Abstract
Objectives
Extracting impacted third molar teeth is one of the most common procedures in maxillofacial surgery. After these operations, symptoms such as trismus, pain, and swelling are seen, negatively affecting patient comfort and defined as postoperative morbidities. The surgeon’s experience is one of the considerable factors affecting postoperative morbidity.
Methods
With our research, we extracted the mandibular impacted molar teeth of 100 patients by oral, teeth, and maxillofacial surgeons and oral and maxillofacial surgery assistants(research assistant). We recorded all patients’ pain, swelling, and maximum incisal opening measurements three times: preoperative, postoperative second day, and seventh postoperative day. We determined the operation times by recording the time between the first incision and the last suture.
Results
When we compared oral and maxillofacial surgeons and oral and maxillofacial surgery assistants(research assistant), the operating time of the surgeon was shorter ( p < 0.001). When we evaluated the facial swelling on the postoperative second and seventh days, we found that the patients operated on by the surgeon had less swelling ( p < 0.001, p:0.005). In our postoperative second-day measurement, the oral openness of the patients operated by the surgeon was greater (p:0.035).
Conclusion
Performing the impacted third molar operations by an oral and maxillofacial surgeon reduces postoperative morbidity.
1
Introduction
The teeth that remain most often impacted in the jaws are the third molars. Extracting these teeth is one of the most common surgical procedures in oral and maxillofacial surgery. , Mandibular third molar teeth show more symptoms than maxillary third molar teeth. Impacted third molar teeth have been associated with pathological formations such as pericoronitis, myofascial pain, trismus, cyst and tumor development. Moreover, these teeth can cause symptoms by rotting and causing caries in the distal of the second molar tooth. The most common symptoms that cause extraction indications are pain, recurrent swelling, and infection. The clinician should weigh the risks and benefits of surgical removal of third molars. Postoperative morbidity after third molar surgery is higher in the mandible than in the maxilla. , Among these discomforts encountered in the postoperative period, pain, swelling, and trismus are the most common. These complaints after the third molar tooth extraction are about the inflammatory response and affect the daily life of the patient. , Besides, complications may occur after impacted third molar extraction. The most common are dry sockets, infection, bleeding, paresthesia, delayed healing, periodontal pocket formation, injury to adjacent teeth, and mandible fractures.
Several factors affect postoperative morbidity after surgical extraction of third molars. These can be classified as patient-related, dental-related, and operational-related factors. Patient-related factors include age, gender, ethnicity, smoking, oral contraceptive use, and oral hygiene. Causes associated with the tooth are the presence of infection, the classification of tooth impaction, the neighborhood of the tooth with the inferior alveolar nerve, the density of the bone surrounding the tooth, and the presence of tooth-related pathological defects such as cysts and neoplasms. Operational factors include drug use, incision, flap design, wound closure technique, surgeon’s experience, and operation time. , Among all these perioperative considerations, the least studied area is the cases in which the experience and expertise of physicians are evaluated. Notwithstanding that less experienced surgeons or non-specialized dentists are expected to encounter more complications after the third molar surgery, this is not always the case. As we mentioned, postoperative morbidity and complication rates depend on many factors, each of which is important in the postoperative process. In studies evaluating the effect of a surgeon’s experience on morbidity, the opinion dominates that the incidence of postoperative complications and morbidity decreases as the surgeon’s experience increases. , However, some studies argue that there is no meaningful relationship between the experience of the physician operating and postoperative complications.
The operative time is between the first incision and the last suture. It is expected that non-specialist physicians spend more time in any surgical intervention than oral and maxillofacial surgeons. Increased operation time will cause long-term tissue injury and increase the risk of complications. For this reason, with the increase in operation time, delays in tissue healing, and a worse prognosis, in general, are expected. Today, specialization in dentistry comes to the fore. Comparing the postoperative morbidity of surgeries performed by specialist physicians with those performed by non-specialist physicians will execute the importance of specialization in dentistry. The aim of this study was to evaluate the postoperative morbidity after extraction of bone retention mandibular third molars(wisdom teeth) performed by dentists who are specialist in oral and maxillofacial surgeons and surgical assistant(research assistants) who are not oral and maxillofacial surgeons, thus demonstrating the importance of expertise..
2
Material and methods
This research was exercised with the decision numbered 2021/1948 of the İnonu University Health Sciences Non-Interventional Clinical Research Ethics Committee. This study was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines to ensure methodological transparency and enhance reproducibility. Our study has been performed in the oral and maxillofacial surgery department at İnonu University Faculty of Dentistry. The study has adhered to the criteria of the Helsinki Declaration. Patients who applied in 2021 to the İnonu University Faculty of Dentistry, Department of Oral and Maxillofacial Surgery with various complaints were evaluated. The impacted third molar was examined clinically and radiographically, and whether they needed to be extracted was evaluated, considering the extraction criteria. One hundred patients with extraction indications were included in the study. Sixty-four of the patients were female, and 36 were male. Patients aged 15–45 years, without any systemic disease, without active drug treatment and with bone retention for extraction indication, regardless of right or left, with mandibular third molars were included in the study. Individuals with temporomandibular joint disorders, individuals with a facial deformity, individuals using oral contraceptives and steroid drugs, individuals with drug allergies, and individuals with systemic disorders were excluded from the investigation. A single impacted mandible third molar was extracted from each patient in the same session.
The surgeries were performed by different physicians using similar surgical instruments and materials. The operations were performed by an oral and maxillofacial surgeon and oral and maxillofacial surgical assistants(research assistant). The same dentist assisted all surgeries, and this assistant physician randomly selected the patients involved in the study using a randomized, double-blind method. All measurements before and after the operation were performed by a single oral and maxillofacial surgery specialist who did not participate. Before the operation, each patient was informed about possible complications, and full informed consent was obtained. All patients were treated under local anesthesia, and 4 % articaine(maxicaine) containing 1:200,000 epinephrine was used for inferior alveolar and buccal nerve blocks. The operation time was recorded by calculating the time between the first incision and the last suture. After tooth extraction, the wound was irrigated with sterile saline solution, and the flap was repositioned and sutured with 3.0 silk. Postoperatively, all patients were prescribed amoxicillin + clavulanic acid, dexketoprofen, and chlorhexidine digluconate mouthwash.
Postoperatively, pain, swelling, and trismus were evaluated. Patients were given a questionnaire containing the Visual Analogue Scale(VAS) and asked to fill it out just before the operation, on the second and seventh day after the operation, and a pain assessment was performed. The pain felt by the patients was recorded as a value between 0 and 10.
As a trismus index, the maximum painless interincisal distance was measured immediately before and on the second and seventh days after the operation. This indication was made by measuring the distance between the incisal surfaces of the right upper central and right lower central teeth ( Fig. 1 ). The first measurement was made just before the operation, while the other measurements were made on the second and seventh postoperative days. The difference between preoperative and postoperative measurements was calculated.
Gabka and Matsumura’s modified band measurement method calculated facial swelling. Three measurements are made between five reference points in this method. These points are tragus-soft tissue pogonion, lateral corner of the eye-outer corner of the mouth, and lateral corner of the eye-mandible angulus ( Fig. 2 ). These indications were repeated three times, just before the operation, on the second and the seventh postoperative day. Differences between preoperative and postoperative values were calculated.
2.1
Power analysis of the study
The study sample was determined by power analysis. According to the calculation made using the G*power 3.1 program, 95 % confidence (1-α), 95 % test power(1-β), d = 0.8 effect size, and two-way independent samples were obtained. As a result of the t -test power analysis, it was concluded that the minimum number of samples to be taken in each group was 42, and a total of 84 people should be examined.
2.2
Statistical method
Data were analyzed with IBM SPSS V23. The Kolmogorov Smirnov test examined the suitability of the data to the normal distribution. Independent Two Samples T -test was used to compare normally distributed data according to paired groups, and the Mann-Whitney U test was used to compare data that were not normally distributed. The Friedman Test was used in data unsuitable for normal distribution to examine the change in VAS score, maximum incisal opening, and swelling values over time. The Dunn test was used in multiple comparisons. Spearman’s rho correlation coefficient was used to compare operation time, age, and variation values. The analysis results for quantitative data were presented in the form of an average ± standard deviation and median(minimum-maximum). The significant level was considered as p < 0,05.
3
Results
The mean age of 100 patients who underwent extraction of impacted lower third molars was 24.2 years. In this study, the age of the patients ranged from 15 to 45 years. There is no difference between the median age values of the groups( p = 0.390). The difference between the median values of the operation time according to the groups is statistically significant( p < 0.001). While the median value of operations performed by oral and maxillofacial surgeons is 10 min, the median value of operations performed by oral and maxillofacial surgery assistants is 17 min ( Table 1 ).
| Groups | Test Ist. | p * | ||||
|---|---|---|---|---|---|---|
| Surgeon | Assistants | |||||
| Avg. ± S . Deviation | Median (Min. – Max.) | Avg. ± S . Deviation | Median (Min. – Max.) | |||
| Age | 23.48 ± 6.8 | 22 (15 – 43) | 24.98 ± 7.85 | 22.5 (15 – 45) | 1374.500 | 0.390 |
| Operation Time (Min) | 11.46 ± 5.1 | 10 (5 – 26) | 17.6 ± 6.37 | 17 (8 – 35) | 1970.500 | <0.001 |
The difference between the groups’ median values of the preoperative maximum incisal opening-postoperative maximum incisal opening on the second day is not statistically significant( p = 0.868). There is no statistically significant difference between the median values of the preoperative maximum incisal opening-the maximum incisal opening difference on the seventh postoperative day between the groups( p = 0.893). There is a statistically significant difference between the groups in the median values of swelling-preoperative swelling variation on the second postoperative day( p < 0.001). While the median value for those who were surgeons was 3.67 mm, the median value for oral and maxillofacial surgery assistants was 5.67 mm. There is a statistically significant difference between the groups’ median values of swelling-preoperative and swelling on the seventh day of postoperative( p = 0.005). While the median value for those who were surgeons was 1.33 mm, the median value for oral and maxillofacial surgery assistants was 2.17 mm ( Table 2 , Fig. 3 ).
| Surgeon | Assistants | Test Ist. | p | |||
|---|---|---|---|---|---|---|
| Avg. ± S . Deviation | Median (Min. – Max.) | Avg. ± S . Deviation | Median (Min. – Max.) | |||
| Maximum incisal opening Preop. – Maximum incisal opening Postop. 2nd day (mm) | 17.36 ± 6.53 | 17 (5 – 37) | 17.58 ± 6.69 | 18 (5 – 34) | −0.166 | 0.868** |
| Maximum incisal opening Preop. – Maximum incisal opening Postop. 7th Day (mm) | 9.12 ± 6.69 | 8 (0 – 26) | 8.82 ± 7.07 | 8 (−8 – 33) | 1230.500 | 0.893 * |
| Swelling Postop. 2nd day – Swelling Preop. (mm) | 4.10 ± 3.73 | 3.67 (−5.67 – 17.33) | 6.39 ± 3.26 | 5.67 (1 – 14.67) | 1802.500 | <0.001 * |
| Swelling Postop 7th day – Swelling Preop. (mm) | 1.55 ± 2.41 | 1.33 (−6 – 10.33) | 2.58 ± 3.23 | 2.17 (−6.67 – 8.33) | 1657.500 | 0.005 * |
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