Research Article

The New Iraqi Journal of Medicine

Oral Surgery

Factors predictive of difficult impacted third molar surgery.

Sundus Anwer M. AL-Hamdani *, Maha M. Al-Sened**, Khawlah Tarteeb Hussein *, Ahmed Samir Al-Naaimi***.

Abstract
Background: Although the removal of third molar is a common procedure, in some cases it can be difficult.

Estimating possible difficulties in the removal of third molars is a constant challenge for dental surgeons.
Aim: Study the association of selected factors with difficult third molar surgeries.
Method: A total of 256 patients having symptomatic third molars and referred to the oral surgery department
for consultation, diagnosis and treatment of partially or completely impacted third molars in the mandible
and maxilla were included in the sample. All had surgical extraction of third molar.
Results: increased surgical difficulty was associated with horizontal impaction, male gender, above 30 years
of age and under 20 years of age, mandibular location in addition to complete impaction type.
Conclusion: In the context of difficult surgery predicted by the above factors one should adequately prepare
the necessary logistics and proficiency level required for the procedure.
The N Iraqi J Med, August 2013; 9(2):

Keywords: third molars, impaction, surgical difficulty.

Introduction
Although the removal of third molars is a common
procedure, in some cases it can be difficult. It is hard
to evaluate factors that complicate removal of
impacted third molars because of the large variation
among patients and the difficulty of creating a study
design [1].

Objectives:
1. Assess the relative frequency of simple
surgeries (flap + tooth elevation) to remove
impacted third molars Vs that of difficult
surgery {flap+ (bone removal+/- tooth
sectioning)}.

The ability to predict the surgical difficulty of

impacted third molars is essential when designing a
treatment plan and has several advantages. It helps
to assess the competence of the dental practitioner
for the particular operation, minimize complication,
and optimize the preparation of the patient and
assist in terms of the postoperative management of
inflammation and pain [2].

2.

Assess the role of selected factors in

predicting a difficult third molar surgery.

Materials and methods

Study design: Cross-sectional.
Study setting: Oral surgery department in AlKarama specialized dentistry center in Baghdad for
consultation.
Study period: The study spanned a period of 6
years (2004-2009).
Study Population: All patients referred to the oral
surgery department for consultation, diagnosis and
treatment of partially or completely impacted third
molars in the mandible and maxilla.

*Oral Surgery Department, Al-Karama

Specialized Dentistry Center.
** The Clinic of Early Detection of Cancer-Medical City.
****Community Medicine, College of Medicine,
University of Baghdad Email:
Sundus Anwer M. AL-Hamdani: drsondos2000@yahoo.ocm
. Maha M. Al-Sened samir7715@yahoo.com
Khawlah Tarteeb Hussein k95ta@yahoo.com
Ahmed Samir Al-Naaimi: ahmed_ihss22yahoo.com

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Statistical analysis: SPSS version 20 computer

software was used for statistical analysis.
Frequency distribution for selected variables was
done first. The statistical significance of difference
in average measure of surgical difficulty between 2
groups was assessed by Mann-Whitney test (nonparametric test), while between more than 2 groups
Kruskal-Wallis test was used. The mean rank is a
by-product of these non-parametric tests as a
measure of central tendency for the compared
groups. Multiple logistic regression analysis was
used to assess the net risk for each of selected
explanatory variables on having difficult surgery. P
value less than 0.05 was considered statistically
significant.

Study sample: The records of all patients available

during the 6years study period. A total of 256
subjects were included in the sample, 138 females
and 118 males, their ages ranged between 16-49
years. Chief complaint (reason for extraction),
clinical examination, combined with radio graphical
evaluation and demographic information was
obtained for each patient.
Definition of study variables:
Angulations: The angulations of third molars teeth
were classified as vertical, horizontal, mesioangular
or distoangular according to winters classification
(Winter 1926) [3]. Other positions such as
buccoangular, lingoangular, transverse and inverted
were classified an aberrant position.

Table 1: Surgical difficulty scale, Garcia et al [5].

The state of eruption: The state of eruption of the

tooth was determined according to this criterion;
completely impacted: when entirely covered by soft
tissue and partially or completely covered by bone
within bony alveolus. Partially erupted: when it has
failed to erupt into a normal functional position and
its partly visible in oral cavity (faculty of dental
surgery 1997) [4].

Type
I
II
III
IV

Technique
Simple extraction
Extraction requiring ostectomy
Extraction requiring ostectomy and coronal section
Complex extraction (root section)

Results
The results were based on the analysis of a sample
of 256 patients with symptomatic impacted third
molars. The age of the subjects ranged from 16-49
years of age with mean of 24.4 years (+/- 5.8 years
SD). Young adults (20-24 years of age) constituted
the highest proportion of cases (43.4%). Females
constituted a slightly higher proportion (53.9%)
than males, table 2.

Evaluation of surgical difficulty: All extraction in

this study done surgically (reflecting of a
mucoperiosteal flap) under local anesthesia. After
that the tooth was removed using these surgical
procedures:
Elevation only (with forceps or elevator).
Bone removal + elevation.
Tooth sectioning +elevation.
Bone removal + tooth sectioning +
elevation.

Table 2: Frequency distribution of the study

sample by age and gender.
N
Age group (years)
16-20
38
20-24
111
25-29
65
30-34
23
35-49
19
Total
256
Mean+/-SD (24.4+/-5.8 years)
Gender
Female
138
Male
118
Total
256
Total
256

According to these procedures, surgical difficulty

was evaluated during surgery and rating of
difficulty on a 3- class-scale:
Class-I (easy): elevation only.
Class-II (moderate): tooth sectioning or bone
removal + elevation.
Class-III (difficult): tooth sectioning + bone
removal + elevation.
In the subsequent analysis of the data, class-II and
class-III grouped together as difficult {tooth
sectioning +/- bone removal} and class-I as easy
(simple elevation).

%
14.8
43.4
25.4
9
7.4
100

53.9
46.1
100
100

In the present study the difficulty level of surgical

extraction of impacted third molars was determined
intra-operatively according to the type of surgical
intervention into a 3 grade scale. The higher
percentage had the simplest surgical procedure
(class-I =44.5%), followed by class-II (37.5%), and
the lowest percentage was for class-III (the highest
difficulty level= 18%), table 3.

The scale used in the current study was almost

similar to that of Garcia et al [5]. His scale was
originally composed of 4 classes, (table 1). The final
scale used in Garcia et al study was dichotomous
also. Class-I and II was considered Easy surgery,
while class-III and IV was classified as difficult
surgery.

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Table 3: Frequency distribution of the study

sample by type of surgical intervention.
Type of surgical intervention
Elevation only
Bone removal
Tooth sectioning
Tooth sectioning+Bone removal
Total

N
114
77
19
46
256

angulation) had significant association with

difficulty level of surgical procedure (p<0.05).Male
gender was associated with a higher difficulty level
in surgical procedure (mean rank=152.1) compared
to females (mean rank=108.3). Mandibular location
of the extracted tooth was associated with a higher
mean rank for difficulty level (130.9) compared to
maxillary location (94.6). Horizontal/transverse
angulation of extracted tooth was associated with
the highest mean rank of difficulty level (192), while
vertical angulation (83.7).

%
44.5
30.1
7.4
18
100

Uni-variat analysis (table 4) showed that three

variables (gender, location and the type of

Table 4: Difficulty grading of surgical intervention by age, gender, location and type of tooth impaction.
Elevation only
(class-I)
1.

2.

3.

4.

5.

Age group (years)

16-20
20-24
25-29
30-34
35-49
Gender
Female
Male
Mandibular location Vs Maxilla
Maxilla
Mandible
Type of tooth impaction
Partially erupted
Complete soft tissue impaction
Complete bony impaction
Type of angulation in tooth
Distoangular
Mesioangular
Vertical
Horizontal / transverse
(Aberrant)

Type of surgical intervention

Tooth
sectioning+
Bone removal
(class-III)
N
%
N
%

Tooth sectioning
(or) Bone removal
(class-II)

12
58
29
8
7

31.6
52.3
44.6
34.8
36.8

22
35
20
10
9

57.9
31.5
30.8
43.5
47.4

4
18
16
5
3

80
34

58
28.8

45
51

32.6
43.2

11
103

64.7
43.1

6
90

84
30
0

48
40
0

11
29
72
2

Total

Mean rank

10.5
16.2
24.6
21.7
15.8

38
111
65
23
19

100
100
100
100
100

136.8
119.2
133.1
141.4
135

13
33

9.4
28

138
118

100
100

108.3
152.1

35.3
37.7

0
46

0
19.2

17
239

100
100

94.6
130.9

62
28
6

35.4
37.3
100

29
17
0

16.6
22.7
0

175
75
6

100
100
100

123.9
136.6
162.5

50
26.4
75.8

10
52
22

45.5
47.3
23.2

1
29
1

4.5
26.4
1.1

22
110
95

100
100
100

113.2
153.5
83.7

6.9

12

41.4

15

51.7

29

100

192

0.42[NS]

<0.001

0.034

0.19[NS]

<0.001

of age. The < 20 years of age group was associated

with 2.6 times increase in the risk of difficult
surgery compared to the reference category (20-29
years of age). In addition the 30+ years of age group
was associated with 3.8 times increase in the risk of
difficult surgery compared to the reference category
(20-29 years of age) after controlling for the
remaining independent (explanatory) variables
included in the model. The vertical type of
angulation was associated with the lowest risk of
having difficult surgery and was therefore used as a
reference category for the effect of angulations type.
The horizontal/transverse location increased the
risk of difficult surgery 53.8 times compared to
reference category (vertical angulations), while
distoangular
and
mesioangular
orientation
increased the risk by 4.7 and 9.9 times after
controlling for the remaining explanatory variables
included in the model. Complete soft tissue

To study the net and independent effect of

mandibular location, type of tooth angulation and
type of tooth impaction after adjusting for age and
gender on the risk of having a difficult surgery
(Tooth sectioning +/- Bone removal compared to
the simpler tissue elevation only) a multiple logistic
regression model was used. With the exception of
location all the remaining 4 explanatory variables
had a statistically significant impact on the risk of
having difficult surgery. Mandibular location was
associated with an increase in risk of difficult
surgery of 80% compared to maxillary location
after adjusting for the remaining independent
(explanatory) variables included in the model.
The 20-29 years of age group was associated with
the lowest risk of having difficult surgery and was
therefore used as a reference category for the effect

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impaction and complete bony impaction increased

the risk of difficult surgery by 2.4 times compared
to partially erupt after controlling for the remaining
explanatory variables included in the model

after controlling for the remaining explanatory

variables included in the model. The model was
statistically significant and had an overall accuracy
of 77.4%, table 5.

Male gender significantly increased the risk of

difficult surgery by 4.4 times compared to females
Table 5: Multiple logistic regression model with risk of having a difficult surgery (Tooth sectioning +/Bone removal compared to the simpler tissue elevation only) as the dependent (response) variable and
selected explanatory variables.
OR
Type of impaction
Complete soft tissue impaction compared to partially erupted
male gender compared to female
Mandibular location compared to maxilla
Type of angulation
Mesioangular compared to vertical
Distoangular compared to vertical
Horizontal / transverse (Aberrant) compared to vertical
Age group (years)
<20 years of age compared to (20-29)
30+ compared to (20-29)

2.4
4.4
1.8

P
0.09
<0.001
0.43[NS]
<0.001

9.9
4.7
53.8
0.007
2.6
3.8

Note: Complete bony impaction increased the risk of having a difficult surgery compared to partially erupted, but the odds ratio can not be
calculated.
Overall predictive accuracy=77.3%
P (model) <0.001

Discussion
Preoperative assessment of surgical difficulty is
fundamental to the planning of extraction of
impacted third molars [6].

Many articles [1, 2, 6, 8, 11] took into consideration

operating time (from the first extraction maneuver
to the completion of surgery) and have evaluated
surgical difficulty according to increase in operating
time. Although time is an objective measure of
difficulty, the present study did not evaluate time
factor, since the researchers of present study felt
that assessment of surgical time may be biased and
confounded by level of patients cooperation (gag
reflex, fear, anxiety, mouth opening).

Several classification systems have been established

to estimate surgical difficulty for removing third
molars but they prove to be of little clinical use [5,
7].
These systems are primarily based on the
preoperative assessment of panoramic radiographs
[1], but other factors such as demographic and
operative variables have also been analyzed [6,8].

The current study assessed the effect of selected

factors on surgical difficulty, some of these factors
are demographic (age and gender) and others are
dental factors (impaction, angulation and location of
impacted tooth). All these variables had a
statistically significant impact on the risk of having
difficult surgery when a multivariate analysis was
used.

Chandler et al, 1988 [9], suggested that

preoperative assessment of surgical difficulty was
unreliable and the best measure was that made
during the procedure.
In the present study the difficulty level of surgical
extraction of impacted third molars was determined
intra-operatively according to the type of surgical
intervention into three class-scales: class-I (easy),
class-II (moderate) and class-III (difficult). Class-I
(flap reflection+tooth elevation) was the most
frequent procedure used, followed by class-II, while
class-III was the least frequent procedure used. This
distribution and ranking of difficulty level agrees
with many previously published articles [6, 10, 11],
Although some of these studies used different types
of classification for difficulty level of surgery.

Renton et al [8] and Gbotoloran[6] observed that

surgical difficulty increased with increment in age
of the patient. This was in agreement with our study
where >30years of age have more difficult
surgeries. Peterson et al [12], also linked increased
bone density (measured radiographically) to age
and increased surgical difficulty, which could
account for positive relationship between increased
age and surgical difficulty.

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therefore omitted from the current study to

eliminate a potential source of bias and error.
Torres et al (2010) [2] found that the use of
panoramic radiograph doesnt allow practitioners
to accurately predicate lower third molar extraction
difficulty and techniques regardless of their level of
experience. Its difficult to predict the difficulty of
extraction from these x- ray techniques (two
dimension) weather panoramic or periapical views
because sometimes its difficult to get some of the
precise details like (root curvature, width of roots,
proximity to mandibular canal, number of
roots.etc.) from them. Instead, if we want to
depend on x-rays we may need more sophisticated
radiographical techniques like three-dimensional
(3D) imaging, such as computed tomography (CT)
or cone beam CT (CBCT) may be valuable.
Ghaeminia et al [15] evaluated the role of cone
beam computed tomography (CBCT) in the
treatment of patients with impacted mandibular
third molars at increased risk of inferior alveolar
nerve (IAN) injury and he found that CBCT
contributes to optimal risk assessment and, as a
consequence, to more adequate surgical planning,
compared with panoramic radiography.

In the present study it was found that surgical

difficulty also increased (but to a lesser degree)
when the patient was <20 years of age. The possible
explanation behind this finding is that younger
patients complain from third molar problems early
in their lives. The tooth is usually still in deeper
position, having unfavorable angulation (horizontal
or mesioangular)[13] making the surgery for
removal difficult. Younger patients tend to be less
cooperative with the surgical procedure.
The other two variables that have been studied in
our model were gender and location. Male gender
and mandibular location are associated with more
difficult surgery and this could be attributed to
alteration in the properties of bone [8].
In the present study the most important factor that
increases the risk of having difficult surgery was the
angulation of the tooth, in which greater difficulty
occurred with horizontal type of angulations.
Wathson et al [14], (2011), in his study of factors
associated with surgical difficulty during removal of
impacted third molars found that age and gender of
the patient was not significant predictors of
difficulty but deviation from the vertical alignment
of the tooth increased surgical difficulty because of
the difficult access to the rotation axis of the tooth.
He also found that greater difficulty occurred with
horizontal type of angulation.

Conclusions
1. Less than half of the cases (44.5%) needed only
tooth elevation as a surgical intervention and
about one third (30.1%) needed bone removal.

Hupp et al [13] found that teeth at certain

inclination have ready-made pathways for removal,
whereas pathways for teeth of other inclination
require the removal of substantial amount of bone.
He considered the distoangular impactions as the
teeth with the most difficult angulation for removal
followed by horizontal impaction and the vertical
type of impaction is the third in difficulty of
removal. The mesioangular impaction is generally
acknowledged as the least difficult impaction to
remove.

2. The following factors increase the risk of having

difficult surgery (Tooth sectioning +/- Bone
removal (class-II and III) compared to the
simpler tooth elevation only (class-I) :
o Horizontal
/
transverse (Aberrant)
orientation.
o Mesioangular and distoangular orientation.
o Male gender.
o Older age (30+ years of age).
o Younger age (<20 years of age).
o Complete soft tissue and bony impaction.

In the present study, according to the state of

eruption, partially erupted molars were easier to
remove than complete impacted molars. Renton et
al [8], found that hard tissue impaction of third
molar was one of the dental factors that increase
the surgical difficulty for removal.

References:

Yuasa et al [1] and Wathson et al [14] studied

additional factors (depth, ramus relationship,
proximity to mandibular canal, abnormal root
curvature, width of roots, spatial relationship, and
periodontal space) that complicate the surgical
removal of impacted third molars. Although these
factors are important in determination of difficulty
but they depend mainly on personal biases in
interpretation of 2 dimensional radiographs. It was

1.

Yuasa H, Kawai T, Suguira M: Classification

of surgical difficulty in extracting impacted
third molars. Br J Oral Maxillofac, 2002;
40:26.

2.

Jos Barreiro-Torres , Marcio Diniz-Freitas ,

LucaLago - Mndez, Francisco GudeSampedro , Jos-Manuel Gndara-Rey , Abel
Garca-Garca: Evaluation of the surgical
difficulty in lower third molar extraction
.Med Oral Patol Oral Cir Bucal. Nov 2010; 15
(6): e 869 -74.

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3.

Winter GB. Principles of Exodontias as

applied to the impacted third molar. St
Louis: American Medical Books, 1926.

4.

Faculty of Dental Surgery: The management

of patients with third molar (syn: wisdom)
teeth. The royal college of surgeons of
England: 35-43. Lincolns Lnn Fields
London, 1997.

5.

Garcia AG, Sampedro FG, Rey JG, et al: PellGregory is unreliable as a predictor of
difficulty in extracting impacted lowerthird
molars. Br J Oral Maxillofac Surg, 2000;
38:585.

10. Akinwande JA.: Mandibular third molar

impactionA comparison of two methods
for predicting surgical difficulty. Nig Dent J,
1991; 10:3.
11. Sulieman MS, AlWattar WT, Jazrawi KH.:
A comparative doubleblind study among
two universal systems of classification of
impacted lower wisdom tooth and duration
of surgery. AlRafidain Dent J. 2006; 6(1):
42-47.
12. Peterson L J, Ellis E III, Hupp J R.:
Contemporary
Oral
Maxillofacial
Surgery(ed 2). St Louis, MO, Mosby, 1993,
237-249.

6. Gbotolorun OM, Arotiba GT, Ladeinde AL.:

Assessment of factors associated with
surgical difficulty in impacted mandibular
third molarextraction. J Oral Maxillofac
Surg. 2007; 65:1977-83.

13.

HuppJ R.,Ellis E III, Tucker M R:

Contemporary Oral and Maxillofacial
Surgery. Fifth Edition, Mosby, 2008, p.154.

14. Ricardo Wathson F.,and Belmiro Cavalcanti

do Egito Vasconcelos: Assessment of
Factors Associated With Surgical Difficulty
During Removal of Impacted Lower Third
Molars J Oral Maxillofac Surg, 2011(articale
in press).

7. Diniz-Freitas M, Lago-Mndez L, GudeSampedro F, Somoza-Martin JM, GndaraRey JM, Garca-Garca A. Pederson scale
fails to predict how difficult it will be to
extract lower third molars. Br JOral
Maxillofac Surg. 2007; 45:23-6.

15. Ghaeminia H., Meijer G. J., Soehardi A.,

Borstlap W. A., Mulder J., Vlijmen O. J. C., et
al: The use of cone beam CT for the removal
of wisdom teeth changes the surgical
approach compared with panoramic
radiography: a pilot study. Int. J. Oral
Maxillofac Surg. 2011; 40: 834839.

8. Renton T, Smeeton N, McGurk M. Factors

predictive of difficulty of mandibular third
molar surgery. Br Dent J. 2001; 190:607-10.
9. Chandler L P, Laskin D M. Accuracy of
radiographs in classification of impacted
third molar teeth. J Oral Maxillofac Surg
1988; 46: 656-660.

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