***WHITE PAPER ON THIRD MOLAR DATA (A Task Force was convened by the American Association of Oral and Maxillofacial Surgeons in March 2007…)***

The removal of impacted third molars:Position of the South African Society for Maxillofacial and Oral Surgeons. (March 1999)***American Public Health Association - Policy Statement Database: Opposition to Prophylactic Removal of Third Molars (Wisdom Teeth) 10/28/2008***Scottish Intercollegiate Guidelines Network S I G N September 1999 Management of Unerupted and Impacted Third Molar Teeth- A National Clinical Guideline*** REPORT OF A WORKING PARTY CONVENED BY THE FACULTY OF DENTAL SURGERY 1997- CURRENT CLINICAL PRACTICE AND PARAMETERS OF CARE THE MANAGEMENT OF PATIENTS WITH THIRD MOLAR (syn: WISDOM TEETH) ( Faculty of Dental Surgery The Royal College of Surgeons of England 35-43 Lincoln’s Inn Fields London)***

Is there justification for prophylactic extraction of third molars? A systematic review / Moacir Guilherme da CostaI, Camila Alessandra PazziniII, Mariele Cristina Garcia PantuzoI, Maria Letícia Ramos JorgeIII, Leandro Silva MarquesIII / Braz. oral res. vol.27 no.2 São Paulo Mar./Apr. 2013***Hospitalisations for removal of impacted teeth in Australia: A national geographic modeling approach / R George, M Tennant, E Kruger Center for Rural and Remote Oral Health, Perth, Western Australia, Australia Published: 20 November 2012***Epidemiological Status of 3rd Molars – Their Clinical Implications /Devi Charan Shetty, Puneet Ahuja, Aadithya B. Urs, Deepika Bablani, Mayura Paul, J Oral Health Comm Dent 2010;4(1):12-15***The Prophylactic Extraction of Third Molars: A Public Health Hazard / Jay W. Friedman, DDS, MPH, PMID:2239906

This question remain controversial, in my experience I do prophylactic extraction after having a consultation with an orthodontic, if I see that the position is very undefavorable for eruption. But I want to see the experience of other specialist

A great review: Kandasamy S, Rinchuse DJ, Rinchuse DJ. The wisdom behind third molar extractions. Aust Dent J. 2009 Dec;54(4):284-92. doi:

10.1111/j.1834-7819.2009.01152.x. Review. PubMed PMID: 20415925.

Dear Pohl. I think that we have to think about many things, before the removal of third molars. First, the condition of the other teeth of the patient must be considered. If my patient has only a few teeth, I reccomend the treatment of this tooth (when it's possible), thinking about a prothesis in the future. In the case of orthodontic treatment, I usually prefer not to remove the third molar, unless it's cousing trauma to soft tissues, or it's position doesn´t allow the patient to clean it adequately. In sum, I prefer to be conservative everytime I can.

Sometimes, even on advised extraction, patients postpone it thinking of complications. Only when they have unbearable pain repeatedly, they get the extraction done.

generally speaking. I do agree with prophylactic removal of mandibular third molars. the type of impactions is of paramount importance in the decision. ..and just to mention an example. the persistent mesioangular impaction is significantly associated with distal cervical caries of second molar. so I think every case should be discussed and managed according to its nature

regards

The Third Molar proceedings published in 2012 is a valuable issue:-

www.joms.org/issues?issue_key=S0278-2391(12)X0003-X

Regarding prophylactic removal I think the decision should be made on a case by case basis until we have further evidence of more reliable nature.

On a cautionary note, it is important to understand the basis of guidelines that are made by governments/associations and the references that are used and to read them to make a more informed decision.

While we may be tempted to remove third molar prophylactically, we must also recogise the potential for III molar to act as a replacement in cases of early loss of first molars! It is easier to make decisions regarding III molar associated with pathologies or those resulting in severe odontogenic infections / space infections. It has become more common to classify III molars based on presence and absence of disease and presence and absence of symptoms! The truly asymptomatic III molar (Disease free and Symptom free) is the MOST challenging decision to make!

One consideration here would be to involve the patient in the decision making process and keep an adequate record of the same - including its mention in informed consent!

Impacted third molars, particularly the mesioangular ones should be extracted prophylactically. Most of the times, they result in distal cervical caries of second molars. Difficult to clean interproximal area between second and third molars result in crestal bone loss between the teeth. Even if it is symptom free and extraction is postponed, the crestal bone loss continues and leaves the second molar in a periodontally compromised state in later life. In many cases of third molar extraction in older patients, there is very little bone found on distal root of second molar. Suprabony pockets that cannot be taken up for regenerative procedures, root caries and root hypersensitivity after extraction of third molars in older age is common and these can be avoided if prophylactic extraction is made a regular practice.

Dear Akilesh,

I notice that my question was not clear enough. I meant the removal of third molars which will not gain a normal position in the mouth. Thus they are most unlikely to erupt when they are needed as a replacement....

Another point in this regard: We recently started to keep the upper third molars - the risk of the development of pathologies or symptoms is nearly negligible, and the risk of late removal is quite low.

According to a recently published review (in German; English version in progress) transplantation of *mature* teeth is a better option than it is believed. Thus these 3rd molars could be kept as a reserve and used to replace a molar tooth.

I consider the risk for keeping lower 3rd molars as too high and also the difficulties to remove these teeth in one piece, thus this reserve function is not valid for these.

Here in Germany, the patient is completely involved, without having the patient informed and without having this very well documented, the patient would not get an appointment for surgery. Patients may inform themselves (Guidelines include a special - better understandable - version for lay people, and they are free), patients are even involved in establishing guidelines. And while I myself tend to inform even too much, because I think that the patient should be included in the decision process, I'm nevertheless sure that I could convince my patients even if the treatment would be the contrary of the guidelines. Thus, I'm not sure if that would give better decisions; I would need just some seconds to have the patient imagine a very difficult removal, the lower jaw being eroded by a huge cyst, while being short before death due to a recent heart attack, including stents and therefore some medicaments which will result in the loss of all his blood if injured... What will be his chance then? ;-)

Dr Yango, You´r ethe great, you´re speech is sharp..

Dear Dr. Yango Pohl,

Your question was clear, I was just trying to summarize the publication reference I gave from JOMS. That is an excellent resource to start with. And latest attempt that lists all areas of III molar research which needs more evidence and so on. Also it has authors from all parts of the globe and their basis of guidelines in their part of the world / country.

Coronectomy is a very good technique and we also found it very useful. And after coronectomy there is evidence for change in position of the roots retained back. I have seen it myself in qutie a few cases.

But about 1/3rd of the patients returned back symptomatic later after 5-7 months and had to be surgically removed. And they had slightly changed positions away from the neurovascular bundle and that made it easier to remove without damaging the vital structure below.

What has your experience been with coronectomy ?

Regards,

Dr. Akilesh. R

I would like to proporse a related question here to the floor for discussion:

How do you manage the exposed pulp of the tooth after coronectomy ?

Regards,

Dr. Akilesh. R

Hi, Akilesh,

1. I don't have ANY experience with coronectomy at all (except some with decoronation of ankylosed front teeth, but that is different). That is one reason for my interest here. I can't remember any permanent and only a few temporary malfunctions with the nerve. However, that is not a very valid report, as it is not based on a study (despite we see all our patients and they are asked for nerve malfunction), and I can't report anything about the relation 3rd molar--nerve canal... Thus, it is as it is: some clinical observation, and is has not much to do with facts...

There seem to be not many studies on coronectomy and the outcome after the final removal of the roots and/or other long-term-result: concerning costs*, overall complications**, development of pathologies***. Did you study your results?

* 2 instead of 1 surgery in quite a number of cases, including i.e. social costs (loss of working hours, costs for journey, etc; treatment costs are just a part) vs. eventual nerve reconstruction (very rare?) or repeated visits for documentation/treatment efforts in case of nerve damage...

**even if the roots move away from the nerve: damage may nevertheless occur, by inadequate incision or by anesthesia (it is not only the alveolar nerve but also the lingual nerve which is at risk; 2 surgical interventions should double these risks?!?)

***1/3 with symptoms after 5-7 months? Could you giive more information? Just pain? How was it treated? If it is pulpitis, you can only solve this by removal of the tooth - as an emergency treatment, unplanned? What in case of systemic illness? How often did you need more than a local anesthesia because in case of acute inflammation it did not work sufficiently? Had there been abscesses? What's about the development of cysts (from left pericoronal tissues, or as a result from pulp necrosis), and so on. What's about the patients? Are they angry that there is a second surgical intervention within sme months? Who covers the costs?

Such a study would be of highest interest.

And - best, of course - in the long run (10 to 20 and more years)...

2. You should perhaps open a new question, it could be better found...

Kind reagards

Yango

Dear Caroline,

I hope not too sharp, that is not my intention.

However, I want to know it exactly. I like to dig as deep as possible, and if I'm not contented, I insist. This sometimes results in the resign of my discussion partners - I know. Usually in cases where I am offered just statements, but no arguments. But is it my fault, if even the most acknowledged scientists use wrong statistics, and are incredibly biased, and thus transport invalid information? My duty as scientist is to uncover these mistakes, to find the real thing. For that I have to use a sharp speech, to name the problems clearly, to not allow anyone to easily escape: only that way I can get the information necessary to decide whether it is opinion, or believe, or proove. I do that even in cases where I have the same conviction, playing the role of an "advocatus diaboli"...

(Un-)Fortunately, scientists are primarily human beings, and therefore emotional, egocentric, narcistic, and therefore not primarily interested in the truth but in being right*... (I include myself, but I'm working on it - more or less unsuccessful ;-) ). And they define themselves by their work, and. Well, despite I never (I hope) offended s.o. personally, I'm not everybodies darling. But if we want to proceed, to improve, we can't look upon the mental wellness of single persons...

There has been a philosopher iin Germany (seems we have had a lot of them) , who said: "It is almost impossible to carry the torch of truth through a crowd without searing someone's beard".

There are several other very interesting quotes and aphorisms, I like (most of) them:

http://en.wikiquote.org/wiki/Georg_Christoph_Lichtenberg

"*It is not the possession of truth, but the success which attends the seeking after it, that enriches the seeker and brings happiness to him."

http://en.wikiquote.org/wiki/Max_Planck

I would add: "Or what is widely considered as truth"...

Best regards

Yango

Better prophylactically extract the third molars. Common reason for mild anterior crowding.

I agree with Dr Pohl´s post above. In medicine, dentistry still contains a high number of clinical practices that are not based on much actual scientific data. I consider it my responsibility to constantly strive to evaluate the treatments I give based on actual scientific evidence and this requires self-criticism also toward my own practices (although it feels painful at times!).

My viewpoint to the matter stated by Dr. Nammalwar above would be that mild anterior crowding in many patients is a preferable outcome to permanent nerve damage/dysesthesias is a select few (although luckily, very rare) patients. I´ve met patients (luckily they were not mine) with lifelong problems due to nerve complications of routine third molar surgery and this has made me consider every surgical case with one question in mind above all: "Can we justify taking such a risk in this case?" Radiographs only tell of low- or high risk cases, not that there is NO risk because there are always risks involved in any surgery.

Also, the Finnish medical guidelines state that third molars are not a significant cause of anterior crowding in any patients, orthodontic or otherwise. This is based on, for example, the following studies which I highly recommend:

http://www.ncbi.nlm.nih.gov/pubmed/2321598

http://www.ncbi.nlm.nih.gov/pubmed/9105149

http://www.ncbi.nlm.nih.gov/pubmed/11199603

Http://www.nice.org.uk/nicemedia/live/11385/31993/31993.pdf

The NICE treatment guide is almost identical to the Finnish guidelines. Thank you Dr.Gaballah for posting!

These are the translated Finnish guidelines as a summary: http://www.kaypahoito.fi/web/kh/suositukset/naytaartikkeli/tunnus/ccs00056

thanks a million Aero for the Finnish guidance

I just found on the net a table from this article, bringing interesting epidemiological data on the pathologies of the included third molar.

Mr. Santosh Patil is a member of RG, I hope he could join this interesting discussion.

ORIGINAL ARTICLE

Year : 2013 | Volume : 2 | Issue : 1 | Page : 10-15

Prevalence and type of pathological conditions associated with unerupted and retained third molars in the Western Indian population

Santosh Patil

Department of Oral Medicine and Radiology, Jodhpur Dental College, Jodhpur National University, Jodhpur, Rajasthan, India

https://www.google.com/search?q=winter+third+molar+pdf&sa=N&rlz=1C2SKPL_enIT447&tbm=isch&tbo=u&source=univ&ei=YvKsUqGeHIfD0QXSs4CQCA&ved=0CE8QsAQ4Cg&biw=1280&bih=665#facrc=_&imgdii=_&imgrc=kxJeQnsr_7pIwM%3A%3Bn7YrW5oTKigF1M%3Bhttp%253A%252F%252Fwww.craniomaxillary.com%252Farticles%252F2013%252F2%252F1%252Fimages%252FJCranioMaxDis_2013_2_1_10_113574_t3.jpg%3Bhttp%253A%252F%252Fwww.craniomaxillary.com%252Ftext.asp%253F2013%252F2%252F1%252F10%252F113574%3B464%3B381

Thanks for the fruitful discussion. I already learned a lot.

The guidelines mentioned above (Nice, Finnish) are relatively short - are there 'long versions' available?

In Germany, we try to establish guidelines in dentistry according to the guideline of the AWMF (working group of the German scientifical medical associations), which is similar to the SIGN guideline.

http://www.awmf.org/die-awmf.html

http://www.sign.ac.uk/

This comprises short and long versions, as well as versions for patients.

Unfortunately they are in German only, as far as I know. And I'm sorry, I didn't and I won't find enough time to translate those.

short

http://www.awmf.org/uploads/tx_szleitlinien/007-003k_S2k_Weisheitszahnentfernung_03-2013.pdf

long

http://www.awmf.org/uploads/tx_szleitlinien/007-003l_S2k_Weisheitszahnentfernung_01-2013.pdf

patient

http://www.awmf.org/uploads/tx_szleitlinien/007-003p_Operative_Entfernung_von_Weisheitsz%C3%A4hnen_122012-2017.pdf

report on the establishment

http://www.awmf.org/uploads/tx_szleitlinien/007-003m_Operative_Entfernung_von_Weisheitsz%C3%A4hnen_122012-2017.pdf

https://www.researchgate.net/publication/256903185_._Incidence_of_impacted_mandibular_third_molars_in_population_of_Bosnia_and_Herzegovina_a_retrospective_radiographic_study

Article . Incidence of impacted mandibular third molars in populatio...

from my experience, i have found that about 90% third molar gives problem such as periconitis, cellulitis, trismus, dysphagia etc. Generally this tooth erupts in between 18 to 25 years.During eruptionof this tooth, we should take an IOPA and search for space availability for the eruption of the tooth. If there is insufficient space, and there is repeated occurrence pericoronitis, it is better to extract the tooth before completion of root formation or closure of apical foramen. I always prefer to extract over conserve the third molar tooth, since it is a vestigial one .

"Predicting lower third molar eruption on panoramic radiographs after cephalometric comparison of profile and panoramic radiographs" , Begtrup, Christensen, Gronastod, I. Kjaer, The European Journal of Orthodontics, 2013