J Oral Maxillofac Surg 65:979-983, 2007

Relationships Between Surgical Difculty and Postoperative Pain in Lower Third Molar Extractions
Luca Lago-Mndez, DDS,* Mrcio Diniz-Freitas, DDS, PhD, Carmen Senra-Rivera, PhD, Francisco Gude-Sampedro, MD, PhD, Jos Manuel Gndara Rey, MD, DDS, PhD, and Abel Garca-Garca, MD, DDS, PhD
Purpose: To investigate the inuence of surgical difculty 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 difculty, 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 signicant relationship was observed between surgical difculty (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 difculty 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 signicant impact on the patients postoperative quality of life. Notably, lower third molar extractions invariably cause some amount of pain, inammation, and trismus.4 Several previous studies have set out to identify factors associated with postoperative pain. Surgical difculty, 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 difculty 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 Odontologa, Calle Entrerros 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

980 tions were carried out at different times. All patients were healthy, without serious medical alterations or blood dyscrasias. No patient had acute pericoronitis or severe periodontal disease at the time of surgery.
SURGICAL PROCEDURE

SURGICAL DIFFICULTY AND POSTOPERATIVE PAIN

between continuous variables. P values less than .05 were considered to indicate statistical signicance. All signicance tests were 2-way tests. All analyses were done using SPSS for Windows (SPSS Inc, Chicago, IL).

All interventions were performed by postgraduate students at the University of Santiago de Compostela. All surgeries were performed under local anesthesia by nerve-block anesthesia of the inferior alveolar nerve, lingual nerve, and buccal nerve with 2 1.8-mL capsules of 4% articaine with epinephrine 1:200.000 (Inibsa, Barcelona, Spain). In cases where forceps proved insufcient, a muciperiosteal ap was raised, generally by an incision distal to the lower second molar along the length of the anterior border of the ascending ramus of the mandible, with another incision mesial to the same molar. Osteotomy, coronal section, or root section was then performed as required, and the wound was closed with 3/0 silk, with a piece of folded gauze applied to the wound to aid hemostasis. The sutures were removed 1 week later. All patients received an antibiotic (amoxycillin, 500 mg every 8 hours for 7 days, starting the day before surgery), an anti-inammatory/analgesic (ibuprofen, 600 mg every 8 hours for 4 days, starting after surgery), and an antiseptic (chlorhexidine 0.12%, 3 mouth rinses per day for 7 days, starting the day after surgery).
EVALUATION OF SURGICAL DIFFICULTY

Results
Of the 139 patients, 50 (36%) were men and 89 (64%) were women. Mean age ( standard deviation) was 27.2 8.1 years (range, 18 to 60 years). Lower third molar extraction was required due to inammatory pathology in 29.8% of cases and for prophylactic reasons in 41.7% of cases. The most frequent surgical difculty classes were III (32.5% of interventions, n 51) and IV (30.6% of interventions, n 48). The mean duration of surgery was 36.8 22.8 minutes. Mean reported pain (as evaluated on the VAS) was highest on the day of surgery and subsequently declined steadily. As shown in Figure 1, patients who underwent more difcult extractions tended to report more severe pain; mean pain evaluation was signicantly higher in difculty class IV than in difculty class I on days 0 to 6 inclusive, signicantly higher in class III than in class I on days 0 to 6 inclusive, and signicantly higher in class II than class I on days 0 to 5 inclusive. No signicant differences were observed between classes IV and III, IV and II, or III and II at any time in the study. In line with these ndings, patients who underwent interventions of longer duration had signicantly higher pain evaluations on days 0 (P .019), 5 (P .041), and 6 (P .032).

Surgical difculty was evaluated on the basis of duration of the intervention (from the start of the exodoncy procedure to the nal suture) and rating of difculty on a 4-class scale: I, extraction requiring forceps only; II, extraction requiring osteotomy; III, extraction requiring osteotomy and coronal section; IV, complex extraction (root section).
EVALUATION OF POSTOPERATIVE PAIN

Discussion
Pain, inammation, and trismus are typically observed in the postoperative period after mandibular third molar extraction.4 The sensation of pain is, of course, subjective, and there are no uniform criteria for its measurement. Pain sensation depends on each individuals subjective pain threshold, which may be inuenced by diverse factors including age, gender, anxiety, and surgical difculty.6,14,15 Diverse procedures and scales have been proposed for pain evaluation, including the semiquantitative verbal scale of Ohnahaus and Adler,16 the McGill Pain Questionnaire of Melzack,17 the VAS of Scott and Huskinsson,13 and analgesic use.7,8 For the present study, we selected the VAS, which is straightforward to apply and widely used. Surgical difculty likewise may be evaluated in diverse ways. Some previous studies have evaluated surgical difculty in lower third molar extraction on the basis of surgical complications,15 but difculty 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, at which time the sutures were removed. On the VAS, the leftmost end represented absence of pain (score 0); the rightmost end, the most severe pain imaginable (score 100).
STATISTICAL ANALYSIS

The Kruskal-Wallis test was used to compare pain evaluations between the various surgical-difculty groups. For paired comparisons, the Mann-Whitney U test with Bonferroni correction was used. Spearmans rank correlation was used to investigate relationships

LAGO-MNDEZ 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 17.19* (21.71) 31.73 (22.72) III 30.86 (24.73) III 36.35 (25.38) Total 30.91 (24.58) 11.09* (18.42) 24.70 (22.58) 27.11 (26.35) 30.12 (20.57) 25.32 (23.38) 8.47* (16.62) 22.54 (22.14) 21.98 (23.31) 26.12 (20.98) 21.57 (22.02) 6.33* (14.20) 17.02 (19.40) 17.23 (20.18) 19.12 (18.18) 16.30 (18.95) 6.23* (17.01) 16.43 (20.89) 14.98 (18.50) 17.45 (16.58) 14.91 (18.52) 3.00* (9.08) 11.83 (16.13) 12.25 (17.12) 12.02 (13.73) 10.84 (15.20) 2.42* (7.37) 7.56 (13.92) 9.17 (15.48) 10.91 (15.52) 8.42 (14.43) EVA 2 EVA 3 EVA 4 EVA 5 EVA 6

Surgical Difficulty Scale

II

FIGURE 1. Mean pain ( standard deviation) evaluation daily until day 6 postsurgery in each category of the surgical difculty scale. Lago-Mndez et al. Surgical Difculty and Postoperative Pain. J Oral Maxillofac Surg 2007.

on radiography. This has been reected in the development of 3 systems based on dental factors: the lines system of Winter,18 the Pell and Gregory classication system,19 and the WHARFE system of MacGregor.20 More recently, Yuasa et al11 proposed a new index taking root anatomy into account. However, some authors believe that surgical difculty cannot be reliably estimated before surgery on the basis of radiographs but rather must be determined during surgery.21 In our opinion, surgical difculty is best measured after surgery, and in the present study we used a 4-class scale for postoperative evaluation and also recorded the duration of surgery. It has also been suggested that patient factors (notably age, gender, and race) can have a major impact on surgical difculty in lower third molar extractions.15,22,23 Our results indicate that pain as evaluated using the VAS was most severe on the day of surgery, as expected and in line with previous studies.7,24-26 For

example, Fisher et al26 found that 97% of their patients reported more severe pain on the rst day. In the present study, pain subsequently declined steadily until postoperative day 7, when the sutures were removed. As in other studies,5 the most severe pain occurred during the rst 3 days. Chapian27 reported that pain continued for at least 2 days. Other studies have found that pain reaches its maximum intensity during the rst 8 hours after surgery, attributable to increased production of pain mediators and to the declining effect of the local anesthetic.28-30 The differing results obtained in various studies may reect differences in the type of anesthetic used and in the analgesics administered after surgery. An ideal study design would involve elimination of postoperative analgesics, but of course this is not possible for ethical reasons. Other factors that may affect pain include the surgeons experience,15 history of pericoronitis,26 poor oral hygiene,31 and contraceptive use.32 The

982 main difference between the present study and previous studies is in the surgeons experience; all surgeons in the present study were postgraduate students in training, without signicant surgical experience. This is reected in the long durations of surgery and should be taken into account in our assessment of the relationship between surgical difculty and postoperative pain. Surgical difculty as evaluated on our 4-class scale was positively correlated with postoperative pain. This nding was as expected, because tissue damage is generally more extensive and more severe at each increasing level of surgical difculty, and pain is due principally to tissue damage.31 Similar results have been obtained in many previous studies.5,9,33-35 In contrast, however, other studies25,30,36 have found that the severity of postextraction pain can vary from patient to patient and does not appear to be related to surgical difculty or the degree of tissue damage. In the present study, the relationship between surgical difculty and pain was observed from difculty class II (requiring the raising of a mucoperiosteal ap) onward. We have reported the affect of this procedure on postoperative pain in a previous study,8 although in that study pain was evaluated on the basis of self-reported analgesic use. Another previous study likewise evaluated the affect of raising a mucoperiosteal ap on postoperative pain in patients subjected to bilateral extraction of mandibular third molars, comparing the side on which the ap was raised with the contralateral side and nding more severe discomfort on the ap side.32 In the present study, the difference in pain evaluations between difculty class II and difculty classes III and IV was not very marked, although some previous studies have found more severe pain in more complicated interventions, in which traction by the mucoperiosteal ap is more severe.5 Yuasa and Sugiura37 likewise reported a relationship between surgical difculty and pain; however, they evaluated the difculty before the surgery. As noted earlier, the present studylike that of Berge and Boe6 evaluated surgical difculty after the surgery, which is probably a more accurate approach (although, of course, for clinical purposes, predicting the difculty before the surgery is more useful). The relationship observed between duration of surgery and postoperative pain was statistically signicant only on day 1 postsurgery, when pain was most severe. Despite the limited experience of the trainee surgeons in the present study, these results are similar to those obtained in previous studies, which likewise reported a relationship of this type.4,5,38,39 Oikarinen5 reported a statistically signicant difference in pain evaluations depending

SURGICAL DIFFICULTY AND POSTOPERATIVE PAIN

on the duration of surgery. In the present study, a relationship was observed on days 4, 5, and 6 postsurgery, implying slower recovery for interventions of longer duration. Pedersen4 recorded analgesic consumption over the rst 48 hours postsurgery and found a signicant correlation between duration of surgery and postoperative pain. However, other authors have not found an association between severity of pain and duration of surgery,25,26,40 and some have not found any relationship between severity of pain and degree of surgical trauma.25,34 In conclusion, longer interventions are typically associated with more pain. Likewise, pain increases with increasing difculty of surgery, notably in operations requiring the raising of a mucoperiosteal ap. In the present study, the surgical difculty was evaluated after the surgery, but for clinical purposes, both presurgical and postsurgical evaluation are required for optimal analgesic management. Furthermore, it should be kept in mind that pain after third molar extraction also depends on other factors, such as smoking, oral hygiene, and history of pericoronitis.

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