Predictive Factors to Assess the Difficulty to Extract Retained Lower Third

Molars*

Factores predictivos para valorar la dificultad para extraer terceros molares inferiores

retenidos

Fatores preditivos para avaliar a dificuldade para extrair terceiros molares inferiores

retidos

Date of reception: 03-12-2019 ǀ Date of acceptance: 27/04/2020

WILLIAM ANDRÉS VARGAS MADRID

Universidad Central del Ecuador. Quito, Ecuador.

[email protected]; https://orcid.org/0000-0001-8165-488X

ANDREA MONTSERRAT GONZÁLEZ BUSTAMANTE

Universidad Central del Ecuador. Quito, Ecuador.

[email protected]; https://orcid.org/0000-0001-5832-3898

PAOLA ELIZABETH ZURITA MINANGO

Universidad Central del Ecuador. Quito, Ecuador.

[email protected]; https://orcid.org/0000-0002-2059-8527
*Original research.

Correspondence: [email protected]; [email protected];

[email protected]

doi: https://doi.org/10.11144/Javeriana.uo39.pfad

How to cite: Vargas Madrid WA, González Bustamante AM, Zurita Minango PE. Predictive

factors to assess the difficulty to extract retained lower third molars. Univ Odontol. 2020; 39.

https://doi.org/10.11144/Javeriana.uo39.pfad

ABSTRACT

Background: Third molar eruption occurs in a very limited space. Several difficulty scales have

been used to determine the complexity when extracting retained molars, which are key for surgical

planning and prediction. A scale including indicators such as quality of mucosa and bone, as well

as shape and number of roots is introduced. Purpose: Evaluate the difficulty in extracting retained

lower third molars, using the scale proposed by Romero-Ruiz, and thus estimate the presence of

intraoperative complications and surgical time. Methods: An observational descriptive cross-

sectional study was carried out, with a sample of 100 extractions of retained lower third molars in

patients between 16 and 40 years of age. The following variables were evaluated: spatial

relationship, depth, relationship with mandible ramus/space, integrity of bone and mucosa, roots,

dental follicle, and surgical time. The data were summarized in absolute frequency tables and
analyzed with Pearson's Chi2 test (p < 0.05). Results: 71 % of third molars were classified as

“difficult” on the scale. There were significant differences in terms of surgical time-age (p =

0.002), presence of complications-location of the third molar (p = 0.015), presence of

complications-follicle size (p = 0.022), difficulty-sex (p = 0.011 ), difficulty-age (p = 0.068).

Conclusions: This scale can be used to plan extraction treatments for retained lower third molars

to reduce surgical times and anticipate complications.

Keywords

dental follicle; dentistry; intraoperative complications; impacted tooth; oral diagnostics; oral

surgery; retained tooth; risk assessment scale; surgical time; third molar; treatment planning

RESUMEN

Antecedentes: La erupción del tercer molar sucede en un espacio muy limitado. Se han empleado

diferentes escalas de dificultad para determinar la complejidad al extraer molares retenidos, son

clave para la planeación y predicción quirúrgicas. Se presenta un escala que incluye indicadores

como calidad de mucosa y hueso, así como forma y número de raíces. Objetivo: Evaluar la

dificultad para extraer terceros molares inferiores retenidos, al usar la escala propuesta por

Romero-Ruíz, y así estimar la presencia de complicaciones transoperatorias y el tiempo quirúrgico.

Métodos: Se realizó un estudio observacional descriptivo de corte transversal, con una muestra de

100 extracciones de terceros molares inferiores retenidos en pacientes entre 16 y 40 años. Se

evaluaron las variables: relación espacial, profundidad, relación con la rama/espacio, integridad
de hueso y mucosa, raíces, folículo dental y el tiempo quirúrgico. Los datos se resumieron en tablas

de frecuencias absolutas y se analizaron con la prueba Chi2 de Pearson (p < 0,05). Resultados: 71

% de terceros molares se clasificaron como “difíciles” en la escala. Hubo diferencias significativas

en cuanto a tiempo quirúrgico-edad (p = 0,002), presencia de complicaciones-localización del

tercer molar (p = 0,015), presencia de complicaciones-tamaño del folículo (p = 0,022), dificultad-

sexo (p = 0,011), dificultad-edad (p = 0,068). Conclusiones: Esta escala se puede usar para planear

tratamientos de extracción de terceros molares inferiores retenidos para disminuir tiempos

quirúrgicos y prever complicaciones.

Palabras clave

cirugía bucal; cirugía oral; complicaciones intraoperatorias; diagnóstico bucal; diente retenido;

escala de valoración de riesgo; folículo dental; odontología; planeación del tratamiento; tercer

molar; tiempo quirúrgico

RESUMO

Antecedentes: A erupção do terceiro molar ocorre em um espaço muito limitado. Várias escalas

de dificuldade foram usadas para determinar a complexidade na extração de molares retidos, que

são fundamentais para o planejamento cirúrgico e a previsão. É introduzida uma escala incluindo

indicadores como qualidade da mucosa e osso, bem como forma e número de raízes. Objetivo:

Avaliar a dificuldade de extração de terceiros molares inferiores retidos, utilizando a escala

proposta por Romero-Ruíz, e assim estimar a presença de complicações intra-operatórias e tempo

cirúrgico. Métodos: Foi realizado um estudo observacional descritivo transversal, com amostra de

100 extrações de terceiros molares inferiores retidos em pacientes entre 16 e 40 anos. As seguintes

variáveis foram avaliadas: relação espacial, profundidade, relação com o ramo/espaço da

mandíbula, integridade óssea e mucosa, raízes, folículo dentário e tempo cirúrgico. Os dados foram

resumidos em tabelas de frequência absoluta e analisados com o teste Chi2 de Pearson (p <0,05).

Resultados: 71 % dos terceiros molares foram classificados como “difíceis” na escala. Houve

diferenças significativas em termos de tempo cirúrgico-idade (p = 0,002), presença de

complicações-localização do terceiro molar (p = 0,015), presença de complicações-tamanho do

folículo (p = 0,022), dificuldade-sexo (p = 0,011), dificuldade-idade (p = 0,068). Conclusões: Esta

escala pode ser usada para planejar tratamentos de extração para terceiros molares inferiores

retidos para reduzir o tempo cirúrgico e antecipar complicações.

Palavras-chave

cirurgia oral; complicações intraoperatórias; dente retido; diagnóstico oral; escala de avaliação de

risco; folículo dentário; odontologia; planejamento de tratamento; tempo cirúrgico; terceiro molar

INTRODUCTION

Third molars, teeth that for the most part do not erupt through a normal process, cause various

complications, including pericoronitis, periodontitis, cavities, root resorption of adjacent dental

organs, cystic pathologies, occlusal disharmony, crowding of teeth, and TMJ dysfunctions, these

mainly due to its anomalous position (1-4). The causes of retention or impaction are associated
with a decrease in chewing activity, either due to the evolution of having fewer teeth in the mouth

or due to the soft nature of the food (5,6). The conference of the National Institute of Agreements

for Development held in 1979 reached a consensus that the management of these impactions is the

extraction of the third molars (5). However, due to the proximity to important anatomical structures

such as the adjacent second molar, the vascular-nerve bundle that passes through the lower dental

canal, the anterior border of the ascending ramus, and the internal and external bony cortices (3,7),

these teeth present different degrees of difficulty and various intraoperative complications that

include damage to the inferior dental, lingual, and long buccal nerves (paresthesia), hemorrhage,

severe trismus, fracture of adjacent teeth, and even mandibular fracture (3,6-10).

Given this background, it is necessary to perform pre-surgical extraction studies (11-15) in relation

to predictive factors of difficulty such as those used in Pederson, Peñarrocha, and Koerner scales

(9-11,16-17). In this work, the use of the Romero-Ruiz clinical-radiographic scale (17), which has

been used by various authors especially in Latin America (11,18-19) and has shown its

applicability worldwide. This scale, by gathering a large number of clinical radiographic variables,

allows for better surgical planning to avoid possible complications inherent to surgery. It is also

carried out through a simple mathematical calculation (adding the values obtained and dividing

them by two) that is useful in daily practice. Due to the aforementioned, the present study aimed

to assess the difficulty to extract retained lower third molars using the Romero-Ruiz scale and to

determine the different intraoperative complications and the surgical time used.

MATERIALS AND METHODS

This descriptive study with an observational and cross-sectional design was approved by the

Bioethics Committee of the Centro Clínico Quirúrgico Ambulatorio Hospital del Día Central Quito

(CCQA-HDCQ) of the Ecuadorian Institute of Social Security and the Subcommittee of Research

Ethics in Human Beings from the Central University of Ecuador, whose sample was non-

probabilistic and selected for convenience. The study subjects were patients who attended the Oral

Surgery service of the CCQA-HDCQ for third molar extractions, whose ages ranged from 16 to

40 years of age (9,20). The sample size was obtained based on two articles by Burgos et al. (11)

and Ribes et al. (14) with a total of 100 extractions of retained lower third molars. Patients with

systemic involvement, who attended without radiography, and who did not agree to participate in

the study, were excluded.

To apply the scale, panoramic radiographs were used as they are the diagnostic test used in this

health care service. Prior to data collection and analysis, all operators were standardized by

videoconference with Dr. Manuel María Romero Ruiz (17), author of the clinical-radiographic

scale to assess the difficulty in extracting third molars (Table 1). After standardization, several

measurements were performed on a significant sample of patients until equal results were obtained

between operators. In addition, it was decided to use vegetable/based paper, which allowed to

eliminate the observation bias in the equipment.

 TABLE 1
MODIFICATION OF THE DIFFICULTY ASSESSMENT SCALE FOR THE EXTRACTION OF THIRD-PARTY MOLARS BY ROMERO-
RUIZ (17)

Variable Indicators Values

Spatial relationship • Mesioangular 1
• Horizontal/transversal 2
• Vertical 3
• Distoangular 4
Depth • Level A 1
• Level B 2
• Level C 3
Relationship to • Class I 1
ramus/available • Class II 2
space • Class III 3
Bone and mucosa • Partially covered by mucosa 1
integrity • Partially covered by bone and mucosa 2
• Fully covered by mucosa, but not by bone 3
• Covered by mucosa and partially by bone 4
• Fully covered by mucosa and bone 5
Roots • More than 2/3 fused 1
• More than 2/3 separated or less than 1/3 fused 2
• More than 2/3, multiple 3
Follicle size • +1 mm 1
• 0-1 mm 2
Difficulty index • Very difficult 8-10
(sum divided by • Difficult 5-7
two) • Little difficult 3-4

For the procedure, after obtaining a signed informed consent for participation in the study by the

patient, the radiographic images of the third molar, second molar, and ascending ramus of the

mandible corresponding to each side were transported to the vegetable paper with a 2b pencil. This

was done with the help of a X-ray viewer for printed X-rays, and the same computer in the case of

digital X-rays. After copied the image of the panoramic radiograph, the procedure carried out was:

To obtain Winter's spatial relationship (21,22), two perpendicular lines were drawn (the first the

major axis of the third molar and the second the long axis of the second molar). Once these lines

were drawn, we proceeded to observe what type of angle was formed to determine if the third

molar was in a mesioangular, horizontal, vertical, or distoangular position (Figure 1).

 FIGURE 1
WINTER'S SPACE RELATIONSHIP DETERMINATION DIAGRAM

To obtain the third molar depth proposed by Peel & Gregory (22,23), three horizontal lines were

drawn. The first covered the highest part of the third molar; the second represented the occlusal

aspect of the second molar; and the third was the cervical line of the second molar. Thus, the

relationship of the third molar with the occlusal plane of the second molar was obtained (Figure 2).

FIGURE 2
PEEL & GREGORY’S DEPTH AND RELATIONSHIP WITH ASCENDING RAMUS DIAGRAM

To obtain the relationship of the third molar with the mandible ascending ramus proposed by Peel

& Gregory (22,23), the mesiodistal width of the retained third molar was measured with a ruler in

millimeters. In addition, the space between the distal aspect of the second adjacent molar and the
anterior border of the mandible ascending ramus was measured with the same millimeter ruler. In

this way, the eruption space of the third molar was obtained (Figure 2).

To assess the integrity of bone and mucosa, both radiographic and clinical analyses were performed.

By inspection, it was observed whether or not the tooth was covered by bone or mucosa (11). For

the analysis of root morphology, a radiographic inspection was also carried out in which the presence

of fusions, separations, or multiplicity of the roots of the retained lower third molar was observed

(14,24). For the size of the follicular sac, the radiolucent space on the crown of the tooth was

measured with a millimeter ruler (14,25). Likewise, the letters D and I were placed on the vegetable

paper to determine if the third molar was located on the right (D) or left (I) (Figure 3).

FIGURE 3
ROOT, TOOTH FOLLICLE SIZE, BONE INTEGRITY, AND LOCALIZATION OF THIRD MOLAR DIAGRAM

Captions: Follicle sac (saco folicular); Separated +2/3 (separadas +2/3); Partially by bone (parcialmente por hueso)

Data were registered in a double-entry spreadsheet and the difficulty scale was obtained. To do

this, all the values (excluding sex, age, time and complications) were added and divided by two.

Difficulty ranges were assigned as follows: 3-4 = “little difficult;” 5-7 = “difficult;” 8-10 = “very

difficult” (11,17).
Surgical Phase

Once the mandibular truncal local anesthesia was verified, we proceeded as follows:

1. With a # 3 handle and # 15 blade scalpel (one blade for each tooth to be extracted), a

linear incision was made around the dental necks.

2. The mucoperiosteal flap was lifted using a Minnesota periosteal and retractor.

3. An osteotomy was performed with a low speed air rotor handpiece, a # 8 tungsten

carbide bur (one bur for each tooth to be extracted) and abundant irrigation with 9 %

sodium chloride.

4. A dental section was performed with the same rotary instruments and, with the help of

a straight elevator, the extraction was performed.

5. The pocket was curetted with a sharp spoon and copious irrigation.

6. It was sutured with 3-0 Vicryl and an atraumatic needle (5).

Any complications that arose during the operative procedure were recorded. The time spent by the

operator between the incision and the suture was also recorded.

Data were transferred to the SPSS® version 22 program through which the statistical analysis was

performed. The data analysis included descriptive statistics for the unique variables and, Pearson's

Chi2 test was used to determine the association between variables (p = 0.05) (22).

RESULTS
Of the 100 third molars extracted, regarding gender, 57 % were of females and 43 % belonged to

males. 10 % of the third molars had a difficulty prediction of “slightly difficult,” 71 % were

classified as “difficult,” and 19 % as “very difficult.” In 32 % of the cases, the operation took 5-

10 minutes to complete, while in 44 % the surgical time ranged from 10.01 minutes to 15 minutes

(this time interval being the most frequent one). The operation took between 15 and 60 minutes in

24 % of cases and the procedures required the use of additional instruments (apical elevators).

Among patients aged 16-20 years, the most frequent surgical time (50 %) was 5-10 minutes. In

ages 21 to 30 years, the most frequent surgical time was 10.01-15 minutes. In the 31-to-40-year

age group the most common surgical time was 10.01-15 minutes (p = 0.002). Similarly, at ages 16

to 20, the difficulty scale tended to be “difficult” (28.9 %). Among 31-to-40 year-olds, the scale

tended to be “very difficult” (23.5 %). This suggests that the older the patient, the more difficult it

would be to perform the extraction and, therefore, longer surgical time would be required (p =

0.002) (Table 2).

TABLE 2
CHI-SQUARE TEST
Statistical asymptotic
Variables compared Value df
significance (2-sided)
Surgical time-age 16.773 4 0.002
Presence of complications-third molar
5.892 1 0.015
localization
Presence of complications-follicle size 5.222 1 0.022
Difficulty scale-sex 9.006 2 0.011

Of the 6 complications reported, all occurred on the left side (quadrant III), which represents 11.5

% of the total (p = 0.015). The same cases had a follicular size of 0.0 mm, which represents 10.9

% (p = 0.022). All complications were anticipated, since in the clinical-radiographic assessment

they were classified as “very difficult,” and the necessary instruments were on hand to resolve

them (Table 2).

The male sex in 86 % of the cases was classified as “difficult” on the scale, which contrasts with

the female sex in which the classifications were “not very difficult” (15.8 %) and “very difficult”

(24.6 %) (p = 0.011). This suggests that male sex is also related to the difficulty of extraction

(Table 2).

DISCUSSION

Third molar surgery is one of the treatments most performed by dentists in daily practice

(5,6,11,21). Therefore, various authors agree that this type of surgery should be carried out by

qualified professionals, should be evaluated prior upon execution, in order to experience minimal

pre-, intra-, and post-operative complications (11,14,18,26,27). This has generated the need to

evaluate scales that allow predicting the difficulty that a third molar extraction may have due to

the proximity to important anatomical structures (9,10).

In this study, the Romero-Ruiz clinical-radiographic scale (17) was used and variables such as

location, surgical time, sex, age, and presence of complications were added. Data were obtained

from panoramic radiographs that, despite not being the gold standard, as argued by various authors

(28-30), are the most widely used diagnostic method in the Latin American community and

especially in the public sector of Ecuador. In this sense, Alvira and Juodbalyz (9,31) consider that

the economic component is a very important factor in the use and prescription of diagnostic
methods. For this reason, cone beam radiography is limited and is only used in very complex cases

or in which clear anatomical elements such as the roots or the mandibular canal are not found (31-

34). These variables, when compared with the panoramic study, are the only ones that presented

statistical significance (p ≤ 0.002) (30-32-34). This validates the present finding, since other

variables were used for the analysis of difficulty, which provides more diagnostic elements.

Shital et al. (4), Ribes et al. (14), Artola et al. (35), Fernández (36), Santosh-Kumar & Aysha (37)

and Olguín-Martínez & Amarillas-Escobar (24), like in this study, agree that the females (57 %)

undergo more frequently retained lower third molar extractions. It is also observed that sex and

difficulty (p = 0.011) have an important surgical relationship. 11.6 % presented a scale of “very

difficult” in males and 24.6 % in females. The “difficult” value was more present in males (86 %),

findings that coincide with those of Bachmann et al. (7) and Fernández-Sainz (36). In the present

study, it was expected to find a high percentage of “not very difficult” evaluations among females.

That was not the case. One of the possible reasons that supported this presumption was based on

the gender-related bone composition differences (38).

Fernández-Sainz (36), Díaz-Encomendero (18), González (12) and Ryalat (22) coincide with this

study’s findings in that age and time are statistically significant variables in third molar surgeries,

in which the older the patient, the longer the surgical time (p = 0.002). Perhaps, this is due to the

fact that the cancellous bone presents greater compaction at an older age (22).

Alvira (31), Díaz (18), Burgos (11), Fernández (36) and González-Barboza & Simancas-Pereira

(12) observed that the most frequent surgical time was 10-20 minutes, findings that are similar to
those of the present study. All of them were classified as “difficult.” Even so, on a scale of “very

difficult,” the results vary from author to author. This may be due to the clinician’s expertise,

which is perhaps a variable not assessed in many studies and that should be taken into account in

future research.

Bachmann et al. (7) found a significant difference between the presence of complications and the

third molar location. Quadrant III presented greater complications and longer surgical time.

Similarly, this work found a close relationship between these two variables (p = 0.015), since 6

out of 6 complications were on the left side. Alvira-González et al. (31), Guzmán et al. (39) and

Quinatoa (40) attribute the presence of complications on the left side to poor visibility of the

operator and not being the operating side of the dominant hand, which will possibly translate into

postoperative complications.

Villafuerte (25) observed that the size of the follicular sac is 0.25 mm, in such a way that, the

smaller this follicle, the more complicated the extraction will be due to the risk of ankylosis, which

entails a higher frequency of complications. Thus, in this study, 6 of the complications occurred

in teeth that had a follicular size of 0. The comparison of these two variables was statistically

significant (p = 0.022).

Finally, Ribes et al. (14), Yasser-Kharma et al. (26), Díaz-Encomendero (18) and Burgos et al.

(11) agree with this research in that the difficulty prediction in the vast majority of extractions is

“difficult” (71 %). In addition, all these authors along with others such as Shital, Santosh

Juodzbalis, Yuasa, Burgos, Ribes and even Peel and Gregory, conclude that the difficulty
prediction with scales described in the literature is very important to pre-surgically assess the

extraction of retained lower third molars. This reduces surgical time and improves planning for

possible complications (4,6,9-11,14,23).

CONCLUSION

The use of the clinical-radiographic scale by Romero Ruiz and his team, to which other variables

such as age, sex, and third molar location were added, allowed predicting and planning surgical

treatment and reducing/avoiding complications and reducing the surgical time, without the need

to resort to more complex diagnostic methods.

RECOMMENDATIONS

Include in the analysis other variables to predict difficulty such as coronal area, length, type and

curvature of the roots, Winter's distance, thickness of the basal bone, relationship with mandibular

canal, experience and expertise of the operator, anxiety, and mouth opening.

Use this scale of difficulty together with a visual analogue scale to, in this way, contrast the

difficulty that each clinician suggests.

Complete a more contextualized scale based on the needs of the Latin American population,

including variables such as socioeconomic status.

Perform analysis with imaging means that use new technologies such as the cone beam.

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