Does the surgical difficulty of impacted mandibular third molar extractions reflect postoperative outcomes?

Surgical extraction of impacted mandibular third molars is one of the most common procedures in oral and maxillofacial surgery. Despite being a routine intervention, the degree of surgical difficulty significantly influences postoperative outcomes, often leading to complications such as pain, swelling, trismus, and functional limitations, all of which negatively affect patients' oral health–related quality of life. Moreover, surgical trauma can activate systemic stress responses, reflected in alterations of biochemical markers such as high-sensitivity C-reactive protein (hs-CRP) and D-dimer, as well as changes in vital signs. The aim of this study was to evaluate the relationship between surgical difficulty, defined according to Escoda's difficulty index, and postoperative biochemical (hs-CRP, D-dimer) as well as clinical parameters (pain, swelling, trismus, vital signs). In addition, patients' pre- and postoperative anxiety levels (Dental Anxiety Scale, DAS) and oral health–related quality of life (OHIP-14) were assessed. Sixty six patients who presented to the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Selçuk University, requiring impacted mandibular third molar extraction, were included. Demographic data were recorded, surgical difficulty was determined using Escoda's index, and blood samples were collected preoperatively and postoperatively on specific days to measure hs-CRP and D-dimer levels. Clinical parameters including pain, swelling, trismus, and vital signs were recorded. Anxiety levels were assessed using the DAS, and oral health–related quality of life was evaluated with OHIP-14. A significant association was observed between higher surgical difficulty and increased severity of postoperative pain, swelling, and trismus. D-dimer levels demonstrated a statistically significant postoperative increase, reflecting the activation of the coagulation and fibrinolytic pathways in response to surgical trauma. In contrast, hs-CRP levels did not show a significant rise, which may be explained by the delayed peak of CRP response and the limitation of measuring only on the 4th postoperative day. Furthermore, higher difficulty scores correlated with elevated dental anxiety levels, adverse changes in vital signs, and poorer postoperative quality of life outcomes. The degree of surgical difficulty in impacted mandibular third molar extractions plays a decisive role not only in determining the severity of postoperative complications but also in modulating systemic biochemical stress responses, vital parameters, and psychological well-being. Incorporating Escoda's difficulty index into preoperative assessment may improve predictability, minimize postoperative complications, and enhance patient-centered outcomes. Keywords: Impacted third molar, Surgical difficulty index, hs-CRP, D-dimer, Dental anxiety, Postoperative complications