Prevalence of Complications and Pericoronitis in Third Molar Surgery: a Cross-sectional Study Using a Brazilian Population Sample of 3455 Teeth. Part 1: the Mandible

doi:10.21203/rs.3.rs-1551235/v1

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Prevalence of Complications and Pericoronitis in Third Molar Surgery: a Cross-sectional Study Using a Brazilian Population Sample of 3455 Teeth. Part 1: the Mandible

https://doi.org/10.21203/rs.3.rs-1551235/v1

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INTRODUCTION: Extraction of third molars is one the most common procedures carried out by Oral and Maxillofacial Surgeons and the potential complications of such intervention are well-documented.

PURPOSE: The objective of this study is to find the associations between these complications and variables related either to the teeth or the patients and thus help surgeons to predict and prevent them.

METHODS: Our study evaluate the prevalence of complications in extractions of the lower third molars using a Brazilian population sample over a period of 10 years to establish the probability of these complications and their association with variables such as age, sex and tooth position in the arch. The same variables were used to determine previous pericoronitis. This is a retrospective cross-sectional observational study, following the STROBE guidelines.

RESULTS and CONCLUSIONS: One thousand and nine patients had 1,822 third molars extracted, with no associations detected between systemic conditions and complications, although these patients are 1.9 times more likely to have pericoronitis. Pericoronitis was more prevalent in healthy patients, with Pell & Gregory classification A and III and distoangular position. These findings corroborate the current literature when comparing Pell and Gregory classification and the higher prevalence of complications.

Third molar

oral surgery

intraoperative complications

postoperative complications

pericoronitis

mandible

Extraction of third molars (M3) is a common procedure carried out by maxillofacial surgeons and it may cause pain, edema and other dysfunctions¹. Impaction of the lower M3 has been reported to be between 9.5% and 39%, which is much higher than the impaction of the upper M3 ^2–3-4.

Potential complications may occur both during and after the surgery, such as hemorrhage, alveolitis, paresthesia, local infections or infections that may invade facial spaces, jaw fractures, periodontal problems or fractures in adjacent teeth along with displacement of teeth for other anatomical spaces ¹. The surgical removal of M3 is often associated with postoperative pain, swelling and trismus. These are expected and generally transient reactions ⁵.

Studies have shown that the rate of these postoperative complications and and the risk of permanent sequelae from extraction of M3 increases with age.

Therefore, prophylactic extraction of these teeth before the age of 25 is often recommended ^7–8.

Epidemiological studies are essential as they provide information to health professionals about a range of conditions which helps to prevent and treat them.

Prevention remains the most effective approach to control these complications and it should be conducted with a careful evaluation of the patient. This involves clinical and radiographic examination, a proper classification of the tooth to be extracted, adequate preoperative planning and a meticulous execution of the surgical procedure. The surgeon's expertise and the use of instruments and surgical techniques are also key factors for a successful intervention. With proper planning, it is possible to predict accidents ^5–9.

This study showed the prevalence of complications in extractions of lower third molars in a Brazilian population sample over a period of 10 years and established their probability related to variables such as age, systemic problems relevant to surgery, tooth position in the arch and history of pericoronitis. We start from the hypothesis 0 (H0) that there is no association between the independent variables and the complications of these surgical procedures.

Ethics committee approval was obtained (registration number 3.280.952) at The Ethics Committee of the Federal University of Espírito Santo in Vitória/ES, Brazil, and the study was carried out in accordance with the current standards recommended for the reporting of observational studies in epidemiology (STROBE statement)¹⁰.

a) Study’s design:

Retrospective cross-sectional observational study

b) Sample, inclusion and exclusion criteria:

This study was composed of a simple random sample and it was conducted between 2008 and 2018. The inclusion criteria was patients who had third molar extractions at the Dental Specialties Center of the City of Vitória (CEO), in Espírito Santo. The surgeries were carried out by the same surgeon. The exclusion criteria adopted were: teeth associated with cysts or tumors, teeth in individuals using anti-resorptive medications and/or smokers/ex-smokers. These exclusion criteria were established with the intention of eliminating factors that can lead to misinterpretation of the sample.

c) Surgical procedure

The surgical procedures were performed by the same surgeon under local anesthesia over a period of 10 years. All procedures were performed using antibiotic prophylactic therapy prior to the procedure with amoxicillin as the first choice and clindamycin as the second choice in patients allergic to penicillin. The antibiotic was not maintained in the postoperative period. In sssociation with the antibiotics, a non-steroidal anti-inflammatory (ibuprofen) was maintained in the postoperative period together with a analgesic drug (acetaminophen). Patients with pericoronitis were treated with antibiotics for 7 days and their surgery were performed at least 21 days after the end of the therapy and in absence of clinical signs and symptoms. The surgical technique used varied according to the position of each tooth, including flaps, osteotomy and section of the crown and/or roots when necessary. All the osteotomies and tooth sections were made using high rotation burs and the flaps were closed with 4 − 0 nylon sutures. After the procedures, the patients were evaluated in an average of 7 days, when their sutures were removed.

d) Data measurement

All data were obtained from medical records by one operator. A second operator processed and revised those data to avoid measurement bias.

The collected data were: (1) from the patient: sex, age, systemic problems relevant to the surgery; (2) from the tooth: position in the arch according to Winter's classification, tooth position in the arch according to Pell & Gregory classification and history of pericoronitis, all independent variables. Information was also collected regarding the presence of intra and postoperative complications related to the procedure (dependent variables).

The teeth were classified by their position in the arch through their radiographic image and clinical examination. Winter classification for standardization and reproducibility was used with the adaptation proposed by Quek et al in 2003¹³ where the degree of tooth inclination in relation to the second molar is measured to establish its position in order to avoid measurement bias. The same procedure was adopted for the Pell & Gregory classification, which was used in its original form.

Complications were classified as operative when they happened during or immediately after the extraction, or postoperative when they became apparent one or more days after operation. Both classification criteria were careful explained to the operator and auditor.

e) Statistical analysis

Initially, a descriptive analysis of the data was performed. The number of individuals, number of teeth, sex, age, systemic problems and types of complications presented were collected and organized in tables

Based on the null hypothesis (H0) - there is no relationship between the independent variables and the prevalence of complications found in these surgical procedures, inferential analysis was performed. The variables (1) intraoperative complications, (2) postoperative complications and (3) previous pericoronitis, which were related to the other variables using the Chi-square test with a 95% confidence interval and a standard deviation of 0.5 and a degree of freedom of 1. Likewise, these three variables were assessed for risk using the OR (Odds Ratio) with a 95% confidence interval. The statistical package used for this analysis was IBM SPSS 20.

The sample comprised patients from 11 to 80 years old (mean of age 26,8 years) with 467 males (43,28%) and 612 (56,72%) females. A total of 1822 lower M3 in 1079 individuals were analyzed.

From these teeth, according to Winter’s classification, 935 (51,32%) were in a vertical position, 481 (26,41%) with mesial angulation, 229 (12,57%) in a horizontal position and 177 (9,7%) with distal angulation.

Using Pell & Gregory’s classification, 219 lower M3 were in class I position (12,02%), 1553 in class II position (85,24%) and 50 class III position(2,74%). According to the level of impaction, 1321 lower M3 were classified as A (72.50%), 462 as B (25.36%) and 39 as C (2.14%).

In the studied sample (1079 patients), 82 patients (7,5%) had a systemic disease under treatment. From these, 21 patients (1,94%) had diabetes mellitus, 14 patients (1,29%) had arterial hypertension, 13 patients (1,2%) were HIV positive, 8 patients (0,74%) had fibromyalgia, 4 patients (0,37%) had hydronephrosis, 3 patients (0,27%) had renal insufficiency, 3 patients (0,27%) had epilepsy, 3 patients (0,27%) previous history of endocarditis, 3 patients (0,27%) had sickle cell anemia, 2 patients (0,18%) had hypothyroidism, 2 patients (0,18%) had thalassemia minor, 2 patients (0,18%) had rheumatoid arthritis, 2 patients (0,18%) had leukopenia, 1 patient (0,09%) rheumatic fever and 1 patient (0,09%) had psoriasis. All these individuals had their systemic conditions under control during the perioperative and postoperative period. Patients with uncontrolled systemic conditions had their surgical procedure postponed until proper control of their clinical situation.

Ten patients (0,92%) required M3 extraction during pregnancy. All patients were referred to their gynecologists prior to surgery for evaluation and the surgical procedure were made preferably in the second quarter of gestation.

Several complications were described in the medical records, corresponding to 8,5% of all procedures and from this total, 4,7% occurred in the intraoperative period and 3,8% happened in the postoperative period.

In the perioperative period we found complications such as: 1. Root fractures, when 2/3 or more of the root remained in the dental socket after removing the tooth with the need of additional procedures to remove it at in the same surgical moment (none root fragment were left in place for a removal in a second procedure); 2. Apical third fractures, when 1/3 or less of the root remained in the dental socket after removing the tooth with the need of additional procedures to remove it at the same surgical moment (no root fragment was left in place for removal in a second procedure); 3. Crown fractures, when an unplanned or non-intentional fracture of the the dental crown happened during the procedure; 4. Alveolar bleeding, defined as bone bleeding from the dental socket that didn’t stop spontaneously; 5. Laceration, defined as tearing of the oral mucosa; 6. Fracture of the lingual cortex, defined as a fragmentation of the lingual cortex besides the M3 area; 7. Oral bleeding, defined as an arterial or venous non-bone bleeding in the soft tissues that didn’t stop spontaneously; 8. Deglutition, defined as swallowing of the M3 or a fragment of the tooth and 9. Dislocation to the submandibular space, when the tooth or a fragment were dislocated to the submandibular space.

Postoperative complications were classified as: 1. Infection defined as inflammatory changes, such as purulent discharge and fluctuation or swelling associated with pain; 2. Paresthesia, defined as any numbness or change in sensitivity in a circumscribed area referring to the innervation of a particular nerve; 3. Alveolitis, defined a pain not significantly relieved by the use of painkiller administered 3 to 4 days after the procedure, and poor healing when there is a mucosal defect or suture dehiscence a week or longer after the operation.

Among the intraoperative complications we found 56 (3.07%) root fractures, 11 apical third fractures (0.61%), 5 (0.27%) crown fractures, 7 (0.38%) alveolar bleeding, 2 (0.11%) lingual cortical fractures, 2 (0.11%) oral bleeding, 1 (0.05%) deglution and 1 (0.05%) displacement of the apical third to the submandibular space.

Postoperative complications included 34 (1.86%) infections, 13 (0.71%) lingual nerve paresthesia, 9 (0.49%) inferior alveolar nerve paresthesia, 8 (0.44%) alveolitis, 2 (0.11%) TMJ dislocation, 1 (0.05%) hemorrhage and 1 (0.05%) lip paresthesia.

In this study, we detected 907 (49.78%) teeth with a report of previous pericoronitis. Pericoronitis is generally defined as an acute infectious process characterized by inflammation of the gingival tissue that partially covers an impacted tooth, clinically presenting with pain and edema, either with or without suppuration. Different degrees of pericoronitis were considered, from the mildest to the most severe. All these patients were operated on for at least 21 days without presenting symptoms.

This data were assessed to determine the relationship (X2) and risk (OR) between age, systemic problems and Pell & Gregory and Winter classifications, along with overall complications, intraoperative and postoperative and pericoronitis.

There was no association between the patients´ sex and complications, both intra and postoperative, and the prevalence of pericoronitis was not related to sex.

3.1. Pericoronitis

We found an association between the prevalence of pericoronitis and age (p = 0.000, df = 3) and systemic problems (p = 0.024, df = 1) of the operated individuals (Table 1). Individuals over 26 years of age had more pericoronitis and from those individuals, the ones without systemic problems were 1.9% more likely to have this condition (OR = 1.952, p = 0.024) (Table 2).

Table 1

Association between age and complications in lower third molar teeth
Complication	until 20		21–25		26–30		31 ou mais		p- value
Complication	N	%	N	%	N	%	N	%	p- value
Intraoperative	11	2,7	35	6,4	18	4,3	29	6,6	0,021
Postoperative	9	2,2	22	4,0	19	4,5	13	3,0	0,236
Pericoronitis	143	34,6	308	56,4	248	58,8	205	46,8	0,000

p-value = chi-square test with 3 degrees of freedom

Table 2

Odd Risk between age and complications in lower third molar teeth
Complication	until 25 years		26 years or more		Odd	p-value
Complication	N	%	N	%	Odd	p-value
Intraoperative	46	4,8	47	5,5	1,147 0,756–1,742	0,518
Postoperative	31	3,2	32	3,7	1,157 0,700–1,913	0,570
Pericoronitis	451	47,0	453	52,7	1,254 1,043–1,508	0,016

OR (Odd Ratio) with a 95% confidence interval

The position in which the tooth is located was also associated with pericoronitis, according to both Winter classification (p = 0.000, df = 3) and Pell & Gregory classification (p = 0.000, df = 2) (Table 3).

Table 3

Association between Pell & Gregory Classification (I, II e III) and complications in lower third molar teeth
Complication	Class I		Class II		Class III		p-value
Complication	N	%	N	%	N	%	p-value
Intraoperative	14	6,3	77	5,0	1	2,0	0,416
Postoperative	1	0,5	59	3,8	9	18,0	0,000
Pericoronitis	71	32,1	813	52,4	23	46,0	0,000

p-value = chi-square test with 1 degree of freedom

According to Pell & Gregory classification, teeth that were classified as A, that is, M3 with occlusal plane at the same level or above of the second molar in the same arch were 1.5 times more likely (p = 0.000) than those classified as B and 2.5 times more likely (p = 0.000) than those classified as C to have pericoronitis. When we evaluated the position of this tooth the mandibular ramus, we found that among teeth classified as II and III and between I and III, there was no increased risk. There is a risk of 2.3 times (p = 0.000) higher of pericoronitis with teeth in position II when compared to those classified as I (Table 4).

Table 4

Risk between Pell & Gregory Classification (I, II e III) and complications in lower third molar teeth
Complication	Class I		Class II		Odd	p-value
Complication	N	%	N	%	Odd	p-value
Postoperative	1	0,4	54	3,5	8,035 1,106–58,372	0,005
Pericoronitis	72	32,3	809	52,3	2,302 1,709–3,101	0,000
	Class I		Class III
	N	%	N	%
Postoperative	1	0,4	8	16,0	42,282 5,153–346,992	0,000
Pericoronitis	72	32,3	23	46	1,787 0,958–3,331	0,048
	Class II		Class III
	N	%	N	%
Postoperative	8	16,0	8	16,0	5,263 2,357 − 11,752	0,000
Pericoronitis	23	46,0	23	46,0	1,289 0,732-2,267	0,230

OR (Odd Ratio) with a 95% confidence interval

As for Winter's classification, we observed that teeth with distal angulation had the highest risk of pericoronitis (OR = 1.76, p = 0.006) when compared to teeth in horizontal postion, which were 1.98 times (p = 0.000) and 2.19 times (p = 0.000) more likely to have pericoronitis than vertical and mesioangulated, respectively. Vertical and mesioangulated teeth did not differ significantly.

3.2. Intraoperative complications

Intraoperative complications were only related to age (p = 0.021), as increased complications were observed in patients aged 26 years and over (Table 1). No other analyzed variable showed increased risk association or probability.

3.3. Postoperative complications

When we evaluated the postoperative complications, we found that they were strongly associated with the position of the teeth (Table 3). In the Pell & Gregory classification regarding the position of the tooth in relation to the mandibular ramus, we observed that there is no statistical difference in risk between teeth in position II and III, but teeth classified as II and III are 8.75 (p = 0.000) and 42.28 (p = 0.000) more likely to present complications than those in position I, respectively (Table 4). The level of impaction position of the teeth in relation to the second molar (A, B and C) did not present significant differences.

Regarding the position of these teeth in Winter classification, we found that teeth in the horizontal position were twice (OR = 2.018, p = 0.046) more likely to have postoperative complications than those in the vertical position. The other positions did not differ significantly from each other.

3.3. Intra and postoperative complications

There were no relation between intra and postoperative complications were not related to each other or were significantly increased

In this study, we started from the null hypothesis (H0) that there is no relationship between patient's variables (sex, age, systemic problems relevant to surgery) and tooth’s variables (position of the tooth in the arch according to Winter's classification, tooth position in the arch according to its Pell & Gregory classification and history of pericoronitis) with the prevalence of complications found in these surgical procedures.

Gathering these data on both prevalence and risk is critical, since the best way to control these complications is through prevention. It is important to be aware of the complications and how they occur in order to avoid them.

Epidemiological studies are indeed essential, since they provide information to health professionals in general about a particular morbid entity, so that it can be better understood, studied, treated and fought by implementing preventive measures.

Epidemiological studies such as the one carried out, involving such number of individuals and relating these risks are rare and therefore important to be undertaken. Most studies follow different methodologies, making it difficult to compare the results obtained. Ethnic variability can lead to a range of variations, particularly in regard to the presence and position of third molars.

This happens for example when we evaluate the age variable. Chiapasco et al. (1995)¹² have evaluated the prevalence of complications after lower third molar extraction in three different age groups and found that in the groups aged between 9 and 16 years and 17 to 24 years, there were no significant differences in the number and type of complications. However, in the group over 25 there was a significant increase in postoperative complications. In the present study, no relationship was found between postoperative complications and age. An association between age and intraoperative complications, however, was found and older patients had more pericoronitis. Neither of these two variables was analyzed by Chiapasco et al.¹² nor by most of the literature.

One exception was Miclotte et al. (2018)¹³ who evaluated both intra and postoperative complications and observed that complications increased with age. In this study, the authors did not separate the complications, and their findings describe intra- and postoperative complications together. But even dealing intra and postoperative complications as one set, the relationship in the present study do not change.

Osunde and Saheeb (2013)¹⁴ did not found differences in age, sex and operative difficulty and postoperative complications, as did our study. But they only evaluated pain, edema and mouth opening limitation as a complication. These variables were not accounted in this study as we did not consider them as complications, but as a constant occurrence in the postoperative period of any third molar extraction to a greater or lesser degree.

According to Winter's classification, 935 teeth (51.32%) were vertical, 481 (26.41%) were mesioangulated, 229 (12.57%) were horizontal and 177 (9.7%) were distoangular. This prevalence also differs from most studies found in the literature, which place mesioangulated teeth in general as more prevalent.^{9,13,11,15,19} Despite this, Pillai et al. (2014)¹⁶ have also found vertical mandibular third molars as the most frequent, followed by the mesioangulated ones, as in our study. These variations can be justified by the way the Winter classification is used. Some authors perform it visually. In the case of this study for standardization and reproducibility; and in order to reduce measurement bias, the Winter classification was used with the adaptation proposed by Quek et al in 2003¹³. But the study by Quek et al.¹³ differs from this one, which leads us to suggest that racial and ethnic patterns may play an important role in variations in the position of third molars.

In the present study, regarding the prevalence of third molars, according to the Pell & Gregory classification, the mandibular molars were predominantly class II (85.24%); and according to the depth of impaction, most presented a light impaction, classified as A (72.5%).

These data differ from those of Quek et al in 2003¹³ who found classification B to be the most prevalent. However, in a similar study, Salmen et al. (2016)⁹ have also found this higher frequency of class II molars (60.22%) and impaction A (48.15%) for the lower ones, thus in line with the studies conducted by Pillai et al. (2014)¹⁶ and Hugoson and Kugelberg (1988)¹⁷. Again, prevalence of impaction seems to differ among different populations. Our study corroborates the research conducted by Hugoson and Kugelberg (1988)¹⁷. They evaluated all third molars with an indication for extraction, while Quek et al in 2003¹³ only evaluated impacted third molars. Morales-Trejo et al.(2012)¹⁹ have also found a greater number of lower and upper molars with mild impaction (54.17%), but there was a higher frequency of class I lower molars (55.66%).

The prevalence of intraoperative and postoperative complications resulting from lower third molar extractions was 8.5%. The most frequent were root fracture, apical third fracture, infection and lingual nerve paresthesia, accounting for 73.55% of all complications.

Studies similar to this one found complication rates of 8.4%, 9.8%, 10.4%, 11% and 18.9% ^{20,21,22,23, 24} According to Bruce¹⁹ these values can vary from 4.6 to 21% for the extraction of lower third molars. This variation, according to the author, are always present due to different factors such as age, degree of difficulty in the surgery, surgeon’s experience and whether the surgery is performed by one or more surgeons. In the present study, all procedures were performed by the same dental surgeon, a certified specialist in maxillofacial surgery. Nevertheless, Azenha et al. (2013)²⁰ have found no differences in the number of postoperative complications when analyzing surgeries performed by dental students vs. experienced professionals.

Age, as we have seen in the literature, has also been considered a significant variable in these complications. In the present study age was associated with more intraoperative complications (p = 0.021).

If we consider the position of the tooth as a factor for the complexity of the surgical procedure, we found that most complications occur in M3 at class III position (p = 0.000) and in teeth classified as horizontal, where the risk of postoperative complications is twice than those in the vertical position (OR = 2.018, p = 0.046). The position of the lower M3 related to the second molar (A, B and C) showed no relationship or increased risk of complications both intra and postoperatively.

The Pell & Gregory classification is widely used for predicting extraction complexity of lower third molars, according to the tooth’s spatial relationship with the ascending ramus of the mandible and with the occlusal plane.²⁵ Freudlsperger et al. (2012)²⁵ have analyzed this issue using Pell & Gregory classification and the Winter classification. The teeth that they classified as moderate or difficult showed more postoperative inflammatory complications, i.e., alveolitis, local infection and abscess. According to the findings of this study, tooth position seems to be a risk factor for postoperative complications.

Pericoronitis is the most common acute problem associated with third molars and there are several predisposing factors²⁶. Given that recurrent pericoronitis is one of the main reasons for indicating lower third molar extraction²⁷, it is essential to understand its relationship with variables such as age, sex, position of the tooth in the arch and complications during and after third molar extraction.

In the present study, 907 (49.78%) mandibular M3 had a history of previous pericoronitis. In their systematic review in 2019, Galvão et al.²⁸ have found a 28% prevalence of pericoronitis in the general population. Since this study was conducted in a service that only treats referenced patients, all patients who made up the sample of this research had indication for lower third molar extraction and cannot be considered a representative sample of the general population, and this may have inflated the prevalence of pericoronitis .

We found that there is an association between the prevalence of pericoronitis and age (p = 0.000, df = 3) and systemic problems (p = 0.024, df = 1) of the operated individuals. Individuals over 26 had more pericoronitis and individuals without systemic problems were 1.9 times more likely to have this condition (OR = 1.952, p = 0.024).

The position of the lower third molar according to Pell & Gregory and Winter classification, played a significant role in the risk of pericoronitis. This is supported by most of the literature. When evaluating risk associations, we found in the systematic review carried out by Galvão et al (2019)²⁸ an increased risk of pericoronitis in lower third molars in position A (OR:7.13;CI:1.31–38.74,I2 = 93%). This is in line with the present study, as we observed a risk1.53 times higher in position A when compared to position B (p = 0.000) and 2.52 times higher when compared to C (p = 0.005). While in the present study we found a higher risk (OR = 1.98) in teeth presenting distal angulation when compared to the vertical ones (p = 0.000), in the review carried out by Galvão et al (2019)²⁸ teeth classified as verticals were at the highest risk. Furthermore, in the present study, teeth classified by Pell & Gregory as class II had 2.3 times more risk of pericoronitis than class I (p = 0.000) and 1.78 times more than class III. Since pericoronitis occurs when the tooth is partially covered by mucosa and the pericoronary tissue. This finding seems logical, but it was not observed in the study conducted by Galvão et al. (2019)²⁸ who did not mention any risk relationship regarding this classification. Vertical and distoangular teeth are more likely to have biofilm between the mucosa and the remaining pericoronal tissue since their crown is covered distally by both mucosa and the pericoronal tissues, which does not occur with mesioangulated and horizontal teeth, which may contribute the to the findings of these two studies. The difference between these two studies regarding the Winter and Pell & Gregory classifications may have occurred because not only those studies but all the literature present limitations regarding the classification of these teeth.

When evaluating the results obtained both for pericoronitis and for intra and postoperative complications in relation to teeth positions, it is important to be aware of these limitations. Most studies^{11, 25, 26, 29}, including the present study, determine the position of third molars according to Winter's classification as: horizontal, mesioangular, vertical and distoangular. Although this classification is universally standardized, angulations are a continuous variable and, in this classification, they are treated as categorical variables. Large variations, for example, between the inclinations of mesioangular teeth can be found but they are not registered by this classification. In order to minimize this measurement bias, we adopted the Winter classification as recommended by Quek et al in 2003¹³, who advocate that the measurement of the degrees of inclination of the tooth in relation to degree of the second molar should be performed in order to establish its proper position, but even so this evaluation was performed as a categorical variable.

In addition, the exclusion criteria adopted were: teeth associated with cysts or tumors, teeth in individuals using anti-resorptive medications and/or smokers/former smokers. These exclusion criteria were established with the intention of eliminating confusing factors from the sample. However, as this is a retrospective study, some potentially interfering factors such as alcoholism, diet, physical activity, educational level and access to basic health conditions, among others, could not be surveyed.

The selection of procedures performed by only one surgeon was also included in the methodology in order to reduce confusing factors. Besides excluding the variable of inexperience, it also allowed the filling in of medical records to be standardized, using the same terms and evaluation criteria.

Based on the results obtained in this study and considering the listed limitations, our findings indicate that: 1. there is a relationship and increased risk of intraoperative complications in patients over 26 years of age; 2. Teeth classified as class II and III, according to Pell and Gregory classification, have more risk of postoperative complications and 3. There is more risk of pericoronitis in lower third molars in patients over 26 with teeth defined as A and class II in the Pell & Gregory classification and with distal angulation in the Winter classification.

These findings may help surgeons to determine better treatments for third molars that fit the characteristics described above. Prospective studies with more robust designs should be carried out to support these findings.

ACKNOWLEDGEMENT

Ethics committee approval was obtained (registration number 3.280.952)

All authors involved in this study have read it and are in agreement with its submission.

FUNDING

None

COMPETING INTERESTS

All authors declare that there is no conflict of interest, and this research is self-funded.

DATA AVAILABILITY STATEMENTS

The data that support the findings of this study are available with Dr. Rafael Vago Cypriano but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Dr. Rafael Vago Cyperiano.

FUNDING

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

COMPETING INTERESTS

All authors declare that there is no conflict of interest, and this research is self-funded.

Author Contributions

AUTHORS	Conception and design of study	Acquisition of data: laboratory or clinical	Analysis of data	Drafting of article and/or critical revision	Final approval of manuscript
Rafael Vago Cypriano	X	X	X	X	X
Renata Pittella Cançado	X		X	X	X
Caroline Arantes Simmer Carlette		X	X	X	X

Ethics approval

Ethics committee approval was obtained (registration number 3.280.952) All authors involved in this study have read it and are in agreement with its submission and informed consent was obtained from all individual participants included in the study.”

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No competing interests reported.

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Prevalence of Complications and Pericoronitis in Third Molar Surgery: a Cross-sectional Study Using a Brazilian Population Sample of 3455 Teeth. Part 1: the Mandible

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Abstract

Introduction

Materials And Methods

Results

3.1. Pericoronitis

3.2. Intraoperative complications

3.3. Postoperative complications

3.3. Intra and postoperative complications

Discussion

Declarations

References

Competing Interests

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