 16 mm. OPG showed the displacement of the tooth into the
19
pterygomandibular area. Coronal, axial and 3D-CT scans confirmed the precise location of the tooth on the medial side of the ramus, near the mylohyoid ridge. [14]
Cervicofacial subcutaneous emphysema was presented by Soylu et al. a 42 years old healthy patient, who had undergone extraction of the maxillary third molar, OPG showed an accumulation of air in the
patient’s right face. CBCT showed air accumulation in the right infratemporal, buccal, sublingual, submandibular, masseteric, pterygomandibular, and upper pharyngeal spaces. It was hypothesized, that the maxillary sinus was perforated because of the displaced fragment since maxillary sinus communicates with the submucosal tissues, air passed from the sinus into the facial layers causing cervicofacial
emphysema. [15]
Picard et al. presented a patient who had extensive cervicothoracic emphysema, air crepitus, and widening of the neck following extraction of the right mandibular third molar. CT showed extensive bilateral subcutaneous emphysema at the right mandibular angle extending to the supraclavicular area and the level of the first lumbar vertebrae. Huge amounts of air were also seen in the mediastinum. [16] Rajaran JR et al. discussed a rare complication of a 42 years old patient, associated with the usage of high-speed handpiece drill for extraction of the mandibular third molar. The patient had a high-speed tungsten carbide bur accidentally broken and dislodged into the mandibular bone. CT scan showed that the displaced 9mm bur was fully embedded in bone, lateral to the extracted tooth. It was positioned near the superior cortex of the inferior alveolar canal. [17]
Raja et al. presented a particular case of ear-bleed associated with styloid fracture after surgical removal of impacted mandibular wisdom tooth. Thirty minutes after the extraction procedure, ipsilateral ear bleeding was spotted. The day after, the patient had dysphagia, restricted mouth opening, otalgia, and temporomandibular joint pain, in addition to periauricular, retromandibular, and pharyngeal regions pain. OPG showed a fracture of the right styloid process; a consultation from an otolaryngologist was obtained to make sure there is no perforation in the tympanic membrane. CT scan for the brain was taken to make sure no skull base fracture was present. [18]
Tamer et al. presented a case of mandibular third molar roots displaced into pterygomandibular space. A CBCT revealed the exact location of the root fragment, located lingual to the ramus, above the inferior margin of the mandible [19]
Tay and Loh, presented a rare case of extensive cervicofacial subcutaneous emphysema,
pneumomediastinum, and pneumorrhachis, after third molars extraction. The patient had no complaints, except for significant swelling the next morning, there was bilateral buccal and generalized swelling of the neck. Lateral X-ray revealed diffused soft tissue emphysema of the neck, in addition to thick soft tissue in the prevertebral region. Chest X-ray showed the presence of pneumomediastinum. CT scan of
20
both neck and spine showed subcutaneous gas all over the face, and deep spaces of the neck extending into the mediastinum and spinal canal. [20]
Treatment management varied among the case mentioned above reports, displaced teeth into infratemporal spaces were treated surgically through intraoral incisions without any medicinal
management. Whereas, case reports presenting displaced teeth into buccal and pterygomandibular spaces, included both medicinal and surgical approaches.
The third molar displaced buccally required preoperative antibiotics and analgesic/antipyretic due to the presence of fever and swelling, followed by surgical intervention through a submucosal incision.
Postoperative analgesics and antibiotics were also prescribed.
Displacement into pterygomandibular required immediate hospitalization, a course of ornidazole and naproxen sodium was initiated. Jaw physiotherapy was needed due to severe trismus. An incision distal to the second molar was performed.
Patient with temporal abscess required preoperative amoxicillin and dipyrone; patient general condition worsens, amoxicillin with clavulanic acid was prescribed later. In 3 days, WBC count increased, the patient put on IV cephalosporins. 2 days after, incisions for drainage were done, no drainage was achieved. Antibiotic was finally switched to clindamycin, the general condition improved in 4 days. Cervicofacial subcutaneous emphysema required 24 hours hospitalization, IV ampicillin, and sulbactam 1000mg. Postoperative ampicillin and sulbactam 375mg.
Whereas patient with cervicothoracic emphysema, pneumomediastinum, pneumorrhachis was put on IV amoxicillin with clavulanic acid and supplemental oxygen. Uneventful follow-up after 5days medicinal treatment.
Moreover, one more patient was presented with cervicothoracic emphysema; pristinamycin was enough for pain relief in this case.
On the other hand, patient with ear bleed and the styloid fracture was asked for a soft diet, limited
mandibular movement and analgesics for two weeks. Finally, a patient with displaced high-speed bur was also presented, surgical approach alone was enough in this case.
DISCUSSION
The present systematic review focused on assessing the rare postoperative complications of surgical procedure applied in the extraction of third molars. The surgical removal of wisdom teeth is a relatively complex procedure, depends on various multiple factors including age, gender, medical history, poor oral
21
hygiene, tooth configuration, type of impaction, the relationship of third molar to the alveolar nerve, surgical technique, surgeon experience, use of perioperative antibiotics, and intra-socket medications. [1,6]
Successful treatment in oral surgery is based on preoperative planning, sticking to basic surgical principles, and adequate preoperative planning. Poor clinical and radiographic examinations, wrong techniques, poor anatomic knowledge, uncontrolled force during extraction, raising an inadequate flap, third molar crown located above the adjacent molar root apices level, and insufficient visualization are risk factors for the displacement of wisdom teeth into the adjacent anatomical sites. [10,21]
Computed tomography has been suggested to determine the precise position of the displaced tooth, into the maxillofacial area. In case of absence of tomography, plain radiographs can be used, keeping in mind the limitations of every single projection. [10]
Displacement into Infratemporal fossa
Maxillary wisdom teeth are commonly displaced into the infratemporal fossae through the periosteum and found lateral to the lateral pterygoid plate and under the inferior pterygoid muscle. [22]
Clinical wise, a patient with displaced maxillary wisdom tooth into infratemporal fossa is either asymptomatic or has typical chronic infection symptoms such as pain, swelling, limited mandibular movements, or trismus. [10,22]
According to literature surgical management of third molars displaced into the infratemporal fossae varies, intra-oral access with Caldwell-Luc technique or coronoid process resection, combined or extraoral access only (hemi-coronal approach) or Gillies method. [23,24,25]
The surgeon must be aware of the risk of injuring adjacent anatomical structures, such as the mandibular nerve branches, maxillary artery, and chorda tympani. [22]
When extracting the third molar, if the tooth is displaced into adjacent spaces, it is advisable to extend the flap and remove the tooth avoiding another procedure, thus reducing infection risk or trismus. [10] In some cases, the displaced tooth cannot be visualized; sutures can be placed for hemostasis, extraction can be delayed, waiting for scar formation around the tooth to make it easier to locate and remove. [10,26]
In the cases mentioned above of displacement into infratemporal spaces, Sverzut et al. removed the displaced tooth a week after the complicated extraction, whereas Primo et al. performed the surgical removal of the displaced tooth after four months, watchful waiting was the primary choice of management. Both patients had no functional complaints after surgical removal.
22
Finally, it may be concluded that there is no universal treatment appropriate to all maxillary wisdom teeth displaced into infratemporal fossae; each case has its applicable treatment method. It is a must to guide the decisions with the signs and symptoms, the precise location of the tooth, and the skills and knowledge of the surgeon.
Displacement into Buccal space
An uncontrolled force applied by the elevator may displace the maxillary third molar into the buccal space, incorrect usage of the elevator may lead to buccal wall fracture, consisting of trabecular bone and a thin layer of cortical bone, leading to the easy displacement of maxillary third molar into buccal space. The risk might even increase if the height of the buccal or/and distal bone is insufficient.
Adipose tissue fills the buccal space, assisting the muscular motion to open and close the mouth, in case of the detached part of a tooth, it can easily travel into the adjacent spaces by the help of adipose tissue and muscles. Buccal space consists of both buccal division of the facial nerve and the buccal branch of V3. The displaced tooth might end up in nerve damage, though no cases concerning neural damage were reported. [11]
In the case as mentioned above, displaced third molar into buccal space was diagnosed using the help of tomography, an intraoral incision below the parotid gland was made to reach the displaced tooth.
In cases of an unfavorable angulation of maxillary third molars, it is recommended to perform an open surgical procedure instead of using elevators, the anatomy of the maxillary tuberosity sorts a trabecular pattern which is more susceptible to fractures, increasing risk of displacement into adjacent spaces. [11]
Temporal Abscess
Reports involving dental infection concerning the temporal space are rare and occasionally reported. The revised case report presented a complication occurred after mandibular third molar extraction. A second surgical interference was needed. A general dental practitioner cannot quickly diagnose temporal fossa infection, might be underestimated. In this case, the reported symptoms were pain, fever, swelling, and malaise. Besides, in the previous case report, the computed tomography was useful and helpful in locating the exact site of drain placement.
As it goes in all cases of infection, the usual worldwide protocol is drainage and medicinal approach with the necessary antibiotics. In the presented case, cephalosporins therapy failed in diminishing the swelling, fever, and the white blood cell count, therefore the antibiotic was changed to clindamycin.
23
Antibiotic resistance such as penicillin resistance and other antibiotics resistance such as clindamycin and macrolide made decision-making treatment challenging. [27]
Displacement into pterygomandibular space
Iatrogenic displacement of an entire third molar or a root during extraction is considered to be a rare event. [28] The occurrence of complications during mandibular third molars extraction is evaluated to be lower than 1%. [2,14]
Fractures during the extraction process, lingual perforations, and excessive force application with forceps plays a significant role in the iatrogenic displacement of third molars. [29]
In the two cases presented in the review concerning iatrogenic displacement of mandibular third molar into the pterygomandibular space, authors thought that the displacement of the tooth was a result of lack of surgical skills or/and improper surgical technique. In this case, CT and 3D-CT views offered useful evidence about the site of the displaced tooth.
The scheduling of surgical retrieval of a displaced tooth or root segment may be debatable. Some authors encourage the late intervention, three to four weeks after the displacement accident to allow the
encapsulation of the tooth with fibrous tissue, thus more stable position. However, this point of view demands close watching with repeated follow-up and radiographic investigation. Advocating this approach, Xavier et al. presented an accidentally displaced mandibular third molar into the
pterygomandibular fossa which traveled instinctively to the oral cavity. Exteriorization of the tooth has been observed for seven weeks, and they managed to extract it under local anesthesia.[29]
On the contrary, a majority of investigators recommended immediate intervention, especially if the extraction was because of infection, leading to a higher risk of swelling, trismus, patient’s discomfort, and migration into deeper areas. [19] To avoid this accident, a full assessment of all-important factors should be taken into consideration prior to the extraction. Third molar extraction must always be completed with appropriate visual access to the site of extraction. Excessive forces applied by the elevators towards the lingual bony cortex must be avoided during the extraction procedure. [30] If a tooth is displaced into adjacent anatomical spaces the patient must be referred immediately to an oral surgeon to avoid further complications.
Extensive Subcutaneous emphysema, pneumomediastinum, and pneumorrhachis
The involvement of the airway down to the lung was seen in a few cases, one with an extensive
high-24
speed turbine or air syringe, it was assumed that the air penetrated the facial layers through a fracture in the buccal bone of the socket, which itself perforated the maxillary sinus.
Whenever air is presented and stuck in the soft tissue below the skin, subcutaneous emphysema develops. The cause can be categorized in three general groups: (1) air from an external source, penetrating trauma or during surgeries, (2) air from an internal source, pulmonary interstitial emphysema or perforated hollow viscus of the neck, (3) gas produced de novo (necrotizing fasciitis). [20]
Formation of Subcutaneous emphysema requires the presence of (1) communication between soft tissue and cavity, (2) air forced under pressure. [31]
Pneumorrhachis can be grouped as intradural, the air within the subdural or subarachnoid space or extradural, the air within the epidural space itself. [20] Furthermore, Picard et al. presented a patient where the air from the posterior mediastinum dissected along the fascial planes through the neural
foramen and into the epidural space in the spinal canal, leading to an extradural type of pneumorrhachis. Subcutaneous emphysema can be treated conservatively. Most of the cases improve 3-5 days and
completely settles after 7-10 days. Patient with pneumomediastinum and pneumorrhachis must be neurologically monitored. Pneumomediastinum might lead to cardiorespiratory problems.
Consensus regarding the management of pneumorrhachis is absent because of the infrequency of this finding and its varied causes. The patient presented by Picard et al. improved with conservative treatment. Several treatments have been described, consisting of hyperbaric oxygen therapy, needle aspiration or decompression, and usage of dexamethasone. However, the indication of those treatments is still unclear. Finally, prophylactic antibiotics can be prescribed to avoid secondary infections, because of air and oral cavity microflora in the mediastinum and epidural space, such a scenario is uncommon but might occur. [20,31]
Iatrogenic displacement of high-speed bur
Very few numbers of cases have been published in the literature concerning accidental displacement of high-speed turbine bur during wisdom teeth surgery. [18]
It is not recommended, to use high-speed handpiece bur in wisdom tooth surgery, high-speed handpieces are operated by a rotary instrument powered by compressed air, rotating at a speed of around 200 000-800 000 rpm.
Generally, thin burs consisting of steel with tungsten carbide or diamond coating are used with this handpiece for the general procedure. Burs used in high-speed handpiece are not manufactured to cut hard cortical bone; for this reason, the risk of fracture is higher when used for bone removal.
25
Other than the risk of bur fracture, emphysema is also related to the use of high-speed handpiece as mentioned previously; air will penetrate the soft tissues through the flap and invades the adjacent spaces. [32]
Concerning the case presented by Rajaran et al. the patient had an embedded fractured bur fragment at the right mandibular bone, the bur segment was retrieved via intraoral approach; fortunately, emphysema did not develop in this case after using the high-speed handpiece. The iatrogenic displacement may have been prevented with the use of appropriate equipment and method. This case report emphasizes the emphasis of avoiding the use of high-speed drills during third molar surgery
Ear bleed and Styloid fracture
Generally, ear bleed is known to be a crucial clinical sign, due to its relation to severe traumatic adverse events such as the fracture of the base of the skull. [33] Ear bleed might also occur after ruptured eardrum or lacerations in the external acoustic meatus.[34] Nevertheless, ear bleed followed by a third molar surgery as reported by Raja et al. is exceptionally uncommon. [17]
It is a must to differentiate ear bleeding caused by posterior displacement of the condyle from bleeding, because of skull base fracture, packing of external acoustic meatus might commence infection into the cranium and lead to complications. Raja et al. also reported styloid fracture in the same patient, styloid fracture during third molar surgery is also uncommon, because of its safe anatomical position. In some cases when the styloid is elongated and shaped as in Raja et al. case report, it fractures due to force applied on it by the displaced condyle. It might also be fractured due to the pull exerted by the
stylomandibular ligament throughout excesses mandibular movement. Diagnosis of styloid fracture is made clinically, when symptoms like temporomandibular pain, dysphagia, limited mandibular
movements, and pain in the periauricular area is present. [17]
Management of styloid fracture can be done conservatively with a soft diet, in addition to NSAIDs, muscle relaxants, carbamazepine, and local anesthesia. [35] To prevent the displacement of the fractured styloid, intermaxillary fixation and cervical collar must be performed to restrict mandibular movements. [35,36,37] On the other hand, when the conservative treatment is not sufficient, a surgical approach for removal of the fractured fragment is needed. [38]
Ear bleed and styloid fracture demand early diagnosis and management to ease patient fear. Avoidance of retro- positioning of the mandible during the third molar surgery requires sufficient attention. [17]
26
CONCLUSION
This systematic review analyzed the unusual complications after the third molar surgical extraction, their diagnostics peculiarities, and further treatment management. It has evidently shown from most of the examined case reports that poor preoperative diagnosis leads to unnecessary troubles that are related to the surgeons’ acuity and skills. It was found that complications varied from relatively simple such as displacement of tooth or bur to life-threatening complications like cervicothoracic emphysema and pneumorrhachis. Consequently, a level of complications’ severity required a different approach of clinical management from just removal of the displaced tooth to hospitalization to ensure the comprehensive treatment in other cases.
PRACTICAL RECOMMENDATIONS
It is critical for general dental practitioners, as well as the oral and maxillofacial surgeons to be aware of all the possible complications and advise the patient of the risk of the scheduled surgery. Informed patient and prepared surgeon together may reduce the degree and the time required to restrict the injury from procedural wrongdoing.
27
REFERNCES
1. Bouloux GF, Steed MB, Perciaccante VJ. Complications of third molar surgery. Oral Maxillofac Surg Clin North Am. 2007;19(1):117-28, vii
2. Brauer HU, Dent M. Unusual complications associated with third molar surgery: A systematic review. Quintessence Int. 2009;40:565.
3. Stacchi C, Daugela P, Berton F, Lombardi T, Andriulionis T, Perinetti G, Di Lenarda R, Juodzbalys G. A classification for assessing surgical difficulty in the extraction of mandibular impacted third molars: Description and clinical validation. Quintessence Int. 2018;49(9):745-753
4. R.W. Carvalho, R.C. Araújo-Filho, B.C. Vasconcelos Adverse events during the removal of impacted maxillary third molars Int J Oral Maxillofac Surg, 43 (2014), pp. 1142-1147
5. Sisk AL, Hammer WB, Shelton DW, et al. Complications following removal of impacted third molars: the role of the experience of the surgeon. J Oral Maxillofac Surg 1986;44:855.
6. Bui CH, Seldin EB, Dodson TB. Types, frequencies, and risk factors for complications after third molar extraction. J Oral Maxillofac Surg 2003;61:1379–89.
7. Costantinides F, Biasotto M, Gregori D, Maglione M, Di Lenarda R. "Abscess" as a perioperative risk factor for paresthesia after third molar extraction under general anesthesia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Feb;107(2): e8-e13. Doi: 10.1016/j.tripleo.2008.10.014.
8. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336-41. Erratum in: Int J Surg. 2010;8(8):658. [Medline: 20171303] [doi: 10.1016/j.ijsu.2010.02.007]
9. Tacconelli E: Systematic reviews: CRD’s guidance for undertaking reviews in health care. Lancet Infect
Dis 2010, 10: 226. 10.1016/S1473-3099(10)70065-7
10. Sverzut CE, Trivellato AE, Sverzut AT, de Matos FP, Kato RB. Removal of a maxillary third molar accidentally displaced into the infratemporal fossa via intraoral approach under local anesthesia: report of a case. J Oral Maxillofac Surg. 2009;67:1316-20
11. Kocaelli H, Balcioglu HA, Erdem TL. Displacement of a maxillary third molar into the buccal space: anatomical implications apropos of a case. Int. J. Oral Maxillofac. Surg. 2011; 40: 650–653.
12. De Oliviera Neto PJ, de Souza Maliska MC, Sawazaki R, Asprino L, de Moraes M, Moreira RW. Temporal abscess after third molar extraction in the mandible. Oral Maxillofac Surg. 2012 Mar; 16(1): 107-10. 10.1007/s10006-011-0262-0.
28
13. Primo BT, Stringhini DJ, Klüppel LE, Costa DJ, Rebellato NLB, Moraes RS. Delayed removal of maxillary third molar displaced into the infratemporal fossa. Rev Esp Cir Oral Maxilofac. 2014; 36: 78-81.
14. Suer BT, Kocyigit ID, Ortakoglu K. Iatrogenic Displacement of Impacted Mandibular Third Molar into the Pterygomandibular Space: A Case Report. Oral Health Dent Manag. 2014 Jun;13(2):179-82. 15. Soylu E, Asan CY, Kilic E, Alkan A. An Unusual Complication After the Extraction of a Maxillary
Third Molar: Extensive Subcutaneous Emphysema. A Case Report. J Clin Anal Med 2016;7(5): 723-6. 16. Picard M, Pham Dang N, Mondie JM, Barthelemy I. Cervicothoracic Subcutaneous Emphysema and
Pneumomediastinum After Third Molar Extraction. J Oral and Maxillofac Surg. 2015 Dec;73(12):2286.e1-3.
17. Krishnakumar R, Gayathri G, Elavenil R, Jegatheesan R, Guruprasad TD, Rajendra AS. Concomitant “Ear Bleed and Styloid Fracture”: An Unusual Complication of Impacted Mandibular Third Molar Removal. Craniomaxillofacl Trauma and Reconstr. 2017 Sep;10(3): 212-215
18. Rajaran JR, Nazimi AJ, Rajandram RK. Iatrogenic displacement of high-speed bur during third molar removal. BMJ Case Rep. 2017 Sep 27;2017. 10.1136/bcr-2017-221892.
19. Tamer Y, Pektas ZO. Accidental displacement of mandibular third molar roots into the pterygomandibular space. Niger J Clin Pract. 2018 Aug;21(8): 1075-1077. 10.4103/njcp.njcp_427_17. 20. Tay YBE, Loh WS. Extensive subcutaneous emphysema, pneumomediastinum, and pneumorrhachis following third molar surgery. Int J Oral and Maxillofac Surg. 2018Dec; 47(12):1609-1612. 10.1016/j.ijom.2018.04.023.
21. Selvi F, Cakarer S, Keskin C, Ozyuvaci H. Delayed removal of a maxillary third molar accidentally displaced into the infratemporal fossa. J Craniof Surg. 2011;22:1391–3.
22. Dimitrakopoulos I, Papadaki M: Displacement of a maxillary third molar into the infratemporal fossa: Case report. Quintessence Int 2007 Jul-Aug;38(7):607-10
23. Patel M, Down K. Accidental displacement of impacted maxillary third molars. Br Dent J. 1994;177:57– 9.
24. Gulbrandsen SR, Jackson IT, Turlington EG. Recovery of a maxillary third molar from the infratemporal space via a hemicoronal approach. J Oral Maxillofac Surg. 1987;45: 279–82.
25. Dawson K, MacMillan A, Wiesenfeld D. Removal of a maxillary third molar from the infratemporal fossa by a temporal approach and the aid of image-intensifying cineradiography. J Oral Maxillofac Surg. 1993;51: 1395–7.
29
26. Gómez-Oliveira G, Arribas-García I, Alvarez-Flores M, Gregoire-Ferriol J, Martínez-Gimeno C. Delayed removal of a maxillary third molar from the infratemporal fossa. Med Oral Patol Oral Cir Bucal. 2010;15:e509–11.
27. Poeschl PW, Spusta, L, Russmueller G, Seemann R, Hirschl A, Poeschl E, Klug C, Ewers R. Antibiotic susceptibility and resistance of the odontogenic microbiological spectrum and its clinical impact on severe deep space head and neck infections. Oral Surj Oral Med Oral Pathol Oral Radiol Endod. 2010 Aug;110(2):151-6.
28. Pasqualini D, Erniani F, Coscia D, Pomatto E,Mela F. Third molar extraction. Current trends. Minerva Stomatologica. 2002; 51: 411-424.
29. Xavier CB, Gonçalves FR, Batista SH, Veras Filho Rde O, Vogt BF. Spontaneous migration of third molar following displacement to pterygomandibular fossa. J Oral Maxillofac Surg 2011;69:1004-7. 30. Aznar-Arasa L, Figueiredo R, Gay-Escoda C. Iatrogenic displacement of lower third molar roots into
the sublingual space: report of 6 cases. Int J Oral and Maxillofac Surg. 2012; 70: e107-e115
31. McKenzie WS, Rosenberg M. Iatrogenic Subcutaneous Emphysema of Dental and Surgical Origin: A Literature Review. J Oral Maxillofac Surg. 2009 Jun;67(6):1265-8. 10.1016/j.joms.2008.12.050. 32. Wong C, Collin J, Hughes C, Thomas S. Surgical emphysema and Pneumomediastinum after
Coronectomy. Br J Oral Maxillofac Surg 2015;53:763–4
33. Lu C, He D, Yang C. Which craniofacial fractures are associated with external auditory canal bleeding? J Oral Maxillofac Surg. 2014;72(01):121–126.
34. Martis C, Karakasis D. Bleeding from the ear in maxillofacial injuries J Maxillofac Surg 19742(2– 3):126–128.
35. Dubey K N, Bajaj A, Kumar I. Fracture of the styloid process associated with the mandible fracture. Contemp Clin Dent. 2013;4(01):116–118.
36. Raman U, Samraj T. Fracture of the styloid process associated with mandibular fracture. A case report. Int J Oral Maxillofac Surg. 1990;19(06):350–351.
37. Gayathri G, Elavenil P, Sasikala B, Pathumai M, Krishnakumar Raja V B. ‘Stylo-mandibular complex’ fracture from a maxillofacial surgeon's perspective—review of the literature and proposal of a management algorithm. Int J Oral Maxillofac Surg. 2016;45(03):297–303.
38. Blythe J N, Matthews N S, Connor S. Eagle's syndrome after fracture of the elongated styloid process. Br J Oral Maxillofac Surg. 2009;47(03):233–235.
