Download this PDF file

American Journal of Oral and Maxillofacial Surgery
Page 1 of 10
http://ivyunion.org/index.php/maxillofacial/
Farshid A et al. American Journal of Oral and Maxillofacial Surgery 2014, 2:43-52
Research Article
Prevalence and Risk Factors for Complications
of Mandibular Third Molar Surgery
Aniseh Farshid, DDS1*; Amir Khosro Mohiti, DDS, OMFS2;
and Omid Ghasemzadeh, DDS,OMFS3
1 School of Dentistry, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2 Department of Oral and Maxillofacial Surgery, Ahvaz Jundishapur University of
Medical Sciences, Ahvaz, Iran
3 Department of Oral and Maxillofacial Surgery, Ahvaz Jundishapur University of
Medical Sciences, Ahvaz, Iran
Abstract:
‘ the most common surgeries performed by maxillofacial
Background: Surgical extraction of third molar is one of
surgeons. This study was aimed to assess the incidence of complications after surgical removal of mandibular third
molar and their risk factors.
Materials and methods: This study was performed prospectively. Patients referred to the School of Dentistry for the
surgical removal of mandibular third molar were included. Surgical time, number and form of roots, as well as
demographic data was recorded. 24 hours later occurrence of complications including bleeding, swelling, pain, trismus,
paresthesia and fracture were assessed. The frequency of reported complications, as well as the influence of risk factors
was analyzed.
Results: A total of 101 patients with a mean age of 22.951.93 years were included. All patients showed mouth opening
limitation, pain and swelling. Two cases had paresthesia (1.98%) and 31 cases (30.7%) complained of excessive
bleeding. The average postoperative pain based on visual analogue scale was 4.010.76. Pain was lower in
men. Trismus and bleeding was less in teeth with conical root compared to teeth with separate roots. In addition, it was
shown that the teeth with more roots had higher occurrence of pain, swelling, trismus and bleeding. All of the
complications increased with increasing surgical time.
Conclusion: Considering the high prevalence of complications following wisdom tooth surgery, in order to control
them, it is necessary to be aware of the risk factors and inform patients.
Keywords: tooth impaction; wisdom tooth; surgery complications; trismus
Academic Editor: Xiaoning Peng, PhD, Department of Internal Medicine, Hunan Normal University School of
Medicine
Received: September 13, 2015 Accepted: October 27, 2015 Published: December *, 2015
Competing Interests: The authors have declared that no competing interests exist.
Consent: We confirm that the patient has given the informed consent for the casereport to be published.
Copyright: 2015 Farshid A et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original
author and source are credited.
*Correspondence to: Aniseh Farshid, School of Dentistry, Ahvaz Jundishapur University of Medical Sciences, Golestan,
Ahvaz, Iran. Email: [email protected]
Ivy Union Publishing | http: //www.ivyunion.org
December * , 2015 | Volume 3 | Issue 1
Farshid A et al. American Journal of Oral and Maxillofacial Surgery 2014, 2:43-52
Page 2 of 10
Introduction
Third molars are the last developed teeth in the growing human dentition and generally called wisdom teeth.
Wisdom teeth impaction might occur due to lack of space. Complications associated with wisdom teeth
mostly happen at age 18 to 25 years [1].
Third molar surgery is one of the most common operations performed by oral surgeons [2] and in most
cases it is done without any complications during or after surgery [3]. Proper treatment planning and
post-operative cares are the most important principles to reduce complications [3]. However, this conventional
surgery may be associated with some complications [4, 5]. The risk of such complications should be discussed
with the patient prior to the surgery and proper treatment should be done at the right time by the surgeon. Rate
of complications following surgical removal of third molar have been reported between 2.6% to 30.9% [6-8].
These complications may occur during or after surgery, and the difference between the reported rates might be
due to the diversity in the definition of the complications.
Wisdom tooth surgery is often associated with pain, swelling and trismus. However, the major
complications include dry socket, infection, bleeding, and paresthesia. In addition, other rare complications
such as fracture, bleeding and jaw dislocation can also occur [3, 9, 10].
Factors influencing wisdom tooth extraction complications include gender, age, systemic disease, oral
contraceptives, poor oral hygiene, smoking as well as type of impaction, relation to the inferior alveolar nerve,
surgery duration, surgical technique and the use of antibiotics [11-18]. In addition, the incidence of
complications is associated with the surgical experience [19].
Surgery complications would influence patient satisfaction. Clinicians knowledge on the incidence of
complications and influencing factors could help to reduce morbidity and better decision making [20]. Most
studies that examined molar surgery complications have been performed retrospectively and mostly assessed
major complications such as paresthesia, infection, dry socket and mandibular fracture [1, 8, 13, 17, 21-27].
However, short-term complications such as pain, bleeding, swelling and mouth opening limitation that are
relatively common and could cause patient discomfort have been less studied. The present study aimed to
investigate the prevalence of complications after surgery mandibular third molar and their risk factors.
Materials and methods
This study was performed prospectively on patients referred to the Department of Oral and Maxillofacial
Surgery, School of Dentistry, Ahvaz University of Medical Sciences, in 2012 to 2014. Study protocol was
approved by the university ethics committee and informed consent was obtained from all patients.
Patients who needed surgical extraction of impacted mandibular third molar were enrolled based on the
inclusion and exclusion criteria (Table 1). All teeth were bony impacted and mesio-angular class II B,
radiographically [28]. Surgeries were performed by second-year surgery resident with the same protocol.
Envelope flap with no releasing incision was used. Bone was harvested and teeth were cut down to facilitate
tooth removal. All patients were advised to take painkillers after surgery.
Prior to the the operation, apart from inclusion and exclusion criteria, demographic data, the maximum
mouth opening (MMO), oral commissure to the tragus distance (TO), and zygomatic protuberance to
mandibular angle distance (ZM) were recorded for each patient. In addition, surgery duration, the number and
form of each tooth roots were also recorded.
After 24 hours, the patients were recalled and pain, bleeding and paresthesia were evaluated subjectively.
Also MMO, TO, ZM and mandibular fractures were assessed.
Ivy Union Publishing | http: //www.ivyunion.org
December * , 2015 | Volume 3 | Issue 1
Farshid A et al. American Journal of Oral and Maxillofacial Surgery 2014, 2:43-52
Page 3 of 10
Table 1 Inclusion and exclusion criteria
Inclusion criteria

Bony impaction of mandibular third molar

Mesio-angular class II B impaction [28]

Informed consent

Older than 16 years

No serious systemic disease (ASA class I and II)

No medication (including OCP)
Exclusion criteria

The risk of infective endocarditis, coagulation problems, local or systemic infection, known
hypersensitivity to acetaminophen or NSAIDs, history of asthma, addiction to drugs or alcohol

Smoking

Signs of infection, such as swelling, fever, pus, and reduce the amount of open mouth

Not returning for follow up
Pain assessment
Pain after surgery was measured by Visual Analogue Scale (VAS). VAS is a psychometric instrument. The
patients were asked to rate their pain intensity based on detailed description of VAS provided in writing to
each patient (Table 2)
Table 2 Visual analogue scale guide
Score
Description
0-1
Very low and mild pain
2-3
There is pain, but you feel comfortable.
4-5
Pain gets your attention and may affect your daily performance. (use of acetaminophen or ibuprofen)
6-7
Annoying pain; however you have the ability to focus on other issues.
8-9
Severe pain that can prohibit your work. You feel discomfort even when you rest.
10
Worst pain you can imagine.
Ivy Union Publishing | http: //www.ivyunion.org
December * , 2015 | Volume 3 | Issue 1
Farshid A et al. American Journal of Oral and Maxillofacial Surgery 2014, 2:43-52
Page 4 of 10
Swelling assessment
A silk thread was used to measure distance between oral commisure to the tragus (TO) oral commisure to the
tragus distance (TO), and between zygomatic protuberance to mandibular angle (ZM) on the surgery side
while teeth were in occlusion and these distances were transferred to a ruler. Measurements were performed
before and one day after surgery. Swelling index was calculated using the following equation:
Vertical index: postoperative ZM - preoperative ZM / preoperative ZM
Trismus assessment
The maximum mouth opening (MMO) was assessed by measurement of the distance between the upper and
lower Incisors before and one day after the operation. The difference between these two measurements was
considered as trismus.
Statistical analysis
The frequency of complications was calculated. As all variables had normal distribution, statistical analysis
included independent samples t-test, one way ANOVA and Chi-Square. In order to analyze surgery duration
correlation with complications Pearson Correlation test was used. Level of significance was 0.05.
Results
Patients
A total of 101 patients with a mean age of 22.95±2.93 years (19 to 28 years) were evaluated in this study. Of
these, 58 (57.4%) were men and 43 (42.6%) were female. Based on inclusion criteria, all patients were
nonsmokers and none of them were taking medications. 57 (56.4%) of the teeth had two roots, 28 (27.7%) had
three roots and 16 (15.8%) hd four roots. Also, 79 teeth (78.2%) had separate tooth roots and 22 (21.8%) had
conical joined roots. Surgery duration was between 25 to 90 minutes (average 44.11±16.54 minutes).
Postoperative complications
After surgery, all patients had pain, swelling, and decreased MMO. One-third of the patients reported
excessive bleeding on the first day. Numbness of the lower lip as a result of damage to the inferior alveolar
nerve was reported in two female patients. Fortunately, no mandibular fracture occurred during or one day
after surgery. No relation was found between the complications and patient age.
Pain
Average pain 24 hours following surgery was 4.01±0.76 (range 2-5) based on VAS system. The pain reported
among men (3.84) is significantly lower than in women (4.24) (P = 0.007). Difference in postoperative pain
between separate and joined conical roots was not significant (P = 0.256). The ANOVA showed that there is
an association between the number of roots and postoperative pain (P <0.001). Scheffe post hoc test showed
that teeth with more roots had more pain but this difference was not significant between the teeth with 3 and 4
roots (Figure 1a). On the other hand a good correlation (r = 0.615) between the duration of surgery and
postoperative pain was shown (P <0.001) (Figure 2a).
Ivy Union Publishing | http: //www.ivyunion.org
December * , 2015 | Volume 3 | Issue 1
Farshid A et al. American Journal of Oral and Maxillofacial Surgery 2014, 2:43-52
Page 5 of 10
Swelling
Average horizontal and vertical swelling index in the first 24 hours after surgery was 0.25±0.14 and 0.28±0.16,
respectively. The difference between swelling index average between men and women (for ZM (P = 0.715)
and for TO (P = 0.100)) and between teeth with separate and joined conical roots was not statistically
significant (for ZM (P = 0.432) and for TO (P = 0.913)).
ANOVA showed a significant difference between the average swelling index of teeth with various root
numbers (P <0.001). Scheffe post hoc test showed that teeth with more roots had higher swelling, but this
difference was not significant between the teeth with 3 and 4 roots (Fig. 1b, c).
Similar to pain, swelling was also correlated with the duration of surgery (P <0.001). The surgery duration
had good correlation with swelling index in the vertical dimension (r = 585) and horizontal dimension (r =
0.519) (Figure 2b, c).
(a)
(b)
(c)
(d)
Figure 1 Relationship between number of roots. a) pain, b) vertical swelling, c) horizontal swelling, and d) trismus 24
hours following surgical removal of mandibular third molar.
Ivy Union Publishing | http: //www.ivyunion.org
December * , 2015 | Volume 3 | Issue 1
Farshid A et al. American Journal of Oral and Maxillofacial Surgery 2014, 2:43-52
Page 6 of 10
(a)
(b)
(c)
(d)
Figure 2 Relationship between duration of surgery. a) pain, b) vertical swelling, c) horizontal swelling, and d) trismus 24
hours following surgical removal of mandibular third molar.
Trismus
The average preoperative MMO was 49.19±2.23 mm (range 43 to 50 mm) and it was 38.24±3.38 mm (range
32 to 45 mm) 24 hours after surgery. In all cases there was a decrease in MMO.
Difference between preoperative and postoperative MMO was considered as the trismus. Amount of
trismus varied between 2 to 14 mm (mean 7.95±3.04 mm). Average trismus in men was 7.91 mm and in
women was 7.98 (P = 0.902). Trismus in teeth with separate roots was 8.24 mm and in teeth with joined
conical roots was 6.91 mm. This difference was statistically significant (P = 0.037). Also a significant
correlation between the number of roots and trismus was shown (P <0.001). Scheffe post hoc test showed that
teeth with more rooth had more trismus (Figure 1d). Duration of surgery and amount of trismus had good
correlation (r = 0.787) (P <0.001) (Figure 2d).
Bleeding
31 patients (30.7%) reported prolonged bleeding during the first 24 hours following surgery. Average surgery
duration in patients who had prolonged bleeding after surgery was 60±13.29 minutes and in other patients it
Ivy Union Publishing | http: //www.ivyunion.org
December * , 2015 | Volume 3 | Issue 1
Farshid A et al. American Journal of Oral and Maxillofacial Surgery 2014, 2:43-52
Page 7 of 10
was 37.17±12.56 minutes. This difference was statistically significant (P <0.001). Chi-Square test showed no
significant difference in bleeding occurrence between men and women (P = 0.668). Bleeding was related to
the root form (P = 0.046). In 13.64% teeth with conical root prolonged bleeding after surgery was reported
while in the teeth with separated roots, bleeding occurred in 35.90% of cases. It was also shown that by
increasing the number of impacted tooth roots, the occurrence of bleeding was increased significantly (P
<0.001). 7.14% of the two root teeth, 46.43% of the three root teeth and 87.5% of the four root teeth had
prolonged bleeding.
Discussion
Surgical removal of impacted third molars is a common ambulatory surgery performed in dental clinics. This
surgery is done more in mandible compared to maxilla [29]. Pain and swelling after dental treatment is one of
the complications that often bring unpleasant experience for patients. After tooth extraction, trauma causes
inflammation at periodontium and damage to the cell wall [30-32]. Rupture of cell membranes release
phospholipids is which turn into prostaglandin and thromboxane and other metabolites by COX-1 and COX-2
enzymes and causes pain and swelling [32, 33]. On the other hand, trismus is caused by inflammation of
masticatory muscles or pain after tooth extraction [34]. Bleeding in the first day after the operation might be
due to the biochemical reasons (lack of coagulatory factors) or mechanical causes (loose stitches or factors
cause frailty clot) [ 9].
Since trismus, pain and swelling usually occur during the first day after surgery [11], the current study,
assessed the incidence of complications after mandibular third molar surgery within 24 hours after surgery and
the influence if risk factors were analyzed. The results showed that on the first day after the operation the pain
is moderate. In all cases somewhat limited mouth opening and swelling occurred. Almost a third of cases
reported prolonged bleeding. Similarly, in previous studies the most common complications in the first days
after the surgery have been pain, swelling and trismus [18, 35, 36].
Pain is completely subjective and each individual reports pain based on his/her own criterion (self-report).
Various tools could be used to determine the degree of pain; VAS was used in this study. As these tools
represent the individual's perception of pain, they are more useful to compare various scenarios is the same
person. Therefore, in many studies, researchers are more likely to describe the qualitative scores to compare
the groups and interventions rather than emphasizing on the score [37]. In the current study, analgesic was
prescribed for all patients and their reported postoperative pain was mild to moderate. However, in another
study, immediate pain after third molar surgery using VAS was mild in 53% of the cases and severe in 47%
and 15.2% of the patients experience severe pain within a week after surgery [14].
In this study, postoperative pain was less in men compared to the women. Although trismus was less in in
males than females, this difference was not statistically significant. Misgarzadah et al. [38] as well as studies of
Akadiri & Berge [5, 35] also found no difference between men and women. In contrast, Grossi [39] reported
that gender is a predictor factor for postoperative discomfort. Similar to the current study, two previous
investigations reported that the risk of pain is more in women than men [14, 18]. Capuzzi, on the other hand,
showed that men had more pain on the first and third days after surgery [15]. It is stated that low pain threshold
in women and the use of a greater number of anesthetic cartridges can increase the risk of trismus and
post-operative pain [34].
In the present study, same as Mesgarzadeh et al. [38], trismus and bleeding were significantly lower in
patients who had conical root teeth. In another study it was demonstrated that teeth with two separate roots
compared to the teeth with conical roots and teeth adjacent to inferior alveolar nerve channel had a higher risk
for longer operation [14]. In the cited article, curved root was the only predictive factor of preoperative pain
Ivy Union Publishing | http: //www.ivyunion.org
December * , 2015 | Volume 3 | Issue 1
Farshid A et al. American Journal of Oral and Maxillofacial Surgery 2014, 2:43-52
Page 8 of 10
[14]. The current study showed that by increasing in the number of impacted tooth roots, trismus, pain,
swelling and bleeding after surgery elevates significantly.
One of the striking findings in this study was the association between duration of surgery with postoperative
complications. However, some previous studies observed no significant relationship between trismus after
surgery and duration of surgery [36, 38, 39]. This controversy may be because the duration of operation can be
influenced by the surgeon skill and in the cited experiments, surgeries were performed by students, residents
and experts with different level of skills. On the other hand, similar to this study, relationship between duration
of the operation and severity of trismus was demonstrated in other studies [12, 40]. Pedersen [12] showed a
significant correlation between the duration of the surgery and postoperative pain, trismus and swelling. In
addition, with increasing duration of surgery, the number of analgesic pills consumed in the first 24 hours after
surgery increased [12]. Similarly, Van Gool [41] and Capuzzi [15] showed that surgery duration is a risk factor
for pain, swelling, and trismus after surgery. Long manipulation of soft tissue and wound could be the reason
for this relation [41]. In the study of Baqain [42] duration of surgery was an independent predictor variable for
pain and the complications increased with long surgery [42].
In this study, two patients (1.98%) complained of lower lip paresthesia. In previous studies, the risk of
paresthesia after mandibular third molar surgery was reported between 0.6% to 7% [1, 8, 13, 14, 18, 21, 24, 25,
41]. Osborne showed that total sensory impairment in patients over 24 years is 6.5 times more than patients
under 24 years of age [8]. Literature review by Alling showed spontaneous recovery of 96% of patients with
damage to the inferior alveolar nerve and 87% of those with damage to lingual nerve [43]. In most patients this
improvement can be achieved in 6 to 8 weeks. However, recovery can be delayed for 9 months and 2 years.
Damage to the inferior alveolar nerve is primarily due to the proximity of root with nerve which could be
detected by X-ray prior to the surgery [44].
Previous studies suggested that other risk factors may also influence third molars surgery complications. For
instance, body composition, weight and preoperative anxiety may be more important determinants than
radiographic features [5, 35]. Further studies should be performed to investigate other risk factors.
Conclusion
Considering the limitations of this study, results showed that 24 hours after mandibular third molar surgery, if
appropriate analgesics were taken, the postoperative would not be severe. Relatively low incidence of the short
term complication rates in the days after surgery, but limited mouth opening occurs in all patients.
Approximately one third of patients reported bleeding and 1/98% had lower lip paresthesia.
Pain was less in men than women. The trismus and bleeding was less in the teeth with conical roots. In
addition, it was shown that by increasing the number of the roots, rate of pain, swelling, trismus and bleeding
elevates. These complications also increased with increasing surgery duration. So it seems that with increasing
surgeon experience and reduce operation duration, complications can be reduced.
References
1.
2.
Blondeau F, Daniel N. Extraction of impacted mandibular third molars: postoperative complications and
their risk factors. J Can Dent Assoc. 2007, 73:325-328
Guerrero M, Botetano R, Beltran J et al. Can preoperative imaging help to predict postoperative outcome
after wisdom tooth removal? A randomized controlled trial using panoramic radiography versus
cone-beam CT. Clin Oral Investig. 2014, 18:335-342
Ivy Union Publishing | http: //www.ivyunion.org
December * , 2015 | Volume 3 | Issue 1
Farshid A et al. American Journal of Oral and Maxillofacial Surgery 2014, 2:43-52
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Page 9 of 10
Bouloux G, Steed M, Perciaccante V. Complications of third molar surgery. Oral Maxillofac Surg Clin
North Am. 2007, 19:117,
Lopes V, Mumenya R, Feinmann C et al. Third molar surgery: an audit of the indications for surgery,
post-operative complaints and patient satisfaction. Br J Oral Maxillofac Surg. 1995, 33:33-35
Berge T, Bøe O. Predictor evaluation of postoperative morbidity after surgical removal of mandibular
third molars. Acta Odontol Scand. 1994, 52:162-169
Calhoun N. Dry socket and other postoperative complications. Dent Clin North Am. 1971, 15:337-348
Muhonen A, VentäI, Ylipaavalniemi P. Factors predisposing to postoperative complications related to
wisdom tooth surgery among university students. J Am Coll Health. 1997, 46:39-42
Osborn T, Frederickson Jr G, Small I et al. A prospective study of complications related to mandibular
third molar surgery. J Oral Maxillofac Surg. 1985, 43:767-769
Jafari SM. Extraction of impacted teeth. Tehran: Shayan Nemudar, 2008, pp.412
Ethunandan M, Shanahan D, Patel M. Iatrogenic mandibular fractures following removal of impacted
third molars: an analysis of 130 cases. Br Dent J. 2012, 212:180-185
Garcia GA, Gude SF, Gandara RJ et al. Trismus and pain after removal of impacted lower third molars.
J Oral Maxillofac Surg. 1997, 55:1223-1226
Pedersen A. Interrelation of complaints after removal of impacted mandibular third molars. Int J Oral
Surg. 1985, 14:241-244
Goldberg M, Nemarich A, Marco 2nd W. Complications after mandibular third molar surgery: a
statistical analysis of 500 consecutive procedures in private practice. J Am Dent Assoc. 1985,
111:277-279
Benediktsdóttir I, Wenzel A, Petersen J et al. Mandibular -third molar removal: risk indicators for
extended operation time, postoperative pain, and complications. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2004, 97:438-446
Capuzzi P, Montebugnoli L, Vaccaro M. Extraction of impacted third molars. A longitudinal prospective
study on factors that affect postoperative recovery. Oral Surg Oral Med Oral Pathol. 1994, 77:341-343
Bui C, Seldin E, Dodson T. Types, frequencies, and risk factors for complications after third molar
extraction. J Oral Maxillofac Surg. 2003, 61:1379-1389
Kafas P, Jerjes W, Hopper C et al. Complications following lower third molar surgery in a specific age
group: A prospective study. Surg J. 2007, 2:50-54
Malkawi Z, Al-Omiri M, Khraisat A. Risk indicators of postoperative complications following surgical
extraction of lower third molars. Med Princ Pract. 2011, 20:321-325
Jerjes W, El-Maaytah M, Swinson B et al. Experience versus complication rate in third molar surgery.
Head Face Med. 2006, 2:14
Chukwuneke F, Onyejiaka N. Management of postoperative morbidity after third molar surgery: a
review of the literature. Niger J Med. 2007, 16:107-112
Brann C, Brickley M, Shepherd J. Factors influencing nerve damage during lower third molar surgery.
Br Dent J. 1999,186:514-516
Christiaens I, Reychler H. Complications after third molar extractions: retrospective analysis of 1,213
teeth. Rev Stomatol Chir Maxillofac. 2002, 103:269-274
Al-Asfour A. Postoperative infection after surgical removal of impacted mandibular third molars: an
analysis of 110 consecutive procedures. Med Princ Pract. 2009, 18:48-52
Azenha MR, Kato RB, Bueno RB et al. Accidents and complications associated to third molar surgeries
performed by dentistry students. Oral Maxillofac Surg. 2014, 18:459-464
Agrawal A, Yadav A, Chandel S et al. Wisdom tooth--complications in extraction. J Contemp Dent
Pract. 2014, 15:34-36
Ivy Union Publishing | http: //www.ivyunion.org
December * , 2015 | Volume 3 | Issue 1
Farshid A et al. American Journal of Oral and Maxillofacial Surgery 2014, 2:43-52
Page 10 of 10
26. Azenha MR, Kato RB, Bueno RB et al. Accidents and complications associated to third molar surgeries
performed by dentistry students. Oral Maxillofac Surg. 2014, 18:459-464
27. Trybek G, Chrusciel-Nogalska M, Machnio M et al. Surgical extraction of impacted teeth in elderly
patients. A retrospective analysis of perioperative complications - the experience of a single institution.
Gerodontology. 2015. doi: 10.1111/ger.12182
28. Pell G, Gregori G. A classification of impacted mandibular third molar. J Dent Educ. 1937, 1:157
29. Nordenram A, Hultin M, Indications for surgical removal of the mandibular third molar. Swed Dent J.
1987, 11:1-2
30. Hargreaves K, Abbott P. Drugs for pain management in dentistry. Aust Dent J. 2005, 50(4 Suppl 2):
S14-S22
31. Singla NK, Desjardins PJ, Chang PD. A comparison of the clinical and experimental characteristics of
four acute surgical pain models: Dental extraction, bunionectomy, joint replacement, and soft tissue
surgery. Pain. 2014, 155:441-456
32. Rashwan WA. The efficacy of acetaminophen-caffeine compared to Ibuprofen in the control of
postoperative pain after periodontal surgery: a crossover pilot study. J Periodontol. 2009, 80:945-952
33. Haas DA. An update on analgesics for the management of acute postoperative dental pain. J Can Dent
Assoc. 2002, 68:476-482
34. Peterson LJ, Ellis E, Hupp JR, Tucker MR .Contemporary oral and maxillofacial surgery. In: Peterson LJ.
Postoperative patient management. 4thed. United States of America: Linda Duncan; 2003. p.219
35. Akadiri OA, Okoje VN, Arotiba JT. Identification of risk factors for short-term morbidity in third molar
surgery. Odontostomatol Trop. 2008, 31:5-10
36. Kim JC, Choi SS, Wang SJ et al. Minor complications after mandibular third molar surgery: type,
incidence, and possible prevention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006,
102:e4-11
37. Aicher B, Peil H, Peil B et al. Pain measurement: Visual Analogue Scale (VAS) and Verbal Rating Scale
(VRS) in clinical trials with OTC analgesics in headache. Cephalalgia. 2012, 32:185-197
38. Mesgarzadeh AH, Hasanpur Kashani A, Jafari M. Effect of Surgical Removal of Impacted Third Molars
on Trismus. Jundishapur Sci Med J. 2013, 12:41-49
39. Grossi GB, Maiorana C, Garramone RA, et al. Assessing postoperative discomfort after third molar
surgery: a prospective study. J Oral Maxillofac Surg. 2007, 65:901-917
40. Oikarinen K, Räsänen A. Complications of third molar surgery among university students. J Am Coll
Health. 1991,39:281-285
41. van Gool A, Ten Bosch J, Boering G. Clinical consequences of complaints and complications after
removal of the mandibular third molar. Int J Oral Surg. 1997, 6:29-37
42. Baqain Z, Karaky A, Sawair F et al. Frequency estimates and risk factors for postoperative morbidity
after third molar removal: a prospective cohort study. J Oral Maxillofac Surg. 2008, 66:2276-2283
43. Alling 3rd C. Dysesthesia of the lingual and inferior alveolar nerves following third molar surgery. J
Oral Maxillofac Surg. 1986, 44:454-457
44. Kaban LB, Pogrel MA, Perrott DH. Complications in oral and maxillofacial surgery. WB Saunders Co;
1997
Ivy Union Publishing | http: //www.ivyunion.org
December * , 2015 | Volume 3 | Issue 1