J Oral Maxillofac Surg 65:979-983, 2007

Relationships Between Surgical Difficulty and Postoperative Pain in Lower Third Molar Extractions
Lucía Lago-Méndez, DDS,* Márcio Diniz-Freitas, DDS, PhD,† Carmen Senra-Rivera, PhD,‡ Francisco Gude-Sampedro, MD, PhD,§ José Manuel Gándara Rey, MD, DDS, PhD,࿣ and Abel García-García, MD, DDS, PhD¶
Purpose: To investigate the influence of surgical difficulty on postoperative pain after extraction of

mandibular third molars.
Materials and Methods: A prospective study was performed of 139 patients who underwent a total

of 157 mandibular third molar extractions. For evaluation of surgical difficulty, a 4-class scale was completed after surgery: I, extraction with forceps only; II, extraction requiring osteotomy; III, extraction requiring osteotomy and coronal section; IV, complex extraction (root section). The duration of surgery was also recorded. Postoperative pain was evaluated using a visual analog scale that each patient completed daily until day 6 postsurgery, at which time the sutures were removed. Results: A statistically significant relationship was observed between surgical difficulty (as rated on the scale) and postoperative pain. Longer interventions generally produced more pain. Conclusions: Pain after extraction of a mandibular third molar increases with increased surgical difficulty and duration of the intervention. © 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:979-983, 2007 Most studies of postoperative complications in the extraction of mandibular third molars have focused on the most serious complications, such as lesion of the inferior alveolar nerve.1-3 However, such complications are rare, and other, less serious but more frequent complications can have a significant impact on the patient’s postoperative quality of life. Notably, lower third molar extractions invariably cause some amount of pain, inflammation, and trismus.4 Several previous studies have set out to identify factors associated with postoperative pain. Surgical difficulty, measured in different ways, has been reported to be one of the factors most closely related to postoperative pain.5-12 Identifying factors determining pain after lower third molar extractions will help establish appropriate and individualized analgesic protocols. In line with this, the aim of the present study was to assess the affect of surgical difficulty and duration of surgery on postoperative pain after mandibular third molar extraction.

Received from the University of Santiago de Compostela, Santiago de Compostela, Spain. *Postgraduate Student, Oral Surgery and Oral Medicine Unit, School of Dentistry. †Professor, Department of Clinical Psychology and Psychobiology. ‡Staff member, Clinical Research Unit, Clinical University Hospital. §Professor of Oral Medicine, School of Dentistry. ࿣Professor of Oral Surgery, School of Dentistry. ¶Section Head, Department of Maxillofacial Surgery, Clinical University Hospital. Address correspondence and reprint requests to Dr Freitas: Facultad de Odontología, Calle Entrerríos S/N, 15706 Santiago de Compostela, Spain; e-mail: cidinizm@usc.es
© 2007 American Association of Oral and Maxillofacial Surgeons

Materials and Methods
PATIENT SELECTION

0278-2391/07/6505-0024$32.00/0 doi:10.1016/j.joms.2006.06.281

Between January 2003 and June 2004, we performed a prospective study of a consecutive series of 139 patients who underwent a total of 157 mandibular third molar extractions. Bilateral extractions were required in 18 patients, but in all cases these extrac979

5 (P ϭ . Pain sensation depends on each individual’s subjective pain threshold. Mean reported pain (as evaluated on the VAS) was highest on the day of surgery and subsequently declined steadily. 500 mg every 8 hours for 7 days.14.8 Ϯ 22. generally by an incision distal to the lower second molar along the length of the anterior border of the ascending ramus of the mandible. the most severe pain imaginable (score 100). Some previous studies have evaluated surgical difficulty in lower third molar extraction on the basis of surgical complications. EVALUATION OF POSTOPERATIVE PAIN Discussion Pain. and buccal nerve with 2 1. subjective. Osteotomy. mean pain evaluation was significantly higher in difficulty class IV than in difficulty class I on days 0 to 6 inclusive. Spearman’s rank correlation was used to investigate relationships . In line with these findings.4 The sensation of pain is. and there are no uniform criteria for its measurement. 3 mouth rinses per day for 7 days. anxiety. and 6 (P ϭ . of course. without serious medical alterations or blood dyscrasias. Mean age (Ϯ standard deviation) was 27. All surgeries were performed under local anesthesia by nerve-block anesthesia of the inferior alveolar nerve.15 Diverse procedures and scales have been proposed for pain evaluation.5% of interventions. n ϭ 51) and IV (30. with another incision mesial to the same molar. complex extraction (root section). the rightmost end.8-mL capsules of 4% articaine with epinephrine 1:200.2 Ϯ 8. or III and II at any time in the study. III. SURGICAL PROCEDURE SURGICAL DIFFICULTY AND POSTOPERATIVE PAIN between continuous variables. The most frequent surgical difficulty classes were III (32.6% of interventions. The mean duration of surgery was 36.8% of cases and for prophylactic reasons in 41. All analyses were done using SPSS for Windows (SPSS Inc. IL). Surgical difficulty likewise may be evaluated in diverse ways. patients who underwent more difficult extractions tended to report more severe pain. 50 (36%) were men and 89 (64%) were women. No patient had acute pericoronitis or severe periodontal disease at the time of surgery.15 but difficulty generally has been evaluated on the basis of anatomical factors and the position of the molar as assessed Postoperative pain was evaluated using a visual analog scale (VAS)13 that the patient completed at home every day after surgery (at approximately the same time of day as the operation) until day 6 postsurgery. with a piece of folded gauze applied to the wound to aid hemostasis. and significantly higher in class II than class I on days 0 to 5 inclusive. lingual nerve. and surgical difficulty. Barcelona.032). On the VAS. and an antiseptic (chlorhexidine 0.12%. the leftmost end represented absence of pain (score 0).1 years (range. starting the day after surgery). and trismus are typically observed in the postoperative period after mandibular third molar extraction. Chicago.000 (Inibsa. All interventions were performed by postgraduate students at the University of Santiago de Compostela.019). No significant differences were observed between classes IV and III. starting the day before surgery). All patients were healthy. For paired comparisons. All significance tests were 2-way tests. including the semiquantitative verbal scale of Ohnahaus and Adler. patients who underwent interventions of longer duration had significantly higher pain evaluations on days 0 (P ϭ . 600 mg every 8 hours for 4 days. extraction requiring osteotomy. which may be influenced by diverse factors including age. inflammation. and the wound was closed with 3/0 silk. EVALUATION OF SURGICAL DIFFICULTY Results Of the 139 patients. IV. Lower third molar extraction was required due to inflammatory pathology in 29. significantly higher in class III than in class I on days 0 to 6 inclusive.6. P values less than . All patients received an antibiotic (amoxycillin.041). the Mann-Whitney U test with Bonferroni correction was used. In cases where forceps proved insufficient. IV and II. gender. extraction requiring osteotomy and coronal section. a muciperiosteal flap was raised. or root section was then performed as required. coronal section. an anti-inflammatory/analgesic (ibuprofen.05 were considered to indicate statistical significance. Surgical difficulty was evaluated on the basis of duration of the intervention (from the start of the exodoncy procedure to the final suture) and rating of difficulty on a 4-class scale: I.8 For the present study. 18 to 60 years).980 tions were carried out at different times. we selected the VAS. II.17 the VAS of Scott and Huskinsson.13 and analgesic use.7% of cases. at which time the sutures were removed.16 the McGill Pain Questionnaire of Melzack. The sutures were removed 1 week later. n ϭ 48).8 minutes. Spain). extraction requiring forceps only. As shown in Figure 1. which is straightforward to apply and widely used.7. starting after surgery). STATISTICAL ANALYSIS The Kruskal-Wallis test was used to compare pain evaluations between the various surgical-difficulty groups.

18 the Pell and Gregory classification system.12 (20.58) 11. on radiography.98 (18.32 (23.14) 21.56 (13.73 (22.42) 24.58) 27.01) 16.02 (19. some authors believe that surgical difficulty cannot be reliably estimated before surgery on the basis of radiographs but rather must be determined during surgery.62) 22.30 (18.7. It has also been suggested that patient factors (notably age.09* (18.11 (26.12 (20.23* (17.92) 9.23 Our results indicate that pain as evaluated using the VAS was most severe on the day of surgery.35) 30.02) 6.71) 31.70 (22.31) 26.12 (18.LAGO-MÉNDEZ ET AL 40 35 30 25 20 15 10 5 0 EVA 0 EVA 1 EVA 2 EVA 3 EVA 4 EVA 5 EVA 6 I II III IV 981 Postoperative Pain Evaluation EVA 1 EVA 0 17. Yuasa et al11 proposed a new index taking root anatomy into account.83 (16. as expected and in line with previous studies.18) 19. Mean pain (Ϯ standard deviation) evaluation daily until day 6 postsurgery in each category of the surgical difficulty scale.72) III 30.28-30 The differing results obtained in various studies may reflect differences in the type of anesthetic used and in the analgesics administered after surgery.19 and the WHARFE system of MacGregor.73) III 36.91 (24.57) 25. and in the present study we used a 4-class scale for postoperative evaluation and also recorded the duration of surgery.00* (9.43) EVA 2 EVA 3 EVA 4 EVA 5 EVA 6 I Surgical Difficulty Scale II FIGURE 1.40) 17.12) 12.91 (15.22.20 More recently.32 The .84 (15.89) 14. surgical difficulty is best measured after surgery.38) Total 30.86 (24.13) 12. J Oral Maxillofac Surg 2007.08) 11.98) 21.20) 2.5 the most severe pain occurred during the first 3 days.25 (17. and race) can have a major impact on surgical difficulty in lower third molar extractions. Fisher et al26 found that 97% of their patients reported more severe pain on the first day.38) 8.48) 10.23 (20.98 (23. Surgical Difficulty and Postoperative Pain. As in other studies.37) 7.95) 6.31 and contraceptive use.20) 17. However.15 history of pericoronitis.26 poor oral hygiene. attributable to increased production of pain mediators and to the declining effect of the local anesthetic.17 (15.42 (14.57 (22. An ideal study design would involve elimination of postoperative analgesics.54 (22.33* (14.45 (16.02 (13. when the sutures were removed.19* (21. pain subsequently declined steadily until postoperative day 7.21 In our opinion. Other factors that may affect pain include the surgeon’s experience. Other studies have found that pain reaches its maximum intensity during the first 8 hours after surgery. gender.52) 8.35 (25.73) 10.47* (16.42* (7.91 (18.52) 3. Chapian27 reported that pain continued for at least 2 days.18) 16.43 (20.50) 17. Lago-Méndez et al.58) 14. This has been reflected in the development of 3 systems based on dental factors: the lines system of Winter.15.24-26 For example. In the present study. but of course this is not possible for ethical reasons.

it should be kept in mind that pain after third molar extraction also depends on other factors. J Oral Maxillofac Surg 61:1436. Donoff RB. Another previous study likewise evaluated the affect of raising a mucoperiosteal flap on postoperative pain in patients subjected to bilateral extraction of mandibular third molars. 1997 8. García A. when pain was most severe.38. however. Gándara JM. predicting the difficulty before the surgery is more useful). Gude F. Surgical difficulty as evaluated on our 4-class scale was positively correlated with postoperative pain. in which traction by the mucoperiosteal flap is more severe. and history of pericoronitis.33-35 In contrast. implying slower recovery for interventions of longer duration. Pedersen A: Interrelation of complaints after removal of impacted mandibular third molars. and pain is due principally to tissue damage. Berge TI. but for clinical purposes. the present study—like that of Berge and Boe6— evaluated surgical difficulty after the surgery. Huskinsson EC: Graphic representation of pain. postoperative pain. other studies25. Boe OE: Predictor evaluation of postoperative morbidity after surgical removal of mandibular third molars. oral hygiene. 2002 12.26. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 97:438.40 and some have not found any relationship between severity of pain and degree of surgical trauma. 1994 7.5. et al: Panoramic radiographic risk factors for inferior alveolar nerve injury after third molar extraction. however.25. We have reported the affect of this procedure on postoperative pain in a previous study. other authors have not found an association between severity of pain and duration of surgery. notably in operations requiring the raising of a mucoperiosteal flap. Petersen JK. 2004 13. Wenzel A. Gow S: Effect of exposed inferior alveolar neurovascular bundle during surgical removal of impacted lower third molar. Acta Odontol Scand 49:7. 1991 6. Olmedo MV. Gude F. Despite the limited experience of the trainee surgeons in the present study. Acta Odontol Scand 52:162. of course. these results are similar to those obtained in previous studies.5 Yuasa and Sugiura37 likewise reported a relationship between surgical difficulty and pain. Pain 2:175. In the present study. This is reflected in the long durations of surgery and should be taken into account in our assessment of the relationship between surgical difficulty and postoperative pain. and 6 postsurgery. Medicina Oral 7:360.36 have found that the severity of postextraction pain can vary from patient to patient and does not appear to be related to surgical difficulty or the degree of tissue damage. which is probably a more accurate approach (although. the relationship between surgical difficulty and pain was observed from difficulty class II (requiring the raising of a mucoperiosteal flap) onward. 2003 11. In the present study. Scott J. 2002 10. Pedersen4 recorded analgesic consumption over the first 48 hours postsurgery and found a significant correlation between duration of surgery and postoperative pain. Bendiktsdottir I. Blaeser BF. comparing the side on which the flap was raised with the contralateral side and finding more severe discomfort on the flap side.39 Oikarinen5 reported a statistically significant difference in pain evaluations depending SURGICAL DIFFICULTY AND POSTOPERATIVE PAIN on the duration of surgery. Dent Update 30:375. References 1. Oikarinen K: Postoperative pain after mandibular third-molar surgery. Gallas M. Br J Oral Maxillofac Surg 40:26.32 In the present study. August MA. J Oral Maxillofac Surg 55:1223. without significant surgical experience. all surgeons in the present study were postgraduate students in training.5. Kawai T. et al: Trismus and pain after removal of impacted lower third molars. J Oral Maxillofac Surg 62:592. 2003 3. Int J Oral Maxillofac Surg 14:241. Phillips C. Tay AB. 2003 2. et al: Risk factors associated with prolonged recovery and delayed healing after third molar surgery. 1985 5. pain increases with increasing difficulty of surgery. Likewise. although some previous studies have found more severe pain in more complicated interventions. the surgical difficulty was evaluated after the surgery. Sugiura M: Classification of surgical difficulty in extracting impacted third molars. 2001 9. White RP.8 although in that study pain was evaluated on the basis of self-reported analgesic use. The relationship observed between duration of surgery and postoperative pain was statistically significant only on day 1 postsurgery. J Oral Maxillofac Surg 61:417. because tissue damage is generally more extensive and more severe at each increasing level of surgical difficulty.9. Vallecillo M. Smith KG. such as smoking. et al: Mandibular third molar removal: Risk indicators for extended operation time. As noted earlier.30.34 In conclusion. which likewise reported a relationship of this type. a relationship was observed on days 4. 5. longer interventions are typically associated with more pain. and complications. Furthermore. 1976 . Gálvez R: Relación de las variables del paciente y de la intervención con el dolor y la inflamación postoperatorios en la exodoncia de terceros molares. However. for clinical purposes.982 main difference between the present study and previous studies is in the surgeon’s experience. Loescher AR. et al: Trismo y dolor tras la extracción de un tercer molar inferior: Efectos de despegar un colgajo mucoperióstico. Shugars DA. Medicina Oral 6:391. both presurgical and postsurgical evaluation are required for optimal analgesic management. the difference in pain evaluations between difficulty class II and difficulty classes III and IV was not very marked.31 Similar results have been obtained in many previous studies. Yuasa H. they evaluated the difficulty before the surgery. 2004 4. In the present study.4. García A.25. Robinson PP: Nerve damage and third molar removal. This finding was as expected.

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