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ABSTRACT

After the various articles compiled by different

authors, is becomes clear that the third molars are

very often what contemplate various complications

at the time of the surgical procedure, due not only to

their eruption but also to their different characteristics

that occur such as anatomy, shape, position of its

eruption, etc. For this reason, the comprehensive

complementary study before proceeding to the

surgical act is the ﬁrst option that is made. For a

correct post-surgical treatment to be effective both

antibiotic-pharmacological, integral biomaterials, etc.

Purpose:

To establish through a review of the literature

which are the actions or surgical procedures being

performed that can avoid the most prevalent

complications in the extraction of included, retained

and impacted mandibular third molars.

Materials and methods:

A descriptive and analytical study is proposed,

respectively, with 2 types of electronic databases:

PubMed and SciELO, taking as support articles that

include meta-analyses, systematic reviews, literary

reviews, etc.

Results:

It was conﬁrmed that the best procedure for perhaps

a possible one: hemorrhage, fractures, lacerations,

etc. It is good pharmacological surgical management

during and after surgery.

Complications in the extraction of impacted, and

retained third molars. Literature Review.

Complicaciones en la extracción de terceros molares

mandibulares incluídos, retenidos e impactados.

Revisión de la literatura

English version

Mena-Alencastro, S.A., Rockenbach-Binz, M.C. - Complications in the extraction of impacted, and retained third

molars. Literature Review. Odontología Vital No. 38, Vol 1, 26-33 2023, ISSN:2215-5740

versión traducida al inglés. Originalenespañol.

Revista Odontología Vital

https://revistas.ulatina.ac.cr/index.php/

odontologiavital

ISSN: 2215-5740

Recibido: Mayo 2022

Aceptado: Julio 2022

Publicado: Enero 2023

Steven Alfredo Mena Alencastro1, Maria

Cristina Rockenbach Binz Ordóñez2

1Estudiante de Odontología,

Universidad Hemisferios, Quito-

Ecuador stevm1997@gmail.com

ORCID: https://orcid.org/0000-0003-

3549-9051

2Docente de la Universidad

Hemisferios, Especialista en Cirugía

Buco– Maxilo Facial PhD en Patología

Bucal, Quito- Ecuador cristinar@

uhemisferios.edu.ec

ORCID: https://orcid.org/0000-0001-

7945-2680

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Conclusion:

With this review of the literature, the

idea is reached that a correct diagnosis,

strict pharmacological management

and knowledge of the complications

that can arise during and after dental

extractions are correct actions that

are very commonly used during the

surgical procedure. , which avoids their

respective difﬁculties.

Keywords:

impacted tooth, unerupted tooth, third

molar

INTRODUCTION

The third molars often manifest a

number of variations in their coronal

and root morphology, this includes de

possibility to be tri or tetra radicular at

root level.

Frecuently they are smaller in size

compared to other teeth such as second

molars.(Palareti et al., 2016) They are the

last teeth to erupt between 18 and 30

years of age, and are capable of causing

dental or local anomalies at any period

of their dental formation or eruption

process.

However, it should be noted that

according to the Pell and Gregory

classiﬁcation, it is useful to determine

the degree of impaction, depth in

relation to the occlusal plane of the

lower second molar and the mesiodistal

diameter in relation to the distance

between the lower second molar and

the anterior part of the mandibular

branch identifying the degree of

complication at the time of surgery.

(Poblete et al., 2020)

As described in the literature, some of

the main characteristics that increase

the difﬁculty of surgery are the roots

due to the chance of being fused, thin,

without a conventional anatomical

shape, making extraction more

complex.(Loureiro et al., 2020)

At the level of the coronal diameter it

seems to be similar to that of the lower

ﬁrst and second molars.

A key problem is that 60% do not

occlude due to the loss of anatomical

space, which induces to the adoption

of inadequate positions, compromising

the rest of the dental organs.(Moreno et

al., 2019)

Different studies reveal that retained

tooth are frequently associated with

embryological conditions, since these

teeth are formed from the epithelial

cord going through a process of

calciﬁcation and root formation.

In addition, this tooth must follow a

known eruption path as a Capdepont

curve so that it can erupt, but it

is necessary to execute a concave

straightening curve backwards and up.

Therefore most of these dental organs

are not positioned in the correct

way.(Rivera-Herrera et al., 2020)

Epidemiologically, retentions affect

women more than men, 58.8% on the

other hand, 9.70% impactions and

24.90% included.

The literature is consistent and ﬁnds

similarities both in Mexico, Brazil,

Colombia and Ecuador. It should be

noted that in terms of people with

African ancestry this condition has

being reported in 2.2% of the population

possibly in association with the size of

the jaw. Nonetheless, the cause has yet

to be conﬁrmed.(Toledano-Serrabona et

al., 2021)

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The treatment for any retained

tooth is the multidisciplinary one,

establishing cost beneﬁt and the

difﬁculties that may occur before the

extraction. (Cervino et al., 2019) A correct

preoperative diagnosis considering

radiological examinations, together with

a clinical examination, complementary

examinations and antibiotic prophylaxis

also greatly reduces the risk of

complications. Once the diagnostic

process has been carried out, the

surgical and pharmacological protocol

will be the next action.(Staderini et al.,

2019)

The most common complications in

retained, included and impacted third

molars can be classiﬁed as direct and

indirect, that is, during and after

surgery:

Direct: In a retained third molar

(upper or lower) the most common

complications vary from oroantral

communication, mandibular scale

fractures, and alveolar lesions to the

inferior dental nerve and bleeding. In

the case of an impacted molar it may

implicate erroneous displacement

of the instruments to anatomical

spaces of great importance. In an

included third molar the issues may

be pericoronitis, the most frequent in

severe cases, abscesses, tumors, cysts.

(Gutiérrez Valdez & Pérez, 2016)Indirect:

generally emphysema, inﬂammatory

processes, hemorrhages, paresthesias,

hyperesthesia, edema and others.

Thus, a review and analysis will be

carried out regarding the essential

maneuvers to avoid complications of

the third molars during their removal,

based on the PubMed, SciElo databases

with selected articles between the years

2016 to 2021.

Objective:

To establish, through a literature review,

which are the actions to be executed

during surgical procedures that can

avoid the most prevalent complications

in the extraction of included, retained

and impacted mandibular third molars.

Conﬂict of intrerest.

The authors declare that they have no

conﬂict of interest, the literature review

described is original and has not been

previously published, nor has ﬁnancial

support been received prior to its

preparation.

Funding Source:

Self ﬁnanced.

MATERIALS AND METHODS

A descriptive study of the literature

is presented, describing the analysis

through 2 types of electronic databases:

Pubmed, SciELO, based on meta-

analysis articles, review articles, brief

reports, systematic reviews, etc.

Corresponding to the years 2016 to 2021

using the “PICO” strategy as support

using search terms such as: Tooth,

Impacted,Tooth, Unerupted, Molar,

Third,Hemorrhage, Surgicaland their

counterparts in Spanish respectively.

Articles were selected considering

concordance between the title and

objective in this way, examining

whether they include meta-analyses,

systematic reviews, literary articles, brief

reports, etc.

Filtering exact years respectively

corresponding to the complications of

the third molars, resulting in the search

of 137.

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On the other hand, a total of 107 articles

were excluded, being duplicate articles,

comparative studies, clinical cases,

etc. It results in a total of 30 articles for

this literary review. All this information

collected was reviewed in its entirety

and exposed.

Identiﬁcados

Total (n=137)

ElegiblesExcluidosInclusión

Artículos identiﬁcados

en base electrónica

PubMed

(n=123)

Artículos elegibles para

revisión de la literatura:

(n=82)

Total, artículos (n=55)

excluidos ya que no

cumplen criterios de

exclusión

Total Artículos incluídos

en la revisión (n=30)

1. Eliminados (n=8)

2. Duplicados (n=8)

3. Artículos de casos

clínicos (n=9)

Artículos no accesibles

en PD (n=27) Total: (n=55)

Total: (n=25)

Artículos en total

identiﬁcados en base

electrónica SciELO

(n=14)

Fig.1 Flowchart for selecting articles from the literature review.

Table 1: Articles included

Year, appointment or appointments

Methodology

Results

(Borges et al., 2017)

(Calzavara & Lhano, 2019)

(Cammarata-Scalisi et al., 2018)

(Cervino et al., 2019)

(Chugh et al., 2020)

(Falci et al., 2017)

(Freitas, 2018)

(Glera-Suárez et al., 2020)

(Jaroń et al., 2020)

(Kim et al., 2018)

(Konkel et al., 2019)

(Loureiro et al., 2020)

(Mahardawi et al., 2020)

(Marinkovic et al., 2020)

literary article

meta analysis

literary article

Systematic review

systematic article

meta analysis

Systematic review

literary article

soft tissue injuries

Radiographic study prior to surgery

Complications of lower third molars before supernumerary teeth.

Pharmacotherapy after extraction. Post extraction antibiotic

therapy. Anxiety in the surgical act

Effect of dexamethasone at the time of third molar surgery. Ideal

option of kinesiology bandage to avoid post-extraction pain.

Correct maneuvers prior to dental extraction

literary review

systematic article

Systematic review

meta analysis

Periodontal disease risk factor as a complication of mandibular

third molars

Form of eruption of impacted third molars

(Moreira Zevallos & Barona Terán,

2021)

(Moreno et al., 2019)

(Di Nardo et al., 2019)

(Oda et al., 2021)

(Pacheco-vergara & Cartes-

velásquez, 2016)

(Palareti et al., 2016)

(Poblete et al., 2020)

(Rivera-Herrera et al., 2020)

(Saber et al., 2018)

(Shuborna et al., 2019)

(Staderini et al., 2019) (Teshome,

2017)z(Xiang et al., 2019) (Yu et al.,

2017)

literary article

literary review

Review article

literary review

analytical study

Research work

literary review

Systematic review

meta analysis

literary review

meta analysis

Postoperative antibiotic therapy. Mandibular third molar

characteristics. Agenesis predisposing factor of a third molar

when erupting. third molar displacement

Third molar physiology at mandibular scale

Complications and generalities in oral surgery

Cardiovascular disease factor as a complication

Higher incidence of post oral surgery complication

Classification of third molars

Consequences of bad practice during surgery

Post extraction hyaluronic acid therapy

Surgical management of mandibular third molars

Post-extraction therapy with chlorhexidine gel to prevent alveolar

osteitis

Treatment for mandibular fracture complication

Platelet-rich fiber therapy (healing)

Anesthetic methods for mandibular third molars

identiﬁed

Overall (n=137)

eligibleexcludedInclusion

Articles identiﬁed in the

PubMed electronic

database

(n=123)

Articles eligible for

literature review: (n=82)

Total, articles (n=55)

excluded as they do not

meet the exclusion

criteria

Total Articles included in

the review (n=30)

1. Eliminated (n=8)

2. Duplicates (n=8)

3. Clinical case articles

(n=9)

Articles not accessible in

PD (n=27) Overall: (n=55)

Overall: (n=25)

Total articles identiﬁed

in SciELO electronic

database (n=14)

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Year, appointment or appointments

Methodology

Results

(Borges et al., 2017)

(Calzavara & Lhano, 2019)

(Cammarata-Scalisi et al., 2018)

(Cervino et al., 2019)

(Chugh et al., 2020)

(Falci et al., 2017)

(Freitas, 2018)

(Glera-Suárez et al., 2020)

(Jaroń et al., 2020)

(Kim et al., 2018)

(Konkel et al., 2019)

(Loureiro et al., 2020)

(Mahardawi et al., 2020)

(Marinkovic et al., 2020)

literary article

meta analysis

literary article

Systematic review

systematic article

meta analysis

Systematic review

literary article

soft tissue injuries

Radiographic study prior to surgery

Complications of lower third molars before supernumerary teeth.

Pharmacotherapy after extraction. Post extraction antibiotic

therapy. Anxiety in the surgical act

Effect of dexamethasone at the time of third molar surgery. Ideal

option of kinesiology bandage to avoid post-extraction pain.

Correct maneuvers prior to dental extraction

literary review

systematic article

Systematic review

meta analysis

Periodontal disease risk factor as a complication of mandibular

third molars

Form of eruption of impacted third molars

(Moreira Zevallos & Barona Terán,

2021)

(Moreno et al., 2019)

(Di Nardo et al., 2019)

(Oda et al., 2021)

(Pacheco-vergara & Cartes-

velásquez, 2016)

(Palareti et al., 2016)

(Poblete et al., 2020)

(Rivera-Herrera et al., 2020)

(Saber et al., 2018)

(Shuborna et al., 2019)

(Staderini et al., 2019) (Teshome,

2017)z(Xiang et al., 2019) (Yu et al.,

2017)

literary article

literary review

Review article

literary review

analytical study

Research work

literary review

Systematic review

meta analysis

literary review

meta analysis

Postoperative antibiotic therapy. Mandibular third molar

characteristics. Agenesis predisposing factor of a third molar

when erupting. third molar displacement

Third molar physiology at mandibular scale

Complications and generalities in oral surgery

Cardiovascular disease factor as a complication

Higher incidence of post oral surgery complication

Classification of third molars

Consequences of bad practice during surgery

Post extraction hyaluronic acid therapy

Surgical management of mandibular third molars

Post-extraction therapy with chlorhexidine gel to prevent alveolar

osteitis

Treatment for mandibular fracture complication

Platelet-rich fiber therapy (healing)

Anesthetic methods for mandibular third molars

Year, appointment or appointments

Methodology

Results

(Borges et al., 2017)

(Calzavara & Lhano, 2019)

(Cammarata-Scalisi et al., 2018)

(Cervino et al., 2019)

(Chugh et al., 2020)

(Falci et al., 2017)

(Freitas, 2018)

(Glera-Suárez et al., 2020)

(Jaroń et al., 2020)

(Kim et al., 2018)

(Konkel et al., 2019)

(Loureiro et al., 2020)

(Mahardawi et al., 2020)

(Marinkovic et al., 2020)

literary article

meta analysis

literary article

Systematic review

systematic article

meta analysis

Systematic review

literary article

soft tissue injuries

Radiographic study prior to surgery

Complications of lower third molars before supernumerary teeth.

Pharmacotherapy after extraction. Post extraction antibiotic

therapy. Anxiety in the surgical act

Effect of dexamethasone at the time of third molar surgery. Ideal

option of kinesiology bandage to avoid post-extraction pain.

Correct maneuvers prior to dental extraction

literary review

systematic article

Systematic review

meta analysis

Periodontal disease risk factor as a complication of mandibular

third molars

Form of eruption of impacted third molars

(Moreira Zevallos & Barona Terán,

2021)

(Moreno et al., 2019)

(Di Nardo et al., 2019)

(Oda et al., 2021)

(Pacheco-vergara & Cartes-

velásquez, 2016)

(Palareti et al., 2016)

(Poblete et al., 2020)

(Rivera-Herrera et al., 2020)

(Saber et al., 2018)

(Shuborna et al., 2019)

(Staderini et al., 2019) (Teshome,

2017)z(Xiang et al., 2019) (Yu et al.,

2017)

literary article

literary review

Review article

literary review

analytical study

Research work

literary review

Systematic review

meta analysis

literary review

meta analysis

Postoperative antibiotic therapy. Mandibular third molar

characteristics. Agenesis predisposing factor of a third molar

when erupting. third molar displacement

Third molar physiology at mandibular scale

Complications and generalities in oral surgery

Cardiovascular disease factor as a complication

Higher incidence of post oral surgery complication

Classification of third molars

Consequences of bad practice during surgery

Post extraction hyaluronic acid therapy

Surgical management of mandibular third molars

Post-extraction therapy with chlorhexidine gel to prevent alveolar

osteitis

Treatment for mandibular fracture complication

Platelet-rich fiber therapy (healing)

Anesthetic methods for mandibular third molars

RESULTS

The complications that occur during

the extraction of third molars are very

frequent and to prevent them from

occurring it is essential to consider

various factors such as: genetics,

environment, development or any

pathology in order to be able to carry

out the respective surgery.(Borges et

al., 2017)Difﬁculties not only occur in

lower teeth but also in upper teeth due

to important anatomical repairs such

as the ﬂoor of the maxillary sinus or

pterygomaxillary or cortical bone fossa.

(Poblete et al., 2020)

Subsequent complications of extraction

result in alveolitis, bleeding or injury

to the alveolar nerve, neurosensory

damage.(Calzavara & Lhano, 2019)The

absence of precaution or the incorrect

surgical technique will increase

soft tissue inﬂammation, risks of

emphysema(Nardo et al., 2019)and other

direct and indirect local complications,

considering that these may manifest

themselves after 24 hours of the

execution of the procedure.(Mahardawi

et al., 2020).

Complications

are unpredictable(Cammarata-Scalisi et

al., 2018)and they occur mainly due to

the difﬁculty of the extraction.(Oda et

al., 2021)

The affectation of neighboring teeth

is very common(Marinkovic et al.,

2020),(Pacheco-vergara & Cartes-

velásquez, 2016) with the second molars

being the most affected.(Saber et al.,

2018)Y(Yu et al., 2017)

DISCUSSION

After a complete literary compilation,

the most frequent complications for

retained, included and impacted third

molars are: involvement of soft bone

tissues, mandibular fractures, and

rupture. They is also an agreement in

the fact that non-cooperative patients

experience the largest number of

Table 1: Articles included

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complications due to the lack of

selfcare.(Kim et al., 2018) (Jaroń et al.,

2020)

Xiang et al., (2019) agreed with the rest

of the reviewed literature in the fact

that these complications are common.

Also, they recommend that in cases

of laceration to soft tissue, the use of

platelet-rich ﬁbrin is optimal, since it

heals and favors epithelial regeneration.

Kim et al. (2018) disagree, since they

considere that there is not enough

scientiﬁc evidence to support this

protocol. Shuborna et al. (2019)

propose the use of hyaluronic acid in

the event of bleeding and Teshome

(2017) also considers that the use of

these biomaterials in addition to 50ml

chlorhexidine gel is a preventive or

solution to possible alveolar osteitis in

the area of the extracted tooth, thus

promoting healing.

Other published articles such as that

of Chugh et al. (2020)agree that the

correct use and pharmacological-

antibiotic administration after

third molar extraction are essential

to avoid any infection or adverse

reaction(Tg, 2020) Y (Konkel et al., 2019)

emphasized that the correct diagnosis

with its respective radiographic

and complementary examinations

are essential for correct surgical

management.

The research carried out presented

limitations related to the fact that

most of the articles were clinical

cases, repeated articles and in-vitro

studies with respect to third molars,

comparative studies.

CONCLUSION

The different methods that may be

carried out for the clinical management

of included, retained and impacted

third molars must be deeply studied in

order to reduce the risk of complications

such as bleeding, hemorrhage, edema,

fractures and lacerations.

We found that, as an innovative and

interesting measure, the Kinesiotape

bandage may provide important

beneﬁts. For example it has shown

to relieve pain, control post-surgical

inﬂammation, the mobility of response

after an injury, improving the neuro-

mechanical response, reducing

bruising, accelerating drainage in

the affected area, as well as blood

circulation and ﬂuid removal. Muscle

stimulation with the ability to relieve

pain before contractions and ﬁnally

postural problems.

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