“abscess” as a perioperative risk factor

8/7/2019 Abscess as a perioperative risk factor

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Abscess as a perioperative risk factor for paresthesia after

third molar extraction under general anesthesia

Fulvia Costantinides, DDS,a Matteo Biasotto, DDS, PhD,b Dario Gregori, MA, PhD,c

Michele Maglione, MD, DDS,d

and Roberto Di Lenarda, DDS,e

Trieste and Torino, ItalyUNIVERSITY OF TRIESTE AND PADOVA

Objective. To evaluate postextractive neurological complications after third molar extraction under general anesthesiaand to identify correlations between the surgical procedure, the third molar-related pathology, and neurologicalinvolvement.Study design. The clinical records of 183 patients were analyzed for a total of 408 third molars extracted at the DentalClinic of Trieste (Italy). Individual effects of clinical data on the presence of paresthesia were evaluated by a logisticregression model.Results. Neurological involvement was observed in 13 patients (6.1%). No permanent inferior alveolar nerve damagewas found (0%) and only 1 patient presented a permanent lesion of the ipsilateral lingual nerve (0.3%). Pell andGregory classification and surgical difficulty were not associated with the incidence or gravity of neurological lesions(P NS). Among the pathologies associated with third molars, only the variable abscess presented a significant

correlation with paresthesia (OR 6.86; 95% CI 1.21-38.8; P

.029).Conclusion. The percentage of nerve injuries agrees with the literature data, inclusion class, and surgical techniqueseem not to influence paresthesia risk. Further studies are necessary to evaluate the role of infectious pathologies as acofactor in the development of neurological lesions after oral surgery. (Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2009;107:e8-e13)

Removal of third molars represents one of the most

common surgical procedures in oral and maxillofacial

surgery.1 Malformation and malposition of these teeth,

often associated with altered eruption (partial or total

impaction) and invalidating conditions (pericoronitis,

abscesses, phlegmons), are indications for third molar

extraction.2-5 Surgical procedures are accompanied by

possible complications that may be divided into intra-

operative and postoperative. The first are a result of soft

tissue lesions (lacerations, emphysemas, dislocations),

vascular and neurological lesions (compression, trac-

tion, overheating, partial or total section by burs), bone

fractures (alveolar, mandibular, maxillary tuberosity),

or lesions to adjacent teeth and anatomic structures

(luxation, avulsion, periodontal involvement, fracture,

oroantral communication). Postoperative complications

are caused by soft tissue lesions (swelling, pain, tris-

mus, dysphagia), vascular involvement (hemorrhage,

ecchymoses, hematomas), and infection (alveolitis, os-

teitis).6,7

Neurological involvement represents an infrequent

but serious complication associated with the removal of

mandibular third molars. As previously reported, infe-

rior alveolar injury ranges from 0.6% to 5.8%.8 Histor-

ical studies have shown the incidence of lingual nerve

injuries to be variable and depend on a number of

factors including techniques used, with rates between

0.2% and 1.6%.9-12

Few data are available on the recovery rate and risk

factors associated with permanent, rather than transient

nerve injury.13 Inferior alveolar sequelae are associated

with a risk of permanent consequences less than 1% ofthe time, whereas the lingual nerve presents permanent

involvement in a range from 0% to 2%.14

The specific aims of this study were to (1) analyze

the prevalence of neurological lesions after third molar

extractions; and (2) correlate nerve injury with radio-

graphic findings, surgical procedure, and the third mo-

larrelated pathology that indicated extraction.

MATERIALS AND METHODSThe study was designed as a retrospective cohort

study of neurological complications after third molar

aResearch associate, Dental Clinic, Clinical-University Department

of Biomedicine, University of Trieste, Italy.bResearcher, Dental Clinic, Clinical-University Department of Bio-

medicine, University of Trieste, Italy.cAssociate Professor, Department of Environmental Medicine and

Public Health, University of Padova, Italy.dAssociate Professor, Dental Clinic, Clinical-University Department

of Biomedicine, University of Trieste, Italy.eFull Professor, The Dean of the Dental Clinic, Clinical-University

Department of Biomedicine, University of Trieste, Italy.

Received for publication Aug 21, 2008; returned for revision Sep 29,

2008; accepted for publication Oct 16, 2008.

1079-2104/$ - see front matter

2009 Mosby, Inc. All rights reserved.

doi:10.1016/j.tripleo.2008.10.014

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extraction under general anesthesia. There were no

exclusion criteria. The clinical records of 183 patients

(median age 28, I quartile 22, III quartile 39; 81 males,

74 females) from 2002 to 2005 were analyzed to iden-

tify correlations between surgical procedure, third mo-

larrelated pathology, and permanent or temporary

neurological involvement.A total of 408 third molars (165 upper and 243

lower) were extracted at the Oral Surgery Unit of the

Dental Clinic of the University of Trieste, Italy.

The same operator performed all the extractions us-

ing general anesthesia and standardized surgical instru-

ments and procedures. When necessary, for totally or

partially impacted upper and lower molars, a buccal

total thickness trapezoidal flap was raised. Accurate

periosteal elevation was made, particularly on lingual

zone. The lingual flap was protected using a lingual

retractor during all the surgical procedures (ostectomy,

tooth sectioning, and luxation) to preserve soft lingualtissues and the lingual nerve that is often localized near

the inferior third molar, a few millimeters distally and

lower with respect to the second molar and leveled with

or superior to the crest of the lingual plate.14 Ostectomy

and tooth sectioning were performed using diamond or

Allport burs inserted on low-speed handpiece (30,000

rotations/minute), always irrigated with sterile saline

solution. Sutures were polyglactin threads (Vicryl), tak-

ing care not to pass the suture deeply in the lingual zone

and trap the lingual nerve in the suture. A recent study

in fact reported that involved nerves were always found

trapped in scar tissue and sometimes expanded to forma neuroma.15

Antibiotic and anti-inflammatory medications were

prescribed (usually amoxicillin 1 g intravenously dur-

ing surgery and orally on subsequent days, 2 times

daily for 5 days when necessary and ketorolac 30 mg

intravenously during recovery when necessary), with

0.2% chlorhexidine rinses 2 times a day for 7 days.

The following data were collected from the clinical

records of all patients: Pell and Gregory class, degree of

inclusion (erupted, mucosal retention, or bone reten-

tion), pathology justifying the extraction (disodontiasis

with recurrent pericoronal infection, periodontitis, mu-cosal trauma, caries, involvement of contiguous teeth,

abscess, orthodontic reasons), and surgical technique

(flap preparation, osteotomy, and tooth sectioning).

Moreover, the presence of permanent or temporary

neurological complications (hypoesthesia, paresthesia,

anesthesia) occurring after the extraction were studied,

classifying lesions as temporary if they resolved in 6

months. Neurological involvement longer than 6

months was considered to be permanent, as it has been

observed that the probability of recovery beyond 6

months is very low.16

Continuous variables are presented as medians (firstand third quartile in squared brackets). Categorical

variables are presented as an absolute number (percent-

age in round brackets). The individual effect of clinical

data on the presence of paresthesia was evaluated by a

logistic regression model. All variables considered

were entered into the model as is, ie, without any

transformation or cutting off. Selection criterion was

the AIC (Akaike Information Criterion) applied back-

ward for each model tested. The final model was se-

lected if superior in terms of AIC at a significance level

of .05. Because data were modeled as teeth and not

subjects, all estimates and the relative confidencebounds and significance tests were adjusted using the

Huber-White sandwich estimator.17 Statistical signifi-

cance was set at a P value less than .05 and indicated if

less than .25; otherwise the NS indication was used.

The S-plus (release 2000) statistical package and the

Harrells Design and Hmisc libraries were used for

analysis.

RESULTSThe Pell and Gregory classification considers

classes I, II, and III and A, B, and C based on the

position of the inferior third molar with respect to themandibular bone and second molar occlusal plane.

Upper molars are classified as belonging to class A,

B, or C with respect to second molar occlusal plane.

Table I shows the extracted teeth divided following

this classification.

Table II presents the motivations or the pathology

related to the third molars extracted and the surgical

techniques applied. A total of 324 elements (80.4%)

were removed because of disodontiasis; 69 teeth

(17.1%) for chronic periodontitis.

Regarding the surgical procedure, 289 teeth (71.2%,

Table I. Subdivision of elements following radio-graphic classification

Pell and Gregory classification No. elements (n 408)

Upper molars n 165

A 104 (63%)

B 34 (21%)

C 27 (16%)Lower molars n 243

IA 89 (37%)

IIA 40 (16%)

IIIA 3 (1%)

I B 22 (9%)

IIB 50 (21%)

IIIB 2 (1%)

IC 14 (6%)

IIC 7 (3%)

IIIC 16 (7%)

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79 upper and 210 lower) needed flap preparation; 222

cases (55.1%, 36 upper and 186 lower) needed ostec-

tomy, and 135 cases (33.5%, 11 upper and 124 lower)

needed tooth sectioning.

After surgery, neurological involvement affected 13

patients for a total of 15 extracted molars (6.1%).

Fourteen cases reported temporary lesions and 1 patient

reported a permanent lesion. In total, 10 cases regardedthe ipsilateral inferior alveolar nerve, 4 cases the ipsi-

lateral lingual nerve, and 1 case both the ipsilateral

inferior alveolar and the lingual nerve. No permanent

injuries to the alveolar inferior nerve were found (0%).

Only one case presented a permanent lesion affecting

the ipsilateral lingual nerve (0.3%). Patients presenting

temporary neurological complications had as an indi-

cation/motivation for extraction disodontiasis (12

cases), periodontitis (1 case), or abscess (1 case); the

patient with the temporary alveolar lesion associated

with permanent lingual lesion presented a disodontiasis

(1 case). Eleven patients needed flap preparation, os-tectomy, and tooth sectioning; 3 patients needed flap

preparation associated with ostectomy; and 1 patient

required flap alone (Table III).

The permanent lingual lesion was observed in a

28-year-old patient who presented at the Dental Clinic

because of an odontogenic abscess, with third inferior

molar belonging to Pell and Gregory class I-A. The

surgical approach required only flap preparation with-

out ostectomy or sectioning.

Relations between neurological involvement and in-

clusion class are reported in Table IV.

At multivariable analysis, only the variable ab-

scess was found to be significantly related to pares-

thesia (odds ratio [OR] 6.86; 95% confidence interval

[CI] 1.21-38.8; P .029).

DISCUSSIONNerve involvement is a rare but serious complication

of third molar surgery. The 4 most common postoper-

ative complications reported in the literature are alve-

olar osteitis, infection, bleeding, and paresthesia.18

Miller et al.19 indicate that nerve dysfunction is the

third most common complication after alveolar osteitis

and postoperative infections with an approximate inci-

dence of 0.57% to 5.30%.

Several studies have identified etiologic factors as-

sociated with nerve injury, such as age of the patient,

radiographic findings, and surgeon experience.1,8,20,21

Regarding surgical technique, the lingual split tech-

nique and other techniques have been introduced toreduce the prevalence of nerve injury.

Our results show a total prevalence of neurological

involvement of 6.1% (5.8% considering temporary in-

juries only) without any case of permanent inferior

alveolar damage (0.0%) and only one case of perma-

nent ( 6 months) lingual nerve lesion (0.3%). These

findings are in agreement with previous reports. Gomes

et al.22 studied a sample of 55 patients operated for

third molar removal under local or general anesthesia.

The authors found that the percentage of sensory dis-

turbance was higher among patients treated under gen-

eral/local anesthesia (13.8%) than among patients op-erated under local anesthesia (3.8%). Brann et al.23

found that lingual and inferior nerve damage was 5

times more frequent when lower third molars were

removed under general anesthesia than under local an-

esthesia. Comparable results were obtained by Rehman

et al.24 who found an incidence of lingual and inferior

alveolar nerves injuries of 0.65% and 0.80%, respec-

tively, with a local block, but 3.58% and 3.26% under

general anesthesia.

However, the small number of cases of paresthesia

limits the generalization of results regarding its associ-

ation with the considered risk factors. Nevertheless, iftaken as a preliminary finding of an uncontrolled, ex-

ploratory study, the multivariate model indicates that

radiological classification and surgical difficulty are not

variables that influence the prevalence and severity of

neurological lesions. Only the variable abscess is

correlated with a higher risk of permanent nerve inju-

ries (OR 6.86). Abscesses are infectious-inflammatory

conditions often associated with the altered eruption of

third molars. However, few cases in the literature have

correlated infectious conditions of dental origin with

nerves injuries.

Table II. Subdivision of elements following preopera-tive and surgical variables

Variables

No. elements (n 408)

Upper molars

(UM)

(n 165)

Lower molars

(LM)

(n 243)

Indications for third molarsextraction, n (%)

Disodontiasis 128 (78) 196 (81)

Periodontitis 23 (14) 46 (19)

Mucosal traumatism 13 (8) 3 (1)

Caries 11 (7) 10 (4)

Involvement of

contiguous teeth

0 (0) 0 (0)

Abscess 3 (2) 7 (3)

Orthodontic motivations 4 (2) 3 (1)

No pathology 0 (0) 0 (0)

Surgical technique, n (%)

Simple extraction 86 (52) 33 (14)

Flap 79 (48) 210 (86)

Ostectomy 36 (22) 186 (77)

Tooth sectioning 11 (7) 124 (51)

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Di Lenarda et al.25 and Giuliani et al.26 underline that

infectious processes in the mandible may result in par-

esthesia. The authors found a direct correlation between

a periapical abscess and inferior alveolar nerve lesion,

considering that tissue metabolism and bacterial toxins

may involve nervous fibers through a compressive

mechanism. Moreover, Giuliani et al.26 hypothesize

two pathogenetic phases: initially, drainage of purulent

exudate could directly damage the myelin sheath with

reversible sequelae, then infection could heal with a

residual fibroticcicatritial reaction causing irreversible

damage to the nerve. Clinical correlations with this

Table III. Clinical details of the observed paresthesiae

Patient

Pell and Gregory

class

Pathology correlated

to third molar

Surgical

technique

Neurological

involvement Duration

4 I A Disodontiasis F; TS; OT IAN T

20 II B Disodontiasis F; TS; OT IAN T



34 I A Abscess F L P

64 I A Disodontiasis F; TS; OT L T

65 I C Disodontiasis F; TS; OT L IAN T

94 I B Disodontiasis F; OT IAN T

97 II B Periodontitis F; TS; OT IAN T

100 I A Disodontiasis F; OT IAN T

100 II A Disodontiasis F; TS; OT IAN T

138 I B Disodontiasis F; TS; OT L T

154 III C Disodontiasis F; TS; OT IAN T


180 II A Disodontiasis F; OT L T

F, flap; TS, tooth sectioning; OT, ostectomy; IAN, inferior alveolar nerve; L, lingual; T, temporary; P, permanent.

Table IV. Characteristics of the study sample in relation to the presence of paresthesia and overall

N

No. cases without

paresthesia

No. cases with

paresthesia Combined

P value(N 228) (N 15) (N 243)

Age 243 23/28/37.25 24.50/28/32 23/28/37 .9396

Gender: M 243 49% (111) 47% (7) 49% (118) .8797

PELL-GREGORY : I-A 243 37% (84) 27% (4) 37% (89) Ref*

I-B 9% (20) 13% (2) 9% (22) .4028

I-C 6% (13) 7% (1) 6% (14) .6710

II-A 17% (38) 13% (2) 16% (40) .8997

II-B 20% (45) 33% (5) 21% (50) .2169

II-C 3% (7) 0% (0) 3% (7) .8531

III-A 1% (3) 0% (0) 1% (3) .9035III-B 1% (2) 0% (0) 1% (2) .9212

III-C 7% (15) 7% (1) 7% (16) .7625

Flap: yes 243 86% (196) 93% (14) 86% (210) .4322

Ostectomy: yes 243 76% (173) 87% (13) 77% (186) .3491

Tooth sectioning: yes 241 50% (114) 67% (10) 51% (124) .2308

Altered eruption: yes 243 81% (184) 80% (12) 81% (196) .9469

Abscess: yes 243 2% (5) 13% (2) 3% (7) .0294

Orthodontic treatment: yes 243 1% (3) 0% (0) 1% (3) .8593

Caries: yes 243 4% (10) 0% (0) 4% (10) .8135

Chronic periodontitis: yes 243 19% (43) 20% (3) 19% (46) .9131

Mucosal trauma: yes 243 1% (3) 0% (0) 1% (3) .8593

Right-Left:Left 243 52% (119) 53% (8) 52% (127) .9318

Paresthesia Localization: lingual 15 33% (5) 33% (5)

Paresthesia type: temporary 15 93% (14) 93% (14)

Continuous variables are presented as median (first and third quartile in squared brackets). Categorical variables are presented as absolute numbers

(percentage in round brackets).

*Reference category.

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pathological finding are not known. In particular, it is

not clear whether acute involvement of the sheath or

cicatritial tissue reaction following the abscess are as-

sociated with clinically evident paresthesia or a sub-

clinical condition.

Our data show that a patient with recurrent infection

associated with a lower wisdom tooth has about a 7times higher risk of manifesting clinically evident nerve

paresthesia. For this reason it may be hypothesized that

repetitive infections, histologically but not clinically

evident, increase the susceptibility of nerve sheaths to

surgical events (fibrous tissue formation between the

tooth and nerve sheath) so that surgical traction or

pressure movements load indirectly on the nerve fibers.

Microscopic evaluations are necessary to confirm this

hypothesis.

The permanent lesion involved only the lingual nerve

in a 28-year-old subject who needed flap preparation

alone for tooth extraction. It is known that the lingualnerve is not identifiable on conventional radiograms so

that a precise evaluation of its anatomic course for

surgical planning is not possible.

Several studies have reported that since the 1980s

there has been no significant decrease in the incidence

of lingual nerve damage, with temporary involvement

ranging from 0% to 22% and permanent damage rang-

ing from 0% to 2% of all lower third molars re-

moved.27,28 This last percentage represents a fixed

value that does not decrease and that seems not to be

correlated with the surgical technique, third molar-

related pathology, or advanced age. Pogrel et al.,14

using a specific lingual retractor in 250 patients, did not

find any permanent lesion of the lingual nerve but a rate

of lingual paresthesia of 1.6%. However, the same

authors stated that a previous meta-analysis, performed

by Pichler and Beime in 2001, had failed to show any

difference in permanent lingual nerve injury rates

whether a lingual retractor was used or not.14,29

Explanation of this phenomenon has to be researched

in lingual nerve anatomical variables that cannot be

analyzed radiographically. Consequently, if there were

been codify several radiographic signs to evaluate con-

tiguity between third molars and inferior alveolar nerve(darkening of the root, interruption of the white line,

diversion/displacement of the inferior alveolar canal,

deflected roots, narrowing of the root) it is not possible

to identify lingual nerve position with conventional

radiology.8

It appears clear that additional exams (magnetic res-

onance or computerized) have to be introduced in clin-

ical practice to localize the lingual nerve and its conti-

guity to third molars. A careful analysis of the risk-

benefit ratio is required to assess the biological and

economic implications of this approach.

CONCLUSIONAnalysis of surgical variables is important to under-

stand and reduce nerve damage after oral surgery. Fur-

ther studies are necessary to:

- explain the importance of each variables (patient-

correlated, tooth-correlated, operator-correlated) on the

prevalence and severity of nerve injuries;- evaluate whether lingual and alveolar nerve histo-

logical features could explain the increased paresthesia

risk in infectious-inflammatory events;

- ascertain whether the use of nonconventional radi-

ology could reduce the percentage of damaged nerves.

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Reprint requests:Fulvia Costantinides, DDS

via Stuparich 1, 34100

Trieste, Italy

[email protected];

[email protected]

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“abscess” as a perioperative risk factor

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