Postoperative course assessment after displaced third molar extraction

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Background

According to published data, impacted mandibular third molars occur in 55% of patients [1–4]. Surgical extraction of impacted mandibular third molars is one of the most challenging outpatient oral and maxillofacial surgical procedures and is associated with the greatest number of complications, involving both the maxillofacial region [5, 6] and the ear, nose, and throat (ENT) structures [7–10].

The most common complications of impacted third molars include inflammatory conditions such as alveolar osteitis, periostitis, and osteomyelitis, as well as more severe complications, including abscesses and phlegmons of adjacent spaces; mandibular fractures; and fractured maxillary tuberosity [11–14].

Surgical management is complicated by the fact that, in most patients, the teeth are malpositioned within the alveolar process or along the alveolar ridge so they need to be extracted. Extraction of mandibular third molars is time-consuming, performed on an outpatient basis, and may occasionally require subsequent hospitalization due to trauma to the jaw bone and adjacent soft tissues. These difficulties are related to the anatomical complexity of third molar roots, impaction, and/or malposition of the wisdom tooth, which complicate the surgical procedure.

Aim

This study aimed to evaluate the postoperative course in patients after third molar extraction using different postoperative management approaches.

Methods

A total of 57 patients aged 20 to 35 years with a diagnosis of impacted and malpositioned third molars were examined and surgically treated at the Surgery Unit of the General Dentistry Clinic of the Kirov Military Medical Academy. All patients underwent radiographic examination at the initial visit. A standard surgical extraction technique was used. Patients were divided into 4 groups according to the method of socket management during surgery:

• Group 1 (n = 14): after extraction, socket healing occurred under a blood clot, and primary wound closure was achieved.
• Group 2 (n = 15): a blood clot was allowed to form in the extraction sockets, which were then sutured, and a glove-finger rubber drain was placed.
• Group 3 (n = 15): extraction sockets were filled with Alvanes, sutured, and glove-finger rubber drain was placed.
• Group 4 (n = 13): extraction sockets were filled with Alvanes and closed primarily.

For mandibular third molar extraction under regional block combined with infiltration anesthesia, an incision was made in the retromolar area, extending along the alveolar ridge in the projection of the crown, and directed downward to the vestibular fold from the midpoint of the second molar (see Fig. 1).

 

Fig. 1. Surgical access in the retromolar region.

 

A mucoperiosteal flap was elevated. To minimize postoperative complications and reduce trauma during mandibular third molar extraction, a straight surgical handpiece was used with the principle of maximal bone preservation. The crown and roots were sectioned. The tooth was luxated using forceps and straight or angled elevators (see Fig. 2).

 

Fig. 2. Impacted and malpositioned mandibular third molar.

 

For maxillary third molar extraction under regional block and infiltration anesthesia, an incision was made in the maxillary tuberosity area over the crown projection, extending along the alveolar process upward toward the vestibular fold from the midpoint of the second molar crown. A mucoperiosteal flap was elevated. A straight surgical handpiece was used in accordance with the principle of maximal bone preservation. Tooth luxation was performed with forceps and a straight elevator. The socket was sutured (see Fig. 3).

 

Fig. 3. Extraction and suturing of the mandibular third molar socket.

 

In groups 3 and 4, extraction sockets were filled with Alvanes hemostatic material (VladMiVa, Russia). Perioperative antibiotic prophylaxis was administered 30 minutes before surgery with Cifran CT, 500 mg.

Patients were examined on postoperative days 3, 5, and 7. The surgical wound was evaluated for healing (see Fig. 4).

 

Fig. 4. Postoperative wound appearance on day 5.

 

Postoperative course was evaluated based on three parameters: body temperature, soft tissue swelling, and pain intensity requiring analgesic intake. Based on these parameters, the postoperative course was compared among groups.

Results and discussion

The changes in clinical parameters demonstrated a statistically significant improvement in the postoperative course in group 3 compared with other groups, supporting the conclusion that this treatment approach exerts a favorable effect on recovery.

The study revealed that soft tissue swelling, febrile response, and pain were most pronounced in groups 1 and 4, and least pronounced in group 2. In group 3, no febrile response was observed, while pain and soft tissue swelling were minimal.

Conclusion

Comparison of postoperative recovery across groups demonstrated that filling extraction sockets with Alvanes hemostatic material after mandibular third molar removal positively influenced postoperative outcomes and reduced complication rates. Postoperative wound drainage reduced soft tissue swelling and accelerated recovery in cases of complex third molar extractions. The study findings support the use of this approach as a recommended surgical strategy for managing impacted mandibular third molars.

Additional information

Author contributions: V.V. Balin, V.V. Dvoryanchikov, V.A. Zheleznyak: conceptualization, writing—original draft; D.N. Borisov, F.A. Sevryukov: formal analysis, writing—original draft, writing—review & editing; R.V. Sleptsov: investigation, writing—original draft, writing—review & editing. All the authors approved the version of the manuscript to be published and agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ethics approval: This study was approved by the local Ethics Committee of the Kirov Military Medical Academy, Ministry of Defense of the Russian Federation (Minutes No. 2, February 21, 2023).

Funding sources: No funding.

Disclosure of interests: The authors have no relationships, activities, or interests for the last three years related to for-profit or not-for-profit third parties whose interests may be affected by the content of the article.

Statement of originality: No previously published material (text, images, or data) was used in this work.

Data availability statement: All data generated during this study are available in this article.

Generative AI: No generative artificial intelligence technologies were used to prepare this article.

Provenance and peer-review: This paper was submitted unsolicited and reviewed following the standard procedure. The peer review process involved two external reviewers, a member of the Editorial Board, and the in-house scientific editor.

作者简介

Vladimir Balin

Kirov Military Medical Academy

编辑信件的主要联系方式.
Email: balu1980@bk.ru
ORCID iD: 0000-0002-9041-8034
SPIN 代码: 4371-1258
俄罗斯联邦, Saint Petersburg

Vladimir Dvoryanchikov

St.-Petersburg scientific Research Institute of Ear, Nose, Throat and Speech

Email: 3162256@mail.ru
ORCID iD: 0000-0002-0925-7596
SPIN 代码: 3538-2406

MD, Dr. Sci. (Medicine), Professor

俄罗斯联邦, Saint Petersburg

Dmitrii Borisov

Kirov Military Medical Academy

Email: vmeda@yandex.ru
ORCID iD: 0000-0002-6213-5117
SPIN 代码: 3100-5127

MD, Cand. Sci. (Medicine), Associate Professor

俄罗斯联邦, Saint Petersburg

Vladimir Zheleznyak

Kirov Military Medical Academy

Email: zhva73@yandex.ru
ORCID iD: 0000-0002-6597-4450
SPIN 代码: 3895-3730

MD, Cand. Sci. (Medicine), Associate Professor

俄罗斯联邦, Saint Petersburg

Fedor Sevryukov

Privolzhsky Research Medical University

Email: fedor_sevryukov@mail.ru
ORCID iD: 0000-0001-5120-2620
SPIN 代码: 5508-5724

MD, Dr. Sci. (Medicine), Professor

俄罗斯联邦, Nizhny Novgorod

Roman Sleptsov

Kirov Military Medical Academy

Email: rvs1000@yandex.ru
ORCID iD: 0009-0003-6072-2451
SPIN 代码: 4736-1450
俄罗斯联邦, Saint Petersburg

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