Med Oral Patol Oral Cir Bucal. 2022 Jan 1;27 (1):e68-76.

Third molar surgical difficulty scales

Journal section: Oral Surgery doi:10.4317/medoral.24951

Publication Types: Review

Third molar surgical difficulty scales:

systematic review and preoperative assessment form

Cosme Gay-Escoda 1, Alba Sánchez-Torres 2, Jordi Borrás-Ferreres 3, Eduard Valmaseda-Castellón 4

1
MD, DDS, MS, PhD, EBOS, OMFS. Chairman and Professor of the Oral and Maxillofacial Surgery Department, School of
Medicine and Health Sciences, University of Barcelona. Director of Master’s Degree Program in Oral Surgery and Implantology
(EFHRE International University / FUCSO). Coordinator and Researcher of the IDIBELL Institute. Head of Oral and Maxil-
lofacial Surgery and Implantology Department of the Teknon Medical Centre, Barcelona, Spain
2
DDS, MS, Master of Oral Surgery and Implantology. Associate Professor of Oral Surgery, School of Medicine and Health Sci-
ences, University of Barcelona. Researcher at the IDIBELL Institute, Barcelona, Spain
3
DDS. Professor of the Master’s Degree Program in Oral Surgery and Implantology, EFHRE International University/FUCSO.
Postgraduate degree on Temporomandibular Disorders and Orofacial Pain, SCOE, Barcelona, Spain
4
DDS, MS, PhD, EBOS. Professor of Oral Surgery and Director of the Master’s degree program in Oral Surgery and Implantol-
ogy, School of Medicine and Health Sciences, University of Barcelona. Researcher at the IDIBELL Institute, Spain

Correspondence:
School of Medicine and Health Sciences
Campus de Bellvitge. University of Barcelona
C/ Feixa Llarga, s/n; Pavelló Govern, 2ª planta, Despatx 2.9
08907, L’Hospitalet de Llobregat, Barcelona, Spain Gay-Escoda C, Sánchez-Torres A, Borrás-Ferreres J, Valmaseda-Cas-
[email protected] tellón E. Third molar surgical difficulty scales: systematic review and
preoperative assessment form. Med Oral Patol Oral Cir Bucal. 2022 Jan
1;27 (1):e68-76.
Received: 23/06/2021 Article Number:24951 http://www.medicinaoral.com/
Accepted: 04/11/2021 © Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
eMail: [email protected]
Indexed in:
Science Citation Index Expanded
Journal Citation Reports
Index Medicus, MEDLINE, PubMed
Scopus, Embase and Emcare
Indice Médico Español

Abstract
Background: The main objective of this systematic review was to collect the pre-existing scales for assessing the
difficulty of third molar extraction. The secondary objective was to design a proposal for a preoperative evaluation
protocol for the difficulty of third molar extraction.
Material and Methods: Two independent researchers conducted an electronic search in Pubmed (MEDLINE),
Cochrane, and Scopus databases during March 2021. Included studies evaluated the prediction of the difficulty of
surgical removal of impacted upper or lower third molars using new indices/scales or pre-existing scales with or
without modifications. Articles referring to coronectomies or assessing pre-surgical difficulty using other tools
were excluded. Neither language nor publication date restrictions were applied.
Results: Out of 242 articles, 13 prospective cohort studies were finally selected. Seven developed new indices/
scales, and 6 assessed the predictive ability of some pre-existing scales. Most of the indices/scales contained radio-
logical variables and few added any patient-related variables. We proposed a preoperative assessment protocol of
the difficulty of third molar extraction to facilitate treatment planning and/or considerate referral in cases of high
difficulty. This proposal used patient-related, radiological and surgical variables.
Conclusions: Using a preoperative protocol to evaluate the surgical difficulty, including different patient-specific,
radiological and surgical variables, could facilitate treatment planning, help clinicians prevent complications and
assess the possibility of referral.

Key words: Wisdom teeth, patient characteristics, radiological variables, surgeon experience, assessment form.

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Introduction Inclusion criteria were studies assessing the preopera-

Removal of third molars (3M) is one of the most common tive prediction of the difficulty of impacted upper or
procedures in oral surgery. Pre-operative evaluation of lower 3M removal using new indices/scales or pre-
surgical difficulty can help the practitioner plan the sur- existing scales with or without modifications. Articles
gical technique, estimate the operating time and foresee referring to coronectomies or that had only evaluated
possible complications (1). In addition, the practitioner the preoperative difficulty by means of visual analogue
can also evaluate the ability to perform the surgery or, scales or operating time were excluded. Neither lan-
if more appropriate, refer the patient to a more qualified guage nor publication date restrictions were applied.
oral surgery specialist (2). Renton et al. (3) underlined Two independent researchers (AST, JBF) performed an
the relevance of preoperative assessment of the surgical electronic search in Pubmed (MEDLINE), Cochrane,
difficulty of 3Ms from a teaching point of view, since and Scopus databases during March 2021. The search
dental or radiological factors are usually more consid- strategy used was “(wisdom tooth OR third molar)
ered in preoperative training, though expert surgeons AND (scale difficulty OR difficulty guideline OR dif-
usually assess other clinical or demographic variables. ficulty form OR difficulty classification OR difficulty
The ability to predict surgical difficulty based on the index)”. Articles were first selected by reading titles
surgeon's experience is controversial, as in the pub- and abstracts, and finally, those that met the eligibil-
lished literature some studies find no difference (4), ity criteria were read in full text. A third researcher
while others have even observed a trend towards bet- resolved any discrepancies (CGE). Moreover, a man-
ter estimation of difficulty for each year of training and ual search into the references of the selected studies
high values for experienced maxillofacial surgeons (5). was also conducted to ensure that all studies related to
The fact that most 3M difficulty scales are mainly based the area of interest were collected. We calculated the
on radiological criteria constitutes a gap between the degree of agreement between the researchers for ar-
impact that patient or surgeon factors can have on ac- ticle selection after the full text reading using Cohen's
tual surgical difficulty (6). In this regard, the American Kappa index.
Association of Endodontists has developed an assess- Data was recorded in tables to collect the following in-
ment form called ‘Endodontic Case Difficulty Assess- formation: author and year, number of patients and third
ment Form and Guidelines’ to be used in endodontic molars treated, objective of the use of a scale or index
curricula as a guide for teachers to assist students in (development of a new one or evaluation of a pre-exist-
making a correct decision process. ing one), name of the index or scale, type of variables
In the field of oral surgery there is no form to determine (patient, radiological or surgical) and individual items
the difficulty and assess the ability to perform surgery recorded by the index/scale, objective post-operative
or to refer the case to a specialist according to the dif- variables that help determine the difficulty, evalua-
ferent variables involved, such as patient, radiological tor of the index/scale, surgeon(s) experience and main
and operative factors, as determined by a recently pub- results. Based on this information and the factors that
lished systematic review (6). Considering that diagnosis determine an increase in difficulty according to a previ-
of third molars is usually performed in primary care ous systematic review (7), the authors designed a guide
services, a tool to assess the difficulty of third molar for assessing the surgical difficulty of 3M removal. The
extractions could help both general dental practitioners level of evidence from the included articles was scored
and more experienced surgeons select the proper setting according to the Scottish Intercollegiate Guidelines
for third molar extractions. Network (SIGN) grading system (8).
The main objective of this systematic review was to
collect the pre-existing scales to assess the difficulty of Results
3M extraction. The secondary objective was to design a The electronic search yielded 242 articles, of which 20
3M difficulty assessment form, based on the previously were selected to be read in full text. After reading, 7
demonstrated influencing factors, to assist clinicians, articles were excluded because they did not assess the
whether they are students, recent graduates or even oral predictive ability of the indexes/scales (9-15). Finally,
surgery specialists, to make a correct treatment plan or 13 articles were included in the systematic review (16-
to make a referral decision. 28). All of them were prospective cohort studies and
1 was a multicenter study conducted in 3 centers (26).
Material and Methods All of them assessed the difficulty of the 3M removal.
This systematic review was carried out according to Fig. 1 shows the flowchart of selected items accord-
Preferred Reporting Items for Systematic Reviews and ing to PRISMA guidelines. The kappa index adjusted
Meta-Analyses (PRISMA) guidelines (7) and the re- for bias and prevalence was 0.71, which indicated
view protocol was registered in PROSPERO database substantial agreement between researchers for article
(number CRD42020186643). selection.

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Fig. 1: Flow-chart of the selected articles throughout the systematic review process according to PRISMA statement.

Table 1 shows the main characteristics of the included ibility constitute the total of patient characteristics
studies. Six developed new indices/scales (17,21,23- included in these indices/scales. The rest of indices/
25,27) and 5 assessed the predictive ability of pre- scales evaluated included only radiological variables.
existing indices/scales (16,18-20,22,26,28). The most Experience of the surgeon was not included in any of
widely used pre-existing index/scale, both to assess the indices/scales.
its predictability and to compare it with new indices, Most of the studies used the operative time (measured
was Pederson scale, which includes only the radiolog- from the incision to the last suture) as a post-operative
ical variables of depth, available distal space and 3M variable indicating the degree of difficulty (17,18-21,24-
angulation. In fact, the only studies that developed in- 28). Others used scales that evaluate the type of surgical
dices that add variables specific to patient character- technique (16,18,20,24,25) and only 1 registered a score
istics were those published by Roy et al. (21), de Carv- reported by the surgeon after the surgery to subjectively
alho and Vasconcelos (25) and Zhang et al. (27). Age, classify difficulty (23). Few studies reported on the ex-
body mass index (BMI), mouth opening, tongue size, perience of the surgeon(s) operating the cases included
angle of the external oblique ridge and cheek flex- in the studies.

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Table 1: Main characteristics of the studies included.

Author N pa- Objective Index / Type of Items Post-operative Evaluator Surgeon Outcomes SIGN
tients Scale varia- objective variable of index / experien- score
/teeth bles scale ce
Akadiri 79 / Pre-exis- Pederson Radio- Depth Operative time A 9-year experienced Se = 94.9% 2+
et al. 79 tent index logical Available distal space oral and maxillofacial Sp = 45%
2009 (22) / scale Angulation surgeon and a less PPV = 62.7%
evaluation experienced surgeon NPV = 90%
Accuracy =
69.6%
Al- 49 / New index Kharma Radio- Depth Modified Parant 2 surgeons specialized Kharma vs 2+
Samman 49 / scale scale logical Available distal space scale in oral and maxilofa- modified
2017 (27) develop- Angulation I: Forceps cial surgery with 6 and Parant scale:
ment Root morphology II: Ostectomy 9 years of experience Se = 18.2%
III: Ostectomy and Sp = 68.4%
odontosection
IV: Complex ex- Operative
traction with root time by
sectioning Kharma:
p=0.716
Operative time Operative
time by
modified
Parant scale:
p=0.007
Barrei- 66 / Pre-exis- Modified - - Modified Parant 14 dentists: Fellows Predictive 2+
ro-To- 80 tent index Parant scale* 2 from pri- of Master ability:
rres et / scale scale* mary care of Oral Primary care:
al. 2010 evaluation Operative time 10 residents Surgery 31.9%
(23) Preop- of oral Residents:
erative surgery 45.1%
VAS 2 maxi- Maxillofacial
0-100 llofacial surgeons:
mm surgeons 38.7%
Conti et 1000 New index Conti Radio- Tooth position and - - - - 2-
al. 2015 /- / scale scale logical orientation
(25) develop- Root morphology
ment Patient Available distal space
Ankylosis
Patient general status
and attitude
Age
Mouth opening
Second molar rela-
tionship
Distance to mandibu-
lar canal
Residual bone volume
de Car- - / New index Pernam- Radio- Depth Surgical technique 1 indepen- 1 senior Se: 93.1% 2++
valho 280 / scale de- buco logical Available distal space Low diff: use of dent eva- surgeon Sp: 87.9%
& Vas- velopment index Angulation elevator luator Precision:
concelos Patient Root morphology Moderate diff: 90.4%
2018 (28) (curvature and num- ostectomy PPV: 87.1%
ber of roots) High diff: ostec- NPV: 93.6%
Second molar rela- tomy and odonto-
tionship section
Age
BMI Operative time
Low diff: < 15 min
Moderate diff: 15-
30 min
High diff: > 30 min
Di- 73 / Pre-exis- Pederson Radio- Depth Modified Parant NC 5 resi- Between 2+
niz-Fre- 105 tent index logical Available distal space scale* dents of scales:
itas et / scale Angulation 2nd year Se=23.8%
al. 2006 evaluation Operative time of Master Sp=76.2%
(21) of Sur-
gery Operative
time:
Pederson:
p=0.055
Modified
Parant:
p=0.000

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Table 1 cont.: Main characteristics of the studies included.

Gar- -/ Pre-exis- Pell & Radio- Depth Modified Parant NC 1 surgeon Depth: 2+
cía-Gar- 166 tent index Gregory logical Available distal space scale* Se=15%
cía et / scale Sp=88%
al. 2000 evaluation
(19) Available
distal space:
Se=50%
Sp=62%
Roy et 100 / New index Radio-New Depth Operative time NC NC Agreement 2+
al. 2015 100 / scale de- Index
logical Available distal space (kappa)=89%
(24) velopment Angulation
Patient Root width
Root curvature
Distance to the eleva-
tor point
Mouth opening
Tongue size
External oblique crest
angle
Cheek flexibility
Pederson Radio- Depth Agree-
logical Available distal space ment (ka-
Angulation ppa)=66.5%
Sainz de 118 / Pre-exis- Pederson Radio- Depth Operative time NC 1 surgeon p<0.001 2+
Baranda 118 tent index logical Angulation
et al. / scale Available distal space
2019 (31) evaluation
Sam- 200 / New index New Radio- Depth Postoperative dif- 1 experien- 5 special- Kappa = 73% 2+
martino 200 / scale de- index logical Available distal space ficulty reported by ced surgeon ized sur-
et al. velopment Angulation the surgeon: geon with
2017 (26) Bone density - Simple similar
Relationship with IAN - Moderately experien-
Buccolingual position simple cie
Tooth morphology - Difficult
(with or without al- - Extremely
terations) difficult
Stacchi 124 / Pre-exis- Juodz- Radio- Mesiodistal position Operative time 1 blinded 1 expert R 2 = 0.126 2++
et al. 124 tent index balys logical Apicocoronal position expert surgeon
2018 (29) / scale and Buccolingual position surgeon in each
evaluation Daugela center
scale
Modified R 2 = 0.204
Juodz-
balys
and
Daugela
scale
Yuasa et 44 / New index New Radio- Depth Operative time 1 radiolo- Maxil- Se=85% 2++
al. 2002 44 / scale de- index logical Available distal space Surgeon-reported gist lofacial Sp=92%
(20) velopment Root width difficulty surgeons
Pederson Radio- Depth with at Se=50%
logical Angulation least 5 Sp=92%
Available distal space years’
experi-
ence
Zhang et 203 / New index New Radio-
Depth Operative time 2 senior 1 surgeon Kappa 77.9% 2++
al. 2019 203 / scale de- index logical
Angulation residents with 25
(30) velopment Root shape years of
Patient Number of roots experi-
Relationship with IAN ence
Age
Pederson Radio- Depth Kappa 65.3%
logical Available distal space
Angulation
All of them are prospective cohort studies that have assessed difficulty of lower impacted 3M removal and have measured radiological vari-
ables from panoramic radiographs. *Modified Parant scale from García-García et al. 2000: I: conventional extraction; II: ostectomy; III:
ostectomy and crown sectioning; IV: complex extraction with root sectioning. Se: sensitivity, Sp: specificity, PPV: positive predictive value,
NPV: negative predictive value.

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All studies showed an improvement on the prediction of The form includes 3 groups of variables: features of the
the surgical difficulty when using the new indices/scales patient, and radiological and surgical features. It classifies
or the proposed modifications of the pre-existing ones in each clinical case into 1 out of 3 categories of difficulty.
comparison with pre-existing indices. Only 1 study failed The scoring was adopted from the ‘Endodontic Case Dif-
to demonstrate improvement of a new index with respect ficulty Assessment Form and Guidelines’. Each item is
to the modified Parant scale (24). scored with 1 point for low difficulty, 2 points for moderate
Table 2 shows the proposal of a form for the assessment difficulty and 5 points for high difficulty. If the sum of the
of surgical difficulty of upper or lower third molars points is less than 20, the case has a low difficulty, suggest-
removal based on the results of the present systematic ing an easy surgical case, that is, a conventional extrac-
review, which combines the scales/indices developed tion that can be performed by a supervised student or by
so far, and the individual variables or factors that have a general dentist. If the sum is between 20 and 40 points,
been related to an increase in surgical difficulty and the case is classified as moderately difficult and should be
which have been recorded in a recently published sys- operated by a dentist with training in oral surgery over
tematic review by the authors (6). However, some of 3 years or by a qualified generalist dentist with specific
these factors have not yet been demonstrated. For this continuing education and over 5 years experience in oral
reason, the authors have completed the evaluation form surgery. In cases over 40 points, considered to be highly
with some categories based on their clinical experience difficult, the surgical intervention should be reserved for
in the field of oral and maxillofacial surgery. senior surgeons with more than 10 years of experience.

Table 2: Proposed pre-surgical assessment form on surgical difficulty of upper or lower third molars removal.

LOW DIFFICULTY MODERATE DIFFICULTY HIGH DIFFICULTY

PATIENTS’ CHARACTERISTICS
Age � < 25 years � 25-50 years � > 50 years
BMI � < 25 � 25-30 � > 30
Ethnic background � Caucasian � Asian � African
Systemic disorders � ASA I � ASA II � ASA III y IV
Anxiety level � Non anxious � Anxious but cooperative � Phobic, non cooperative
Facial pattern � Dolichocephalic � Mesocephalic � Brachycefalic
Mouth opening � > 45 mm � 35-45 mm � < 35 mm
RADIOLOGICAL VARIABLES
� Germ
Root morphology � Conical fused roots � Multi-radicular (≥ 2 roots) � Bulbous roots
� Dilacerated roots
Available distal space � Pell & Gregory I � Pell & Gregory II � Pell & Gregory III
Depth � Pell & Gregory A � Pell & Gregory B � Pell & Gregory C
� Horizontal
Angulation � Mesioangular � Vertical
� Distoangular
Maxillary � Apex without contact � Apex overlapping or
� Apex in contact with the cortex
sinus with the cortex exceeding the cortex
Proximity to
anatomical � Overlay/loss of both cortices
� Apex away from the
structures Inferior al- � Apex overlapping the upper cortex � Narrowing of the duct
veolar nerve upper cortex of the lower � Darkening of the roots � Deviation of the duct
dental canal � Bent apices
� The tooth contacts the crown of � The tooth contacts the crown
Second molar relationship � Absent the 2nd molar and/or root of the 2nd molar
Periodontal space � Radiolucent � Mixed � Radio-opaque
SURGICAL VARIABLES
Anesthesia � No history of problems � Vasoconstrictor intolerance � Previous anesthetic failure
� Semierupted
Degree of impaction � Erupted � Intraosseous
� Partial bony impactionl
� Conventional extraction � Ostectomy and tooth
Surgical technique with elevators and forceps � Need of ostectomy sectioning
Presence of associated � Absence of lesions � Associated lesion < 10 mm � Associated lesion > 10 mm
lesions Thickened follicle
� Senior dentist with oral � Dentist with Master or regulated
training in oral surgery > 3 years � General dentist
Surgeon’s experience surgery experience > 10 � General dentist with specific continu- � Supervised student
years ing education in oral surgery > 5 years

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Discussion as well as greater post-operative morbidity when the

This study aimed to collect pre-existing scales assess- procedure is performed by generalists (35).
ing the difficulty of third molars in order to design a dif- In the field of oral and maxillofacial surgery there are
ficulty assessment form to help professionals and to be no studies to assess the learning curve of the extraction
used in an educational setting. The importance of having of impacted 3M. The learning curve is the time and/or
indices/scales that indicate the degree of surgical diffi- number of surgical interventions that a novice surgeon
culty lies in a correct treatment planning to avoid under- needs to be able to perform a procedure independently
estimation of the difficulty and to minimize the number and with a good result, thus becoming a competent sur-
of intra- and post-operative complications (29). Some geon (37). Therefore, during this training period until
scales such as those of Pell and Gregory, Winter and the surgeon acquires the necessary skills, the risk of
Pederson are widely used although several studies have morbidity and complications is higher (38).
shown that they poorly predict surgical difficulty (16,18). However, although the more experienced surgeons have
Juodzbalys and Daugela (29) carried out a literature re- fewer post-operative complications, the less experi-
view and designed an index/scale based on anatomical enced ones may also have a low number of complica-
and radiological factors. This classification relates the tions, provided that their learning curve is good and
3M to adjacent structures such as the mandibular ra- progressive (39). In the area of endoscopic surgery, Qu
mus, the second molar, the alveolar ridge, the mandibu- et al. (40) studied the performance of surgery for an
lar canal, and the spatial position of the tooth. Another endoscopic thyroidectomy with an intra-oral approach
study published by Manuel et al. (30) shows a proforma and concluded that this competence was acquired after
for the collection of clinical history data in order to be 20 cases, when a significant reduction in operative time
used by residents of an oral and maxillofacial surgery was observed. In their study they detail some of the
service in India. The benefits of a good history are the more challenging surgical steps and therefore recom-
early evaluation of difficulty and possible intra- and mend that a novice surgeon initially imitate and practice
post-operative complications, among others. However, under the close guidance of an experienced supervisor.
until now there is no specific tool to evaluate the surgi- Unfortunately, the number of interventions required to
cal difficulty of 3M in a multidimensional way, as the master or be competent at extracting 3M is unknown as
one presented in this paper. this issue has not been studied in our field. In addition,
The results obtained in the present systematic review it should be noted that individual learning will depend
show that most of the existing indices/scales include on the surgeon's own manual skill and knowledge of
radiological variables collected from panoramic radio- anatomy or technique. Usually, as the clinician acquires
graphs, and only some contain variables or characteris- skills, the difficulty of the cases increases, which can
tics of the patient himself, such as age or BMI, among have a temporary negative impact both in complication
others. However, taking into account the results of a rates and operative time (37).
recently published systematic review (6), these scales In our opinion, the learning curve on difficulty assess-
are not aligned with the factors that have been shown to ment has to be developed also during the first years of
influence the increase in surgical difficulty. These are clinical practice, both for generalists and for specialists
divided into three blocks: patient characteristics, radio- in oral and maxillofacial surgery. Correctly predicting
logical factors and surgical factors. the difficulty of the impacted 3M removal is relevant
Surgical factors are usually treated separately from in order to avoid iatrogeny in less expert surgeons and
other factors. There are indices/scales that assess dif- perform a progressive learning curve.
ficulty only by the type of surgical technique, such as Therefore, the development of the present form for as-
the modified Parant scale (31). However, none of these sessing the difficulty of surgical extraction of 3Ms
refers to the surgeon's experience. The measurement of based on the available scientific evidence and the clini-
experience is a controversial issue. There are studies cal experience of the authors is an opportunity to im-
that refer to the number of years worked after comple- prove the training of students and to guide recent gradu-
tion of training (32) but some of those included in this ates and even oral surgery specialists. It is intended to
review cite the senior category without explaining the help reduce intra- and post-operative complications and
number of years of experience (23,25,26). In this line, a to assist with referral to an experienced surgeon.
study published by Ashton-James et al. (33) determines
experience in terms of the number of 3M extractions Conclusions
performed throughout the professional career. Although The existing indices/scales are mainly based on radio-
few, some studies have linked the surgeon's experience logical variables that can be evaluated in a panoramic
with post-operative complications and morbidity and radiography. Very few authors introduce variables re-
have found more complications in less experienced pro- lated to the patient's own clinical characteristics. The
fessionals (34,35) or non-specialized generalists (35,36), few scales that evaluate surgical variables only include

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the type of surgical technique. None of them values the 18. Diniz-Freitas M, Lago-Méndez L, Gude-Sampedro F, Somoza-
surgeon's experience. Martin JM, Gándara-Rey JM, García-García A. Pederson scale fails
to predict how difficult it will be to extract lower third molars. Br J
The use of a protocol designed to evaluate the difficulty Oral Maxillofac Surg. 2007;45:23-6.
of 3Ms removal that includes patient-specific, radio- 19. Akadiri OA, Fasola AO, Arotiba JT. Evaluation of Pederson in-
logical and surgical variables can facilitate treatment dex as an instrument for predicting difficulty of third molar surgical
planning, help the professional foresee possible com- extraction. Niger Postgrad Med J. 2009;16:105-8.
20. Barreiro-Torres J, Diniz-Freitas M, Lago-Méndez L, Gude-
plications and decide whether to refer the patient to a Sampedro F, Gándara-Rey JM, García-García A. Evaluation of the
specialist with proven knowledge and experience. surgical difficulty in lower third molar extraction. Med Oral Patol
Oral Cir Bucal. 2010;15:869-74.
21. Roy I, Baliga SD, Louis A, et al. Importance of clinical and ra-
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Acknowledgements
This study was conducted by the research group "Dental and Max-
illofacial Pathology and Therapeutics" of the Bellvitge Biomedical
Research Institute (IDIBELL).
We thank CERCA Programme / Generalitat de Catalunya for insti-
tutional support.

Funding
This research has not received any specific funding from public,
commercial, or non-profit sector funding agencies.

Conflict of interest
The authors deny any conflict of interest related to this study.

Authors contributions
Prof. Dr. Gay-Escoda participated in the design of the study, the in-
terpretation of the results and the correction of the manuscript.
Dr. Sánchez-Torres participated in the preparation of the study, in the
analysis of the results and in the writing of the manuscript.
Dr. Borrás-Ferreres participated in the preparation of the study, in
the analysis of the results and in the writing of the manuscript.
Prof. Dr. Valmaseda-Castellón participated in the interpretation of
the results and in the correction of the manuscript.

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