however, there are no data to support continued antibiotic administration beyond the first 24 hours after surgery [12–14]. In relation to third molar surgery, 50% of infections are localized subperiosteal abscess‐type infections occurring approximately two to four weeks after surgery [10]. This type of infection is attributed to debris left under the surgically created mucoperiosteal flap and would likely not be prevented with the use of antibiotic prophylaxis. The remainder of third molar SSIs are rarely severe enough to necessitate further surgery or antibiotics. SSI occurring within the first postoperative week occurs only 0.5–1% of the time [10, 11, 15].
The risk of developing an SSI associated with the removal of third molars increases with an increased degree of impaction, need for bone removal or sectioning of the tooth, the presence of gingivitis, periodontal disease, and/or pericoronitis, surgeon experience, increasing age, and antibiotic use. The benefit of systemic antibiotic administration on incidence of SSI in relation to third molar extractions is questionable and is not currently recommended as the incidence of adverse reactions from antibiotic administration is higher than the incidence of SSI, 11% and 0.8–4.2%, respectively [10, 11, 15]. It is also unlikely that perioperative systemic antibiotics are of any benefit in delayed, subperiosteal type, infections due to the nature of these infections as described previously [10].
Signs of SSI can vary from localized swelling and erythema to fluctuance and trismus or systemic manifestations with fevers, dehydration, etc. [10]. The treatment of SSI due to third molar surgery involves surgical incision and drainage in addition to the administration of systemic antibiotics. Penicillin is often used as the vast majority of infections are caused by a mixed flora of microorganisms, with anaerobic and Gram‐positive streptococci being the most common. Amoxicillin has a slightly wider spectrum of activity and metronidazole can be added to cover anaerobic organisms. For the penicillin allergic patients, clindamycin is a good choice of antibiotic and can also be used when aerobic and anaerobic coverage is desired. Most often, patients will present with a vestibular, body of the mandible, or localized subperiosteal abscess. A rare occurrence is the spread of infection along fascial tissue planes and involvement of multiple potential spaces. This situation requires surgical drainage, intravenous (IV) antibiotics, and close follow‐up as progression to parapharyngeal, submandibular, and retropharyngeal spaces can lead to airway embarrassment and even mediastinal abscess formation with potentially fatal result [10, 15] (Algorithm 2.2).
Algorithm 2.2: Surgical Site Infection
Bleeding/Hemorrhage
Etiology: vessel injury, undiagnosed vascular malformation, patient risk factors
Management: pressure and packing, vessel ligation, electrocautery, bone wax, topical hemostatic agents, interventional radiology
The incidence of clinically significant bleeding as a result of third molar surgery ranges from 0.2% to 5.8% [4–6]. According to the AAOMS Age‐Related Third Molar Study, approximately 0.7% occur intraoperatively and 0.1% occur postoperatively [1]. Significant bleeding or hemorrhage is most often associated with mandibular third molar surgery (80%) when compared with maxillary third molar surgery (20%) [16]. Specific risk factors include advanced age, distoangular impactions, and deep impactions [6]. Massive intraoperative bleeding is a rare occurrence and is often attributed to the presence of an undiagnosed arteriovenous malformation (AVM) [16]. As such, examination of the surgical site for gingival discoloration, palpable thrill, or bruit is necessary. Imaging may demonstrate a multilocular radiolucency in the area of AVM. In these patients, angiography is essential to confirm diagnosis and treatment with embolization before the extraction is preferred.
The most common inherited bleeding disorder, von Willebrand disease, affects an estimated 1% of individuals. Hemophilia A or B is present in 1 in 5000 live births. Depending upon patient age and sex, the first surgical procedure a patient undergoes may be third molar extraction, and patients with mild to moderate forms of certain coagulopathies may have gone undiagnosed previously. Patients with acquired or congenital coagulopathy will require further workup prior to surgery. Depending upon the specific condition, recent laboratory values, coagulation factor replacement, hematology consultation, or inpatient surgery and hematological management schemes may be necessary.
Antithrombotic treatment with medications such as warfarin (Coumadin), clopidogrel (Plavix), and aspirin is commonly encountered among patients requiring extractions. Coumadin and Plavix rank among the top 100 prescribed medications in the United States, with an estimated 25% of individuals over age 75 currently on Coumadin, and according to the US Food and Drug Administration, over 100 billion aspirin pills are consumed each year. Most current literature does not recommend withholding these medications for uncomplicated tooth extraction. The risk of a thrombotic event outweighs any benefit of withholding the medication. In patients taking Coumadin, a preoperative INR (international normalized ratio) may be of value in assessing the current status of bleeding risk. According to Potoski, an INR value of 4.0 is acceptable for minor surgical procedures, an INR of 3.0 is preferred if the patient is also taking Plavix, aspirin, or another antiplatelet medication, and an INR of 2.5 is preferred for more involved or complex surgery where significant bleeding is anticipated [16].
Algorithm 2.3: Hemorrhage
The management of bleeding or hemorrhage begins with local measures including pressure with gauze and socket packing (gelfoam, or collagen). Intraoperative bleeding from the surrounding soft tissues can usually be controlled with electrocautery with care taken to avoid any nearby neurovascular structures. Bone bleeding, or bleeding from extraction sockets, can be controlled through a variety of measures. Intra‐alveolar hemostatic agents such as gelfoam, surgicel, microfibrillar collagen (Avitene), Collaplug, Collatape, thrombin, TISEEL fibrin sealant, or bone wax may be used alone, or in various combinations. Oversuturing and primary closure of the extraction site can also assist in hemostasis and serve to contain the various hemostatic agents. Oral rinsing with an antifibrinolytic agent such as Amicar (epsilon‐aminocaproic acid) or Cyclokapron (tranexamic acid) can prevent fibrinolysis and aid in maintenance of an organized blood clot [16].
In the case of prolonged postoperative bleeding, the patient should be instructed to remove loose clots gently and bite firmly and continuously on a moist gauze pack for 30 minutes. If this is unsuccessful, exploration and debridement of the wound should be completed under local anesthesia without vasoconstrictor to allow for a visual diagnosis of the cause of the bleeding. Granulation tissue should be debrided, irregular sharp bony edges removed, and hemostatic agents used within the alveolus to assist in bleeding control. As with intraoperative bleeding, oversuturing and primary would closure can assist in hemostasis and maintenance of the various hemostatic agents within the extraction socket (Algorithm 2.3).
Mandibular Fracture
Etiology: excessive and inappropriate force, patient risk factors
Management: soft non‐chew diet, closed treatment, open reduction, and internal fixation
Mandibular fracture following third molar surgery is a rare occurrence, and most often associated with deeply impacted third molars in patients over 40 years of age [17]. The reported incidence of mandibular fracture, both intraoperatively and in the postoperative period, ranges from 0.0049% to 0.00003%, with a mean time to fracture ranging from 6.6 to 14 days following