Effect of Age on Immediate Postoperative Tissue Reaction Following Surgical Extraction of Impacted Mandibular Third Molar

Background: Postoperative morbidity following third molar surgery is affected by a number of factors.The aim of this study was to determine the effect of age on immediate postoperative tissue reactions following mandibular impacted third molar surgery. Objectives: To assess the discomforts after impacted mandibular third molar extraction in different aged patient. Methods : 100 patients, 54 Female and46 Male,aged lSto 42 years comprised the study materials. Tooth extraction was performed with buccal guttering technique after adequate elevation and reflection of fulI thickness mucoperiosteal flap. Pain, swelling and trismus were evaluated preoperatively and on 2nd POD and 7th POD. Data was processed and analyzed using SPSS and was compiled and test of significance was done using Chi square (x2) test and unpaired't' test. Results: Statistical analysis of the data indicated that pain and swelling was significantly less and significant maximum mouth opening was achieved in early aged patient than late age when preoperative and postoperative results were compared. Conclusion: As postoperative immediate tissue reactions are more in late aged patient than younger so impacted mandibular third molar should exhact in early age.


Introduction :
The third molar considered impacted when it is not fully erupted to the assumed normal functional position in the occlusal plane.Although a tooth may occasionally remain unerupted because of factors other than impactionl.The angulation of impaction of mandibular third molar was determined by the angle formed between the intersected longitudinal axes of the second and third molars.Vertical impaction:lO0 to-100, Mesioangular impaction :110 to 79A, Horizontal impaction: 800 to 1000, Distoangular impaction:-110 to-790 and others:1110 to-80012.
Relative depth of the third molar in bone was considered in relation to bone and the cervical line of second molar teeth.Position A: The highest portion of the tooth on a Address for Correspondence: Chandan Kumer Paul, Indoor Medical Officer, Oral & Maxillofacial Surgery Department, Dhaka Dental College Hospita .IBSMMU J 2014 ; 7 (2) : ]20-1281 level with or above the occlusal line, Position B: The highest portion of the tooth below the occlusal line, but above the cervical line of the second molar, Position C: The highest portion of the tooth on the level with or below the cervical line of the second mola/.
The surgical removal of impacted mandibular third molar is the most frequent procedures in oral and maxillofacial surgery and can cause some postoperative pain, swelling, and trismus3.Moreover removal of impacted mandibular third molar is so common that the population morbidity of minor complications may be signific anta.Age of the patients , type of impaction and duration of operation have been mentioned in scientific literatures as factors that influence the immedrate postoperative reactions following third molar surgery but objective assessment are lacking.It was observe that the controversy sulrounding third molars has focused on the pathologic problems they may cause and the risk / benefits of their removals.This study aims to determine the effect of age on pain, swell- ing, and rismus following mandibular third molar surger- ies.
The patient's age when the mandibular molar is removed has been reported to be of importance, and many studies have related postoperative complications to older age.The patient's age was found to be a risk indicator for an extended operation time .The older age groups had more than two times higher risk of an extended operation time compffied with youngest age group.Older age was found to increase the risk of an extended operation time6.It was observed for every minute increase in operating time there was a 9Vo increase in chance of experiencing pain (vAS>1)?.
Patient's age was found to be a risk factor only for severe trismus; that is, patient's age<22.0years were found to have a lower risk than older patients.Older patients are at greater risk of severe trismus after third molar surgery4.The suffounding bone in young patients is relatively soft and more resilient compare to older patient.
As a result the patient's above 35 years were recorded more swelling and trismust.Ag" is commonly cited as a risk factor for post extraction complications and age was found to be significantly associated with complications.In addition to change in bone density, increased age is associated with complete root formation and diminished wound healing capacrties, which can result in higher operative and inflammatory complicationse.Sub3ects over age 25 would be statistically significantly more likely to experience complications after third molar surgery compared with those under age 2510.Female and adult patients (age>25 years) should be informed before third molar surgery about the likelihood of requiring more time for improvements in oral function, lifestyle, and pain recovery compared with male and younger patients (age<21 years) following third molar surgery.It was observe that with increasing age and BMI the total time for extraction increasedll.The amount of facral swelling varied depending on age and sext'.
There are significantly more females (567o) than males (44%o) with at least one impacted third molar.The propor- tion of impacted mandibular third molars was signifi- cantly more than that of impacted maxillary third molar.
Impacted third molars were 3.2 trmes more likely to occur in the mandible than in the maxilla.Mesioangularimpaction (607o) and level B impaction (80Vo) was the most cofilmon13.
The most frequent immediate and late complications were patfi, swelling, and trismus'3.The longer the duration of tissue injury, the more the amount of mediators released and therefore could be a reflection of the severity of pain, swelling and trismus.The type of impaction gives a prediction of the difficulty of extraction and hence the severity of postoperative tissue reactions.Duration of surgery is an operative factor that has been found to influence the immedtate postoperative factors following impacted third molar surgeryt.Older patients had more trismus and dry socket.Longer duration of surgical extraction was associated with more swellingl3.Patient should expect to find it difficult to open their mouth fully and eat comfortably even after one week.Some will experience a change in their ability to talk even at day 7r4.
In this study, we assess the immediate postoperative tissue reactions after surgical extraction of impacted mandibular third molar in different aged patient.

Methods:
The present prospective study was carried out in the Department of Oral & Maxillofacial Surgaty, BSMMU, Dhaka from January 2010 to December 2011.A11 the patients, undergone to surgical extraction due to impacted mesioangular third molar, who fulfilled the basic requirements of inclusion and exclusion criteria.The Surgical Procedure each and every tooth extraction was done under loco-regional anesthesia in the same operating room with the same type of instruments under similar conditions.Sterile physiologic saline solution was used for irrigation and 3-0 silk suture was used to close the wound.All the parts of tooth were loosened with a dental elevator and were removed.Sutures were removed on 7th post operatine deriod.Post operative instructions were given to each patients following extraction.Patients were asked to do the regular follow up on 2nd POD and 7th POD for evaluation of pain, swelling and maximum mouth opening.In addition to postoperative instructions and prescriptions for analgesics, patients received a stand- ard visual analog scale (VAS) form to complete.The scale used in this study was a 10-cm scale with no pain indicated on the left hand side and worst pain imaginable indicated on the right hand side.Patients were asked to mark along the scale where they felt their pain experience best coffespondedls.Three measurements were made between five reference points: tragus, soft tissue pogonion, lateral corner of the t22 eye, angle of the mandible, and outer corner of the mouth, preoperatively, and on the second and seventh postop era- tive days.The preoperative sum of the 3 measurements was considered as the baseline for that side.The differ- ence between each postoperative measurement and the baseline indicated the facial swelling for that duy'u.Line A: The distance between lateral corner of the eye and angle of mandible, Line B: tragus and outer corner of the mouth, Line C: tragus and soft tissue pogonion (in chin) were measured preoperatively, 2nd POD and 7th POD.
The evaluations of facial swelling were carrted out on2nd POD and 7th POD.
Fig- 2: Tape measuring method fo, evaluation of facial swelling A: The distance between lateral corner of the eye and angle of mandible, B: tragus and outer corner of the mouth, C: tragus and soft tissue pogonion (in chin) were measured preoperatively, 2nd POD and TthPOD.The mouth opening was measured before the surgical procedure and on 2nd POD, 7th POD with a vernier caliper, measuring scale/ruler or measuring tape from the incisal edge of the upper and lower right central incisors at maxi- mum opening of the jaw.
The data were screened and checked for any missing values and discrepancy.Computer based statistical analy- sis was carried out with appropnate techniques and systems.Data were processed and analyzed using SPSS version 16.0 for windows.Both qualitative and quantita- tive tests were performed.For comparison between groups, Chi square (x2) test was performed for qualitative variables and student't' test was performed for quantitabetween 18-25 years, 38.OVo were in26-35 age group and tive variables.The level of significance was set at 0.05 only 7.OVo were within 36-42yearsof age.Regarding this and p < 0'05 considered significant' The summarized data age distribution a]l the respondents were divided between were interpreted accordingly and were then presented in three groups as Group I (1s-25 years), Group II (26-35 the.form of tables, graphs and bar diagrams. years) and group trI (36-42 years) and MMO, swelling Result i aad level of pain were compared between these three In this prospective study a total 100 subjects were groups' The mean age of all the respondents was 26'42 + interviewed.Among the responde nts 55.0%o were aged 5'503 years (Table 1) Preoperatively the mean difference for maximum mouth opening between Group I and Group II was 4.162 ffiffi, which was also statistically highly significant (P<0.01).
On 2nd POD mean difference was 0.008 nlm and during 7th POD a high significance level (P<0.01)represents 3.672 mm as a significant difference between groups.
Preoperatively and on 7th POD maximum mouth opening was more in Group II than in Group I. Between Group I and III preoperative difference were 2.878 which was also statistically significant (P<0.05),on2nd POD 0.745 mm and on 7th POD 2.g0g mm though any of these differences did not show any statistical significance.And between group II and III preoperative difference was 1.289 lnrrl, on 2nd POD 0.737 nlm and 7th POD 0.763 mm.So, there were significant (P>0.05)differences revealed between older age groups (  Effect ofaqe on immediate DostoDerative tissue reaction following surgical extraction ofimpacted mandibular third molar. Chmdan Kumer Paul et al Among all respondents, in average Group I subjects showed 84.677o of their total mouth opening in the Znd postoperative day, in comparison with 77 .647oby the Group II and 8l.I47o of Group III.And during 7th POD all the groups represented around 99.007o of their total mouth opening (Fig: 4).
Fig- 4: Comparison of mean percentage of mouth opening among three age groups in follow up visits The number of patients having their Teeth in Position A and B, in Group I were 66.77o and 46.67o respectively and in Group II were 28.67o, and 44.87o respectively.Only 4.87o of position A and 8.6Vo of position B belonged to Group III (Fig: 5).In averzge, Group I participants had 10.91 mm of swell- ing, in contrast with 23.71 mm and 25.7t fitm among older age groups.And during 7th POD mean swelling of group I was only 0.29 mm.So, younger patients repre- sented rapid elimination of swelling than the seniors (Fig: 6).among all three groups and mqan pain score of Group I was 3.527 with SD 1.015 and mean difference between Group I vs. II and Group I vs. III were highly significant (P<0.01).But Group II and III did not represent any significant (P>0.05)difference in mean pain score.And during 7th POD mean difference between Group I and II was only 0.685 but still very highly significant (P<0.01).
Group I and III showed mean l.478level of difference in pain score, Group II and III demonstrated0.T93 of highly significant (P<0.01)difference (Table 4).There was significant relationship in distribution of sex in impaction.It was observe that the distribution of impacted third molars by sex is shown in figure I; there were significantly more female s (567o) than males G|To)with  In our study 547o of respondents were female and 467o were male which was similar to that.
Surgical removal of third molars causes significant pain, swelling, and trismus even when teeth are removed using a gentle surgical techniqueli.
In our study total 100 patients with mesioangular impac- tion were investigated .A11 the patients were categorized into three age groups, Group I (IS-25 years), Group II (26-35 years) and Group III (36 -42 years).Ir was stated that, older age was found to increase the risk of an extended operation timea.The patient's age when the 126 mandibular molar is removed has been reported to be of LnJ'h POD) and Group II (6.710+0.731in2nd POD and 0.921L+0.149rn 7'h POD) .The longer the duration of tissue injury, the more the amount of mediators released and therefore could be a reflection of the severity of pain, swelling and trismus6.The patients in the age range of 35-42 years recorded a significantly lower pain score (p=0.5)compared with lower age groups on day 1 , but subsequently the pain recorded was significantly higher than that recorded for the lower age groups ( p=0.01,0.2 on day 3 and 4 respectively) which also coffesponds to our study.Age is commonly cited as a risk factor for post extraction complications and age was found to be significantly associated with complications.In addition to change in bone density, increased age is associated with complete root formation and diminished wound healing capacities, which can result in higher operative and inflammatory complications'.Sub3ects ovet age 25 would be statistically significantly more likely to experience complications after third molar surgery compared with those under age 258.Female and adult patients (age>25 years) should be informed before third molar surgery about the likelihood of requiring more time for improvements in oral function, lifestyle, and pain recovery compared with male and younger patients (age<21 years) following third molar surgery.
Each and every tooth extraction was done under loco- regional anaesthesia in the same operating room with the same type of instruments.All the patients were free of pain and other inflammatory conditions like swelling, hyperemia and trismus at the time of surgery.Immedi- ately before tooth extraction all patients were asked to rinse the mouth for 1 minute with a 0. l27o chlorhexidine mouthwash.The technique was standar dized for tooth extraction.Extraction was performed with buccal gutter- ing technique after adequate elevation and reflection of full thickness buccalmucoperiosteal flap.
The older patients suffer more this could be due to the delayed healing capacities associated with aging as well as the increased bone density that might make the sur gery more difficult.Longer duration of the surgical extraction was associated with more swellingt'.The Facial swelling is affected by individual characteristics such as age and sextO.Swelling was more common in patients over 40 years of age; pain did not vary with age.In our study in ayefage, Group I participants had 10.91 mm of swelling, in contrast with 23.71 mm and 25.71 mm among older age groups.And during 7th POD mean swelling of group I was only 0.29 mm.So, younger patients represented rapid elimination of swelling than the Group II and Group III which showed similarity.
Patient's age was found to be a risk factor only for severe trismus ; that is , patient's age<22.0years were found to have a lower risk than older patients'.Older patients are at greatu risk of severe trismus after third molar surgery.
The patients above 35 years recorded more swelling and trismus.That study recorded a significant influence of age on postoperative morbidity following surgical extraction of impacted third molar teeth.A higher degree of trismus and facial swelling was recorded in patients with advanc- ing age.In our study the mean difference for Maximum Mouth Opening between Group I and Group II on 2nd POD mean difference was 0.008 mm and during 7th POD a high significance level (P<0.01)represents 3.672 mm as a significant difference between groups.Preoperatively and on 7'h POD Maximum Mouth Opening was more in Group II than in Group I. Between Group I and III preop- erative difference were 2.8J8 which was also statistically significant (P<0.05), on 2nd POD 0.745 mm and on7'h POD 2.909 nlm though any of these differences did not show any statistical significance.And between group II and III preoperative difference was L289 rnm, on 2nd POD 0.737 mm and 7'h POD 0.763Inm.So, there were no significant (P>0.05)differences revealed between older age groups. (Table II.) The postoperative seventh day, all symptoms had restored to the preoperative level in both groups, which is almost parallel to our studyl8.Some authors believe that all impacted third molars should be removed even if no symptoms are observed , with the pu{pose being to minimize the risk of disease associated with these teethle.

Conclusion:
After assessment of results of the study the rate of postop- erative morbidity (pain, trismus and swelling) and the risks of permanent sequelae increase with age.Therefore, it is recommended that, once a decision has been made to extract an impacted third molar, the surgery should be carried out as soon as possible and well before the age of 25 years.The knowledge of the effect of age on postop- erative inflammatory reactions following third molar surgery is very important because it will assist in treatment planning.It could be used as an objective tool to educate patients on the need for early extraction of an impacted third molar to minlmuze postoperative morbid- ity.A11 18-20 years aged young should be screened radio logically and clinically to find out impacted tooth.Once a decision has been made to extract an impacted third molar, the surgery should be carried out as soon as possi- ble and well before the age of 25 years.
100 patients were included in this study (54 Female and 46 Male).All the patients were divided into three groups according to diagnosis and age.In group I Patients were selected between 18-25 years old, in group II 26-35 years old patients and group III 36-42 years old patients.The inclu- sion criteriaa) l8-42years old patient.b)Mesioangular impaction of mandibular third molars.c)Patientsshowing cooperation with the study and with postoperative follow-up.And the exclusion criteriaa) Age: Below 18 years and above 42 years. (Prophylactic removal of third molar in orthognathic and orthodontic case).b) Grossly carious tooth.c) Diabetic, Cancer, Bleeding disorder.d) Pregnancy.
Fig Lz Visual Analogue Scale consisting of 10cm horizon- tal line

Fig- 3 :
Fig-3: Pie diagram showing Sex distribution amongthe respondents 46.07o and 54.07o were male and female respectively.
Fig-S: Distribution of respondents according to teeth position among three age groups

Fig- 6 :
Fig-6: Comparison of swelling among three Sroups during 2nd and 7th POD Fig-7: Showing level of pain in average during the follow up visits
m Group Group 0.763 0.837 ns ns = Not Significant.Statistical analysis was done by Unpaired 't' test.Significant cutoff value <0.05 t24

Table - III
Presence of pain regarding age groups importance, and many studies have related postoperative complications to older age.The patient's age was found to be a risk indicator for an extended operation time.The older age groups had more than 2 times higher risk of an extended operation time compared with youngest age group.Older age was found to increase the risk of an extended operation time.It was observe that the every minute increase in operating time there was a97o increase in chance of experiencing pain (VAS>1)5.In our study group III experienced more pain in 2'dPOD(6.285+2.058)andrnJ'h POD(1.714+0.488)rhan Group I (3 .527+1.015 in 2'd POD and 0.236+0.507tn 7'h POD) and Group II