Complications in Impacted Third Molar Surgery: Evidence-based Risk Assessment, Prevention and Management

Abstract

Impacted third-molar surgery involves a range of outcomes extending from expected short-term inflammatory morbidity to uncommon but potentially persistent neurosensory, periodontal and anatomical complications. These outcomes are frequently grouped together despite differences in severity, causal mechanisms, measurement and clinical consequences. This critical narrative review evaluates the evidence linking surgical indication, risk assessment, operative choices and postoperative management to complication prevention, with emphasis on mandibular nerve injury, alveolar osteitis, infection, haemorrhage, adjacent second-molar outcomes and maxillary sinus-related events. Peer-reviewed trials, observational studies and evidence syntheses were selected through targeted searches of accessible scholarly sources, with appraisal focused on methodological limitations and agreement or disagreement among findings. The strongest available comparisons do not establish that routine cone-beam computed tomography reduces inferior alveolar nerve injury, although selective imaging can inform planning when a defined clinical question remains unresolved. Coronectomy offers a nerve-sparing option for appropriately selected high-risk mandibular impactions but carries retained-root monitoring and possible reintervention obligations. Selected chlorhexidine regimens can reduce alveolar osteitis; prophylactic antibiotics reduce some postoperative infections in studied populations but require consideration of limited certainty, absolute benefit and antimicrobial stewardship. Analgesics, corticosteroids and bone-cutting technologies may improve specific early recovery measures without demonstrating universal protection against long-term complications. Evidence about durable periodontal benefit, nerve-repair timing and patient-reported functional recovery remains heterogeneous. An integrated decision approach is proposed in which the indication for surgery precedes anatomical risk stratification, proportionate prevention, documented consent and complication-specific follow-up. Future studies should harmonise outcome definitions, measure long-term patient-important harms and compare entire management strategies rather than technical or imaging surrogates. Safer care depends on matching interventions to individual risks and maintaining accessible pathways for recognition and escalation when complications occur.