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American Journal of  
Life Science and Innovation (AJLSI)

Post-Operative Complications Following Third Molar Extraction in Qassim Region
Saudi Arabia: A Retrospective Study

Faris Almutairi1*, Faraj Alotaiby1, Abdullah Alrashid2, Nimran Almodhaibri2

Volume 3 Issue 1, Year 2024
ISSN: 2833-1397 (Online)

DOI: https://doi.org/10.54536/ajlsi.v3i1.2440
https://journals.e-palli.com/home/index.php/ajlsi

Article Information ABSTRACT

Received: January 30, 2024

Accepted: March 02, 2024

Published: March 06, 2024

Third molar surgery is one of  the most common dental procedures that can be done in 
the outpatient clinic. Extraction complications can be very mild, like discomfort or mild 
pain, or severe, like a mandibular fracture. The study aims to investigate postoperative 
complications after a third molar extraction in the oral surgery dental clinic at Qassim 
University. This retrospective study analyzed postoperative complication rates following 
third molar extractions performed at dental clinics in Qassim, Saudi Arabia, between August 
2022 and March 2023. Descriptive statistics characterized the sample, and comparative 
analysis evaluated relationships between complications and factors like gender, age, and 
surgical aspects. Ethical approval was granted, and sensitive patient information remained 
confidential. A total of  199 third morals were extracted from 70 patients with an average 
of  2.8 teeth per patient. More mandibular third molars were removed (55.8%) from the 
patients who participated compared to maxillary third molars extractions (44.2%). The 
results indicated that the rate of  postoperative complications ranged from 2.5% to 64.7%. 
The most frequent postoperative complications were pain (64.7%), followed by swelling 
or edema (55.5%), trismus (32.8%), and dry socket (9.2%). This study’s postoperative 
complication rate of  10.4% following third molar surgery was consistent with other reports. 
Younger patients and mandibular extractions presented higher complication risks. Regional 
outcome data can guide clinicians locally to optimize preoperative planning and techniques, 
reducing risks for those undergoing this standard dental procedure.

Keywords

Third Molar, Tooth Extraction, 
Surgical Procedures, Complications, 
Postoperative

INTRODUCTION
Impacted third molars, also known as wisdom teeth, are 
among the most prevalent dental abnormalities seen in 
oral surgery practices (Miloro et al., 2004). According to 
various research studies examining different populations, 
approximately 16.7-68.6% have at least one impacted 
third molar (Brown et al., 1982). The surgical removal of  
impacted or partially erupted third molars is among the 
most routinely performed outpatient dental procedures 
(Visintini et al., 2007; Woldenberg et al., 2007). While 
symptoms may vary depending on the individual, 
impacted third molars can lead to complications if  left 
untreated, prompting their surgical extraction. This 
operation is commonly conducted in outpatient clinical 
settings to manage problems from impacted wisdom 
teeth (Woldenberg et al., 2007).
While third molar removal is typically uncomplicated, 
potential issues can occasionally emerge during the 
procedure or in the postoperative recovery phase (Sayed 
et al., 2019). Adverse outcomes range from mild, transient 
discomfort or pain to severe risks, like mandible fracture 
(Chen et al., 2021; Sayed et al., 2019). The reported 
complication incidence varies widely from 4% up to 
30% or more of  cases (Bui et al., 2003), depending on 
surgery complexity, patient characteristics, and anatomic 
relationships of  the impacted tooth (Askar et al., 2019). 
Pain and swelling are among the most prevalent issues 
after third molar surgery (Bui et al., 2003), while mandible 

fracture is exceedingly rare (Jerjes, Swinson, et al., 2006). 
References indicate that many wisdom tooth operations 
proceed smoothly when handled professionally with care 
for individual variability. However, careful follow-up is 
prudent given the possibility of  complications, though 
their severity and likelihood depend on various surgical 
and non-surgical influences (Bouloux et al., 2007).
Patient age is one of  the most significant factors associated 
with increased postoperative complications following 
third molar extraction (Osunde & Saheeb, 2015). In 
general, older patients have higher rates of  complications 
compared to very young patients, who have much lower 
incidence (Osunde & Saheeb, 2015). Smoking and other 
tobacco
Products also increase risk, primarily for developing local 
infections and dry sockets (Rakhshan, 2018). High-level 
evidence is still required, but some research suggests that 
the frequency of  complications may be slightly higher in 
females than in males, possibly due to hormonal factors 
involving oral birth control (Benediktsdóttir et al., 2004). It 
has been demonstrated that careful pre-surgical planning, 
which includes the best surgical concepts and techniques, 
is essential for lowering the likelihood of  unfavorable 
outcomes (Benediktsdóttir et al., 2004; Jerjes, El-Maaytah 
et al., 2006; Yuasa & Sugiura, 2004). The body of  research 
emphasizes how crucial it is to consider patient variability 
and use clinical and technical best practices to reduce 
complications (Bouloux et al., 2007).

1 Department of  Maxillofacial Surgery and Diagnostic Sciences, College of  Dentistry, Qassim University, Buraidah, Qassim, Saudi Arabia
2 College of  Dentistry, Qassim University Buraidah, Qassim, Saudi Arabia
* Corresponding author’s e-mail: FarisAlmutairi558@outlook.com



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Surgical removal of  impacted third molars is a standard 
outpatient procedure but can result in post-operative 
complications. Local data on complication rates and 
trends after these extractions in Qassin, Saudi Arabia, 
must be included. Understanding regional outcomes 
may help optimize preoperative planning and surgery to 
reduce risks. The study evaluates complications following 
third molar complications at Qassim  University clinics to 
provide insights for improving local postoperative care 
and guidance for those undergoing this frequent dental 
operation in the region.

MATERIALS AND METHODS
Study Design
This retrospective study analyzed complications after 
wisdom tooth removal by reviewing past patient records 
from Qassim, Saudi Arabia. The retrospective format 
provided an effective way to collect long-term data from 
many patients. However, complications were limited 
to those explicitly documented rather than directly 
observed. The records of  patients who underwent third 
molar extraction between August 2022 and March 2023 
were reviewed.

Ethical Approval
Ethical approval was obtained from the local research 
ethics committee registration. No. H-04-Q-001, Qassim 
Province. All patient demographics, history, and diagnosis 
information was kept strictly confidential.
 
Eligibility Criteria Inclusion Criteria

• Patients who underwent extraction of  one or more 
mandibular and maxillary third molars.

• Extractions performed at the oral surgery department 
of  Qassim University dental clinics between August 2022 
and March 2023.

• Procedures carried out under local anesthesia/local 
infiltration on an outpatient basis.

• Patients who were over 18 years of  age.
• Both male and female patients were included.
• Patients who had at least one post-operative follow-

up visit to assess healing and complications.

Exclusion Criteria
• Extractions done under general anesthesia
• Patients with concomitant systemic illness/diseases 

that could affect wound healing, such as diabetes, HIV/
AIDS, etc.

• Patients with pericoronitis, odontogenic infection, or 
facial space infection related to the targeted tooth.

• Patients requiring hospitalization or intravenous 
antibiotic therapy post-extraction.

• Pregnancy or lactation.
• Missing or incomplete medical records.

• Failure to attend scheduled postoperative follow-up 
visits.

• Extractions involving severe bone removal/impaction 
requiring flap surgery or osteotomy procedures

• Patients with a history of  allergy or hypersensitivity to 
local anesthetic agents or antibiotics.

Surgical Procedure
An oral and maxillofacial surgeon worked in the dental 
clinics at Qassim University to extract every third 
molar. The surgeon used a variety of  methods under 
local anesthesia, depending on the location and extent 
of  impaction of  the tooth. This involved exposing the 
tooth by elevating the mucoperiosteal flap and retracting 
the lingual flap, if  necessary. When necessary, elevators, 
forceps, and surgical drills were  
It breaks through bone, loosens tooth attachments, and 
extracts the impacted molars. After extraction, saline 
irrigation was used to clean and visualize the area. Any 
remaining irregularities in the bone were cut away. After 
that, absorbable sutures were used to close the mucosal 
incisions or soft tissue flaps. Patients were given analgesics 
and comprehensive wound care instructions after surgery.

Data Collection
Data was collected by reviewing patients’ files for 
postoperative complications and then recalling them for 
follow-up in 1-week post-op appointments to record 
postoperative complications. All complications were 
recorded, including pain, swelling, edema, trismus, dry 
socket, infection, broken root, and any signs of  nerve 
injury.

Data Analysis
Data analysis was performed using SPSS Statistics Version 
25 software from IBM. Descriptive statistics included the 
mean and standard deviation for numerical variables and 
frequencies and percentages for categorical variables—
comparative analyses employed Chi-square and Fisher’s 
exact tests as relevant. Results were considered statistically 
significant at the p ≤ 0.05 level.

RESULTS
A total of  199 third morals were extracted from 70 
patients with an average of  2.8 teeth per patient. There 
were more mandibular third molars extracted (55.8%) 
from the patients who participated compared to maxillary 
third molars extractions (44.2%) (Fig. 1-2). The majority 
of  patients were males (62.9%), while females comprised 
(37.1%) of  the participants (Fig. 3). The age ranged from 19 
to 54 years with a mean (±SD) age of  28.2 ± 7.4 years. The 
most frequent age category among the participants was 25 
to 29 years (35.7%), followed by 19 to 24 years (32.9%), 
then 30 years and older (31.4%) (Fig. 4). [See Table 1]

Table 1: Demographic characteristics of  patients and extracted third molars location
Characteristics n %
Age (mean ± SD) 28.2 ± 7.4
19 - 24 years 23 32.9%



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Table 2 presents the frequency and percentage of  
postoperative complications by patients and the total 
number of  teeth extracted.  Concerning the total number 
of  Third molars extracted, the results indicated that the 
rate of  postoperative complications ranged from 2.5% to 
64.7%. The most frequent postoperative complications 

were pain (64.7%), followed by swelling or edema 
(55.5%), trismus (32.8%), and dry socket (9.2%). At the 
same time, infections, broken roots, and nerve injuries 
were found in less than 10% of  third molar extraction 
(Fig. 5). [See Table 2]

25 - 29 years 25 35.7%
30 years and older 22 31.4%
Gender
Male 44 62.9%
Female 26 37.1%
Location of  extracted third molars (N = 199)
Maxilla 88 44.2%
Mandible 111 55.8%
Extraction Site (N = 199)
18 46 23.1%
28 42 21.1%
38 54 27.1%
48 57 28.6%

Figure 1: Location of  extracted third molars

Figure 3: Patients’ gender

Figure 2: Extraction site

Figure 4: Patients’ Age

Table 2: Frequency and percentage of  complications following third molar extraction
Complications n (%) n (%)

patient (N = 70) tooth (N = 119)
Pain 44 (62.9 %) 77 (64.7 %)
Swelling / Edema 38 (54.3 %) 66 (55.5 %)
Trismus 27 (38.6 %) 39 (32.8 %)



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According to the previous results, the most frequent 
postoperative complications following third molar 
extraction were pain, swelling/edema, trismus, and 
dry socket. Next, the relationship between these 
complications and patients’ gender, age, and the location 
of  extracted third molars was studied. The results in Table 
3 indicated that most patients with pain complications 
were males (68.2%) compared to females (31.8%). 
However, the results showed no significant association 

between patients’ gender and pain complications (P = 
0.230). Similar results were revealed concerning swelling/
edema complications (60.5% vs 39.5%, P = 0.660) and 
trismus complications (74.1% vs. 25.9%, P = 0.0.124). 
On the other hand, results indicated more females with 
dry socket complications (54.5%) than males (45.5%). 
However, the results showed no significant association 
between patients’ gender and dry socket complications (P 
= 0.193) (Fig. 6). [See Table 3]

Dry socket 11 (15.7 %) 11 (9.2 %)
Infection 5 (7.1 %) 5 (4.2 %)
Broken root 3 (4.3 %) 3 (2.5 %)
Nerve injury 3 (4.3 %) 3 (2.5 %)

Figure 5: Third molars extraction complications

Table 3: Third molars extraction complications according to patients’ gender
Complications Males Females P- value†
Pain No 14 (53.8 %) 12 (46.2 %) 0.230

Yes 30 (68.2 %) 14 (31.8 %)
Swelling / Edema No 21 (65.6 %) 11 (34.4 %) 0.660

Yes 23 (60.5 %) 15 (39.5 %)
Trismus No 24 (55.8 %) 19 (44.2 %) 0.124

Yes 20 (74.1 %) 7 (25.9 %)
Dry socket No 39 (66.1 %) 20 (33.9 %) 0.193

Yes 5 (45.5 %) 6 (54.5 %)
† Chi-square Test / Fisher exact test

Figure 6: Third molars extraction complications according to patients’ gender



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Table 4: Third molars extraction complications according to patients’ age
Complications 19 - 24 years 25 - 29 years 30 years and older P- value†
Pain No 6 (23.1 %) 10 (38.5 %) 10 (38.5 %) 0.379

Yes 17 (38.6 %) 15 (34.1 %) 12 (27.3 %)
Swelling / Edema No 5 (15.6 %) 15 (46.9 %) 12 (37.5 %) 0.018

Yes 18 (47.4 %)* 10 (26.3 %) 10 (26.3 %)
Trismus No 10 (23.3 %) 19 (44.2 %) 14 (32.6 %) 0.067

Yes 13 (48.1 %) 6 (22.2 %) 8 (29.6 %)
Dry socket No 18 (30.5 %) 22 (37.3 %) 19 (32.2 %) 0.618

5 (45.5 %) 3 (27.3 %) 3 (27.3 %)
† Chi-square Test / Fisher exact test

Figure 7: Third molars extraction complications according to patients’ age

Table 5: Third molars extraction complications according to location
Complications Maxilla Mandible P- value†
Pain No 76 (62.3 %) 46 (37.7 %) < 0.001

Yes 12 (15.6 %) 65 (84.4 %)
Swelling / Edema No 73 (54.9 %) 60 (45.1 %) < 0.001

Yes 15 (22.7 %) 51 (77.3 %)
Trismus No 86 (53.8 %) 74 (46.3 %) < 0.001

Yes 2 (5.1 %) 37 (94.9 %)
Dry socket No 88 (46.8 %) 100 (53.2 %) 0.001

Yes 0 (0 %) 11 (100 %)

Results in Table 4 indicate a significant relationship 
between patients’ age and swelling/edema complications 
(P = 0.018). The results showed that around half  of  
patients with swelling/edema complications were aged 
19-24 years (47.4%), compared to (26.3%) in other age 
groups. In addition, the results showed a higher proportion 
of  patients with pain (38.6%), dry socket (45.5%), and 
trismus (48.1%) complications among patients aged 19-
24 years compared to the other age groups; however, the 
results indicated no significant association between these 
complications and patients’ age (Fig.7) [See Table 4]

A statistically significant relationship was observed 
between the location of  extracted third molars and 
each pain, swelling/edema, trismus, and dry socket 
complication (P < 0.05) (Table 5). The results indicated 
that the majority of  trismus (94.9%), pain (84.4%), and 
swelling/edema (77.3%) complications corresponded 
to mandibular third Molars compared to maxillary third 
molars extractions. Moreover, the results showed that all 
dry socket complications corresponded to mandibular 
third molars. [See Table 5]



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DISCUSSION
This study provides insight into complication rates after 
third molar surgery in Qassim. Pain and swelling were 
most common, while severe issues were rare. In this 
discussion, we compare our results to other studies and 
explore Factors influencing trends. We also acknowledge 
limitations and recommend optimizations to reduce risks 
for patients undergoing this procedure in the region.
The present study indicated that the range of  different 
postoperative complications was 2.5% to 64.7%. 
Fortunately, the majority of  reported complications 
were minor and transitory. The current study focused on 
postoperative complications rather than intraoperative 
complications. A recent survey by Azenha et al. reported 
an overall postoperative complication rate of  10.4% 
following third molar surgery. This is comparable to rates 
found in other similar studies, such as 9.8% reported by 
Bui et al. and a slightly lower rate of  9.1% observed by 
Muhonen et al. (Azenha et al., 2014; Bui et al., 2003). Our 
study differed in finding most male patients, whereas this 
new study found more females. We also reported higher 
rates of  more common issues like pain, swelling, and 
trismus as chief  complications.
In contrast, their overall lower complication rate of  
10.4% included less prevalent issues like hemorrhage, 
fractures, and dry sockets as tops (Azenha et al., 2014). 
The present study demonstrated that complications arose 
more frequently following the extraction of  mandibular 
third molars than maxillary third molars. Most other 
research that has examined complications associated 
with the removal of  impacted wisdom teeth has likewise 
found that mandibular extraction sites are more prone to 
postoperative issues than maxillary locations (Bui et al., 
2003; Sisk et al., 1986).
According to existing research, dry sockets, infection, 
bleeding, and sensory issues caused by nerve damage 
are frequently reported postoperative complications 
following third molar surgery (Bouloux et al., 2007; 
Middlehurst et al., 1988). These published findings align 
with the results of  the current study, which also observed 
dry sockets, infection, and sensory complications. The 

extraction of  a third molar frequently causes expected 
but usually transient postoperative problems such as pain, 
swelling (edema), and restricted jaw opening (trismus). 
However, the pain from these procedures can last longer 
than the first week after surgery, and sometimes more 
care is needed, like dressing changes or antibiotics, which 
need to be given at a follow-up appointment (Bouloux et 
al., 2007).
According to studies, dry socket occurs in 0.3-26% of  all 
extractions, with third molar extraction being the most 
common (Bouloux et al., 2007; Haug et al., 2005).
Following the extraction of  mandibular third molars, 
specific controlled research has discovered an occurrence 
of  up to 25%–30% (Blum, 2002). Various research has 
identified several risk factors associated with an increased 
likelihood of  dry sockets occurring following third molar 
extraction. Some of  these risk factors include advanced 
age, female gender, oral contraceptive use, smoking, more 
incredible surgical trauma during the procedure, and a 
pre-existing condition known as pericoronitis (Blum, 
2002; Haug et al., 2005). The study findings also align 
with the results of  our current study results. The present 
study found a comparatively low incidence of  dry sockets 
(9.2%); all cases happened following the extraction of  
mandibular third molars, and five occurred in patients 
aged 19–24.
In this study, patients aged 19-24 had a higher incidence 
of  dry sockets, which contradicts previous studies.
In the literature, infections after surgery following third 
molar extraction have been documented at a prevalence 
of  0.8 to 4.2% (Bouloux et al., 2007). Similar to the current 
study, postoperative infections following third molar 
extraction were 4.2%. Nerve injury to the lingual nerve 
or inferior alveolar nerve (IAN) is one of  the least desired 
side effects after third molar extraction (Kushnerev & 
Yates, 2015).
Because of  its effect on speaking, mastication, swallowing, 
and social relations, it can be disastrous for sufferers 
(Ziccardi & Zuniga, 2007).
In the current study, nerve injuries accounted for 4.3% of  
patients, and luckily, all of  these injuries were temporary 

Figure 7: Third molars extraction complications according to patients’ age



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and healed without any medical or surgical intervention.
The depth of  impaction and the proximity of  molar 
roots to the alveolar canal are risk factors for injury to 
the inferior alveolar nerve (Kang et al., 2020). Root tip 
fractures are relatively common after third molar removal 
because of  the high curvature of  the roots and the 
presence of  extra roots (Kang et al., 2020). Usually, the 
removal of  the tips takes a little spare time to finish. 
Deliberate preservation of  the apical section of  the roots 
may be required to avoid IAN injury if  preoperative 
imaging indicates a close relationship between the tooth 
root and the inferior alveolar nerve (Meyer & Bagheri, 
2011).
 
LIMITATION
One limitation of  this study is that it needed to 
distinguish between simple dental extractions and more 
complex surgical extractions of  third molars. This lack 
of  procedure classification makes it difficult to compare 
postoperative complication rates based on the degree of  
difficulty.

CONCLUSION
A spectrum of  post-operative complications of  the 
third molar extraction in the Qassim Region was 
documented in this study. The most commonly reported 
complications are pain and swelling, while the least 
common complications are root fracture and nerve 
injury. Two-thirds of  these complications were reported 
in patients younger than 30 years. Lower third molars are 
associated with a higher complication prevalence than the 
upper third molars.
 
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