J Oral Maxillofac Surg 65:1977-1983, 2007 Assessment of Factors Associated With Surgical Difficulty in Impacted Mandibular Third Molar Extraction Olalekan Micah Gbotolorun, BDS, FMCDS,* Godwin Toyin Arotiba, BDS, FMCDS, FWACS, FDS RCSEd,† and Akinola Ladipo Ladeinde, BDS, FMCDS, FWACS‡ Purpose: The aim of this prospective study was to investigate radiologic and clinical factors associated with increased difficulty in the removal of impacted mandibular third molars. We also aimed to form an index to measure the difficulty of removal of the impacted molars preoperatively. Patients and Methods: A total of 87 patients who required 90 surgical extractions of impacted mandibular third molars from November 2003 to May 2004 were involved in the study. Radiologic and clinical data were taken preoperatively. All extractions were performed under local anesthesia by a single operator. Surgical difficulty was measured by the total intervention time. Results: Increased surgical difficulty was associated with increasing age and body mass index. It was also associated with the curvature of roots of the impacted tooth and the depth from point of elevation (P  .05). Conclusion: Both clinical and radiologic variables are important in predicting surgical difficulty in impacted mandibular third molar extractions. © 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:1977-1983, 2007 Surgical removal of mandibular third molar is one of the most common surgical events. 1 This is why, in spite of the diversified demands of practice, many dental surgeons will still need to face the problem of removal of impacted mandibular third molars. 2 Both the patient and dentist must therefore have scientific evidence-based information concerning the estimated level of surgical difficulty of every case. There are a number of previous studies to evaluate surgical difficulty in the extraction of impacted man- dibular third molars. 1-6 However, most of these stud- ies were based only on dental factors evaluated by radiologic assessment. 2-5 Opinions vary on these ra- diologic factors, but most authors agree that they play some role in estimating difficulty. 1-6 Other authors believe it is difficult to estimate actual difficulty by radiologic methods only, and that it is only intraoper- atively that actual difficulty can be estimated. 7 Some authors also believe that clinical variables such as age, gender, and weight of the patient are also very impor- tant. 1,6 Few authors have proposed indexes for mea- suring intraoperative/surgical difficulty. 5 Pederson proposed such an index, but it is seldom used be- cause it has been reported that it does not match actual surgical difficulty. 5 This study aims to use both clinical and radiologic variables in estimating intraoperative difficulty. We also propose a preoperative index based on both clinical and radiologic variables. Patients and Methods Patients who were referred for extraction of im- pacted mandibular third molars between October 2003 and April 2004 at the Oral and Maxillofacial Clinic of the Lagos University Teaching Hospital (La- gos, Nigeria) were included in the study. Approval for the study was obtained from the local ethics commit- tee and informed consent was obtained from all par- ticipating patients. Received from the Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos, Lagos, Nigeria. *Lecturer. †Associate Professor and Consultant. ‡Senior Lecturer and Consultant. Address correspondence and reprint requests to Dr Gbotolo- run: Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos, P.M.B 12003, Lagos, Nigeria; e-mail: lekangbotol@yahoo.co.uk © 2007 American Association of Oral and Maxillofacial Surgeons 0278-2391/07/6510-0012$32.00/0 doi:10.1016/j.joms.2006.11.030 1977