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 studies11, 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.