CC

The patient states, “My lower wisdom teeth are hurting.”

HPI

A 27-year-old female is referred to your clinic for consultation regarding her third molars. The patient completed her orthodontic therapy in her teen years. For the past few weeks, she had experienced increasing discomfort in the posterior mandible. She was subsequently referred by her dentist for evaluation. She denies any fever, swelling, drainage, or trismus as a result.

PMHX/PDHX/medications/allergies/SH/FH

The patient reports no significant medical problems and takes birth control medicine regularly. She recalls having had tonsillectomy and ear tubes as a child. Thorough past medical and dental histories are important to determine any potential concerns with general health, fitness for anesthesia, and any possible anesthetic or surgical risks. Although this patient does not report any medical problems regarding these concerns, the surgeon must consider an appropriate plan to contend with the following: bleeding from coagulopathies (secondary to derangement of hemostasis or medication induced); wound healing affected by medications (i.e., immunosuppressants) or underlying medical concerns (i.e., diabetes or autoimmune diseases or radiation to a surgical site); fitness for anesthesia and surgery with regard to cardiac, circulatory, and respiratory status; and mental status with regard to the patient’s ability to understand the procedure or be able to cooperate with a surgical plan. Although bleeding disorders (i.e., coagulopathies) may be of concern, the surgeon more commonly encounters bleeding problems as a result of anticoagulant medicines, such as warfarin or newer antiplatelet drugs or over-the-counter nonsteroidal antiinflammatory drugs (NSAIDs) or herbal medicines. Countermeasures are considered based on the mechanism of action of these specific drugs and may include simply stopping the medicine versus a counter drug. The patient may be taking anticoagulant therapy to prevent a thromboembolic event. The surgeon must stratify the patient’s risk as low, moderate, or high for a perioperative thromboembolic event as a result of stopping or modifying anticoagulant therapy. The surgeon may coordinate care with the patient’s cardiologist and consider the urgency and nature of the planned surgical intervention. Wound healing is also of paramount concern and may require optimizing medical therapy for an underlying medical condition (i.e., diabetes) or perhaps holding certain medicines (i.e., bisphosphonates) to accomplish a procedure or considering prophylactic removal of compromised teeth before the start of radiation to the head and neck or closely monitoring wound healing from an oral surgery procedure in an irradiated field. The patient’s fitness for surgery and anesthesia may be assessed in metabolic equivalents as a functional assessment. One may also inquire about prior cardiac history (i.e., stents, cardiac surgery, peripheral artery disease) and exercise tolerance to help determine the need for perioperative cardiac diagnostics (i.e., electrocardiography [ECG], echocardiography, stress testing, or perfusion imaging). As a result, the patient may require “medical optimization” or perhaps more invasive cardiac procedure to minimize the risk of cardiac event in the perioperative phase of oral surgical care.

The patient does report intermittent symptoms suggestive of temporomandibular joint dysfunction (TMD). She does have intermittent clicking noises on function but no history of locking. TMD may be aggravated in rare cases as a result of anatomic predisposition of the temporomandibular joint (TMJ) (i.e., discal dislocation, condylar pathologies) or surgical techniques (i.e., mouth opening position, length of time for surgery, use of mallet and chisel). She has been taking ibuprofen for her dental pain and no other medicines on a regular basis. The patient smokes approximately a half pack of cigarettes per day for the past 6 years (risk factor for the development of dry sockets). Al-Belasy (2004) has reported the incidence of dry sockets to be reduced with smoking cessation. The patient may be counseled on smoking cessation for general health as well as its effect on wound healing.

Examination

General. The patient is a well-developed and well-nourished female in no apparent distress. Patients exhibiting higher levels of anxiety may require a deeper level of sedation and anesthesia.

Maxillofacial. There is no soft tissue abnormality or lymphadenopathy. The patient has a good range of mandibular motion with a maximal interincisal opening (MIO) of 45 mm. Examination of the TMJ reveals no clicks or pain on palpation nor any deviation on range of motion. The muscles of mastication are nontender to palpation. It is important to detect preexisting symptoms of TMD. The range of motion of the mandible and of the neck and classification of the airway may indicate the difficulty of intubation if needed.

Intraoral. Oral soft tissue is free of lesions, and there is no evidence of acute infection. The mandibular third molars are impacted and hypoerupted, with approximately 20% of the crown visible in the oral cavity with insufficient space for functional eruption. The overlying operculum appears slightly inflamed, with evidence of plaque and periodontal pockets of 6 mm on the distal of the left and right mandibular second molars. The right and left maxillary third molars are hypoerupted and buccally malposed with occlusal caries. Oral hygiene is fair. An examination of the oropharynx is without tonsillar hypertrophy, and the patient has a Mallampati score of 1.

Obvious indications for the removal of third molars include pain, infection, dental and periodontal disease (of the third molar or adjacent teeth), nonrestorable status of the tooth, malposition, and lack of space leading to such conditions. However, other indications according to the parameters of care of the American Association of Oral and Maxillofacial Surgeons (AAOMS) include abnormality of size or shape not allowing appropriate function, facilitation of prosthetic rehabilitation, facilitation of orthodontic positioning of teeth, tooth interfering with mandible fracture repair or orthognathic surgery, teeth with associated pathology (odontogenic tumors), prophylactic removal in the face of pending medical or surgical care (e.g., transplant surgery, bisphosphonate, chemo- or radiation therapy), tooth fracture, pathologic resorption of tooth, malposed third molars adversely influencing the eruption of adjacent teeth, and third molar as a donor tooth for autotranplantation, The decision to remove symptomatic third molars may be more straightforward on complete discussion of the informed consent process with the patient or their family. However, the decision to remove asymptomatic third molars (impacted or otherwise) or to monitor them has been the subject of some controversy over the years. Unfortunately, there is no clear guidance from multiple studies for either decision. Despite the lack of clear evidence, the decision for removal or monitoring the third molars is one that should be best undertaken with the patient based on their clinical and radiographic examination and discussion of the pros and cons of both possible choices and the various rationales for removal. As indicated by Pogrel, it is clear younger patients (younger than 25 years old) do fairly better in the recovery process. Conversely, the risk of complications and recovery do increase with increasing age. The decision to remove asymptomatic third molars should be driven by evidence-based decision making; the predominant guiding principle should be the patient’s preference.

Imaging

A panoramic radiograph is the minimum imaging modality necessary for the evaluation and treatment of impacted third molars. This imaging affords an overall view of the position of the third molars in a two-dimensional representation. Most important, it can indicate the proximity of the roots of the third molars to the inferior alveolar nerve (IAN) canal. The radiographic markers of possible IAN proximity and subsequent possible adverse outcomes are well-known for panoramic imaging, such as deflection of the canal, narrowing of the canal, darkened appearance over the roots of these teeth, or loss of cortical borders of the canal (Rood’s predictors: Box 27.1 ). As a result, the surgeon may recommend three-dimensional (3D) imaging to better visualize the relationship of these vital structures and better predict the risk of removal of these teeth. Cone-beam computed tomography (CBCT) is becoming more common place in practice. Computed tomography (CT) scans are not always necessary for routine evaluation, but they may be used in select cases of suspected maxillofacial pathology or for accurate determination of the IAN anatomy. Multiple studies suggest that the CBCT is “a valuable diagnostic adjunct for identification of an increased risk for IAN injury, the use of CBCT does not translate into a reduction of IAN injury and other postoperative complications, after removal of the complete mandibular third molar” (Fee et al.). Tofangchiha et al. found the root apex darkening of impacted third molars and interference with the white line of the inferior alveolar canal on panoramic radiographs had a high positive predictive value for determination of the contact of impacted mandibular third molars with the inferior alveolar canal.

Slavos et al. assessed the degree of compression of the IAN canal with outcomes of the mandibular third molar removal surgery and found that a greater degree of compression may predict an increased risk of IAN injury postoperatively. Multiple studies have identified the buccolingual IAN position and decorticalization of the IAN canal with lingual position of the nerve are associated with high risk of nerve damage. Direct contact with the root of third molars and IAN canal or nerve and appearance of a teardrop or dumbbell shape of the canal or nerve in cross-section on a CT are indicative of anatomic risk factors.

Given the risk of postoperative IAN injury, partial odontectomy (coronectomy) may at times be an alternative treatment in patients requiring removal of a third molar that is in close proximity to the IAN. However, this procedure does not eliminate the risk of IAN injury and possible future infectious complications because of retention of root fragments. More recent studies support coronectomy as an alternative to minimize the risk to the IAN. However, the decision to perform coronectomy versus total odontectomy should be discussed thoroughly with the patient, weighing the pros and cons of each procedure and the patient’s risk tolerance.

In the current patient, the panoramic radiograph ( Fig. 27.1 ) reveals a lack of space to accommodate the eruption of the distoangularly impacted mandibular third molars with 100% root development. The roots are completed in development and extend inferior to the level of the neurovascular bundle. The outlines of mandibular canals are easily discerned on the radiograph. There is no diversion of the inferior alveolar canal, but there is interruption of the cortical white line, and there is darkening of the third molar root (risk factors associated with IAN injury). The maxillary third molars are buccally malposed and hypoerupted. The maxillary sinuses and the remainder of the radiograph are within normal limits. The primary risks associated with the maxillary third molars, depending on their degree of impaction, are displacement to the maxillary sinus or to the infratemporal or pterygoid spaces or perhaps iatrogenic creation of oroantral communication. For this patient’s case, given the panoramic image findings of the mandibular third molar teeth position relative to the inferior alveolar canal, a 3D CBCT was ordered to better evaluate the relationship of these structures ( Fig. 27.2 and eFig. 27.3 ). In the 3D imaging, it was evident that there was loss of cortical bone around the inferior alveolar canal in relation to the root position. eFigs. 27.4 and 27.5 show the IAN canal in orange highlight .

Panoramic radiograph demonstrating the position of the impacted third molars.

Cone beam computed tomography reconstruction with outline of the mandibular canal with transverse and coronal analysis as different angles.

Cone beam computed tomography reconstruction with outline of the mandibular canal with transverse and coronal analysis as different angles.

Cone beam computed tomography reconstruction with outline of the mandibular canal with transverse and coronal analysis as different angles.

Cone beam computed tomography reconstruction with outline of the mandibular canal with transverse and coronal analysis as different angles.

Labs

No routine laboratory tests are indicated for the routine evaluation of impacted third molars unless dictated by underlying medical conditions. Female patients in their childbearing years should be questioned as to pregnancy because pregnancy has implications on the choice of anesthetics and perioperative analgesic medications (e.g., NSAIDs are contraindicated in pregnancy). Depending on the patient’s medication list or medical problems, the surgeon may require results of an international normalized ratio or coagulation studies, a complete blood count and chemistry panel, and perhaps cardiac evaluation with ECG or stress testing and may consult with the patient’s medical doctor for any specific questions that may arise.

Assessment

A 27-year-old female in good health with partial bony impaction of the right and left maxillary and mandibular third molars with insufficient space for functional eruption; carious malposed maxillary third molars, localized gingivitis, and periodontal pocketing are noted around the left and right mandibular third molars.

Treatment

The patient was seen in the clinic for extraction of teeth #1 and #16 and coronectomy of #17 and #32 under intravenous sedation. The patient has taken preoperative antibiotics (amoxicillin 1 g orally). Monitors (pulse oximetry, capnography, blood pressure, and three-lead ECG) were placed, and oxygen was delivered via a nasal mask at 4 L/min followed by nitrous oxide. Midazolam, fentanyl, and propofol were slowly titrated until a comfortable state of conscious sedation was achieved. A local anesthetic with epinephrine was injected, and adequate time was allowed for the local anesthetic block. A bite block was placed for TMJ stabilization. An oral screen with loosely packed, moist gauze was placed to protect the airway from accidental aspiration. A full mucoperiosteal flap was elevated using a buccal envelope incision with a distal hockey-stick extension for the mandibular third molars. Special consideration was given to preventing trauma to the lingual tissue. A buccal trough was made using a high-speed instrument (impaction drill and burr with irrigation), and the crown of the impacted tooth was exposed. The crown was sectioned from the roots with careful attention paid to avoid violation of the lingual cortex (although at times, disrupting the lingual cortex is unavoidable).

The position of the lingual nerve is found to be very variable by multiple studies. In the largest cadaveric study of lingual nerve anatomy by Behnia and associates, 669 nerves from 430 fresh cadavers were examined. In 94 cases (14%), the nerve was above the lingual crest, and in 1 case, the nerve was in the retromolar pad region. In the remaining 574 cases (86%), the mean horizontal and vertical distances of the nerve to the lingual plate and the lingual crest were 2.1 mm and 3 mm, respectively. In 149 cases (22%), the nerve was in direct contact with the lingual plate of the alveolar process. The unpredictable anatomy of the lingual nerve in relation to the mandibular third molar increases this nerve’s susceptibility to injury. More recent studies confirm the lingual nerve ranges in horizontal position from direct contact with the lingual cortical plate to up to 4 mm, and the vertical range varies from the alveolar crest to up to 16.8 mm (Mendes et al.).

The remainder of the coronal aspect of the root was trimmed to eliminate any remnants of the enamel of the crown. The root remnant was smoothed to ensure it remained at least 3 to 4 mm apical to the bony margin. The neurovascular bundle was not visualized, and there was no excessive hemorrhage from the socket. (Visualization of the neurovascular bundle, on total odontectomy, and excessive hemorrhage from the socket are associated with an increased risk of IAN injury.) The wound was irrigated with normal saline, Platelet-rich fibrin (PRF) plugs were placed into the sockets, and the flaps were closed primarily with chromic suture, with careful attention paid to suturing only the superficial lingual mucosa and thus preventing lingual nerve injury. Recent systematic reviews and meta-analyses have shown that L-PRF may facilitate soft tissue healing. The variety of PRF may be fabricated based on specific spin protocols using a centrifuge.

The maxillary third molars were removed through an envelope mucoperiosteal flap, and the teeth were elevated and extracted with forceps. Care was taken to avoid the roots of the maxillary second molars (a possible complication). There was no evidence of oral antral communication. The tooth follicular remnants were removed, and the sites were irrigated. Gauze was placed between the sites to promote hemostasis, and the patient was monitored in the recovery room until she was fully awake and alert. A postoperative Panorex was taken indicating the results of the recent procedure and to document the coronectomy and position of the remaining roots ( Fig. 27.6 ). The patient may be discharged home with her family upon meeting the Aldrete scoring system for postoperative recovery.

Postoperative panoramic radiograph showing coronectomy of teeth #17 and #32 and extraction of teeth #1 and #16.

The safe removal of third molars is one of the most common surgical procedures in the skill set of oral and maxillofacial surgeons. As mentioned previously, the decision to monitor or treat the third molars should be a patient-driven decision because there is limited clear guidance for practitioners. The decision to provide perioperative antibiotics is also somewhat controversial in terms of whether to provide a prophylactic antibiotic to an otherwise healthy individual patient. If one does decide to provide antibiotic, there is also no expected regimen to follow because there is no clear evidence as to any one antibiotic choice or regimen. In general, however, the outcomes from various studies indicate equivocal outcomes for those given antibiotics and those not. The one guiding principle for an antibiotic choice would be to cover the appropriate oral flora. If one is not allergic, then penicillin is still the most recommended choice. There is also no clear guidance as to the technique of tooth removal; it essentially comes down to “surgeon preference.” It will commonly be suggested for a surgeon to develop his or her own protocol based on the survey of the literature to guide evidence-based practices and to follow sound surgical principles. Although the majority of patients undergoing third molar surgeries have excellent outcomes, the surgeon should be prepared to manage all variety of complications that may arise. Although many are trained to remove teeth, oral and maxillofacial surgeons are in the unique position to manage oral and maxillofacial wounds and complications arising from the removal of third molars or any other tooth. A variety of complications may arise in the perioperative management of third molars, including pain, swelling, bleeding, fracture of the tooth in question and having to leave a root fragment, displacement of root fragment to an adjacent fascial space or to the maxillary sinus or mandibular canal, local or fascial space infection and possible hospitalization and emergent airway procedures, injury to adjacent teeth, alveolar osteitis, periodontal defects, trismus, jaw fracture, oroantral communication, dentoalveolar fracture, injury to the IAN or lingual nerve resulting in hypoesthesia, and instrument fracture. More extreme complications include hematoma formation tracking to the airway resulting in death, aspiration of tooth fragment, mediastinitis from fascial space infection, hemorrhage, or infection via the inferior orbital fissure leading to periorbital infection or compression and vision changes.

Coronectomy may be considered as a surgical approach in patients with high-risk third molar teeth with IAN proximity and coronal pathology or symptoms from their impacted position. A systematic review of the complications of high-risk third molar removal surgery was evaluated by Pitros et al. indicating that coronectomy “reduced the risk of nerve injury in high risk third molars.” However, they caution that “outcomes such as the need for re-operation . . . may alter the cost ratio of coronectomy:extraction” and suggested that “higher quality studies with longer follow up are needed.” Monaco et al. also found that a coronectomy may be recommended for treatment of third molars in close proximity to the IAN or inferior alveolar canal because of their findings of low postoperative complications and no cases of neurologic lesions nor any cases of late infections with the retained root in their prospective study with 5-year follow-up. Vignudelli et al. found “restoration of a clinical healthy periodontium distal to the second molar was observed” after third molar coronectomy.

For the sake of completeness, another alternative treatment option with high-risk third molars is orthodontic extrusion using various orthodontic traction methods, resulting in an improved position of the impacted tooth relative to the inferior alveolar canal.

Complications

Third molar extraction is the surgical procedure that oral and maxillofacial surgeons perform most often. A well-planned surgical approach, with the goal of prevention, is the best way to minimize complications. But despite our best efforts, complications are expected, and it is best to counsel patients preoperatively for potential risks. Clinicians need to be aware of the risk factors associated with an increased risk of complications for this commonly performed procedure.

Pogrel concluded, “The age of 25 years appears in many studies to be a critical time after which complications increase more rapidly.” No studies indicate that complications decrease as age increases. In fact, the older a patient is, the more likely it is that the recovery from complications will be prolonged, less predictable, and less complete.

Sensory nerve injury is well documented. The anatomy of the IAN is variable, but the canal is usually located inferior and buccal to the impacted mandibular third molars. A lingual position of the canal in contact with the roots of the mandibular third molars increases the risk of injury. Injury to the IAN can lead to a range of symptoms along its distribution (anesthesia, hypoesthesia, dysesthesia, or paresthesia). A review of the literature demonstrates an incidence of nerve injury between 0.4% and 7%. In one large study with 367,170 patients, the incidence of nerve injury was 0.4% (22% of whom had symptoms lasting longer than 12 months). The risk of nerve injury is greater with increasing patient age, degree of root development, degree of impaction, and the radiographic relationship of the roots to the inferior alveolar canal. The incidence of injury to the IAN is slightly higher than that for the lingual nerve, but the IAN has a higher incidence of spontaneous recovery (because of its position in the bony canal, which allows a greater possibility that the nerve endings will reapproximate); however, older patients are more likely to have incomplete recovery. Injury to the long buccal nerve is also possible, but it is less of a concern, causing minimal to no subjective disability. Patients with severe IAN or lingual nerve injury should be referred to a microneurosurgeon for prompt evaluation and potential surgical intervention (decompression, neurolysis, or neurorrhaphy). Suhaym and Milono reported: “A trend towards early repair achieving better functional sensory recovery outcomes was observed, but the specific time period is unknown.” Complications from local anesthesia also have been reported, probably caused by direct needle trauma to the IAN. The reported incidence ranges from 1 in 400,000 to 1 in 750,000 patients.

As with any other procedure, infections are commonly associated with third molar removal, both preoperatively and postoperatively. This appears to be more common after removal of partial and full bony impactions. Infections can occur as early as several days after the procedure, or they may present late (within several weeks). They can be localized to the area of the third molar or occasionally can spread to adjacent fascial spaces to cause life-threatening conditions. Most infections are easily managed with local measures and the use of antibiotics. The incidence of postoperative infection is approximately 3%. There is increasing evidence to challenge prophylactic use of perioperative antibiotics in otherwise healthy patients undergoing removal of wisdom teeth (impacted or otherwise). Lodi et al. performed a meta-analysis including 23 trials randomizing 3206 participants to prophylactic antibiotics or placebo and found that the vast majority of studies (21 of 23) included mostly healthy individuals. “On average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection.” As a result, these results are not generalizable to overall population. Immunocompromised patients or patients with medical problems should be treated on an individual basis and their susceptibility to infection as a result of a procedure. Morrow et al. found postoperative antibiotic use to decrease inflammatory complications compared with no antibiotic use. Mariscal-Cazalla also found that perioperative antibiotic decrease postoperative pain and inflammation compared with placebo. The decision on whether to prescribe antibiotics is multifactorial, and generally left to the clinical decision of the practitioner.

In the event of coronectomy procedures, Pitros et al. found the risk of root migration to be variable (13%–85%) and the average incidence of reoperation to be 2.2%, low rates of infection, and reduced IAN injury by 84%. Leung studied factors such as age, sex, type and pattern of impaction, and root form with regard to root migration rate and found that 91% of root migrations occurred within the first 6 months, decreased thereafter, and dropped to less than 5% after 24 months. They also found that “migration decreased with increasing age” and other factors unrelated to migration. A younger patient is more likely to have root migration in their lifetime and should be counseled as such.

Localized osteitis (dry socket) is a well-known complication of tooth extractions. Although the cause of dry socket is still not completely understood, it is believed to be the result of disintegration of the clot by localized fibrinolysis via the activation of the plasminogen pathway by direct and indirect substances. The incidence widely ranges from 1% to 37% for mandibular third molar removal sites. The most plausibly identified risk factors of dry socket development may be related to surgical trauma or difficulty in removing a third molar (i.e., level of impaction, local bony conditions, length of time) surgeon experience, oral contraceptive use, female gender, smoking history (amount and length of time), localized bacteria, prior history of localized pericoronitis, and increased age. Known beneficial methods of prevention include systemic antibiotic use to reduce postoperative inflammatory complications and use of topical chlorhexidine 0.12% oral rinse. There is no consensus for treatment other than pain management. Recent studies have suggested application of PRF. Some studies have demonstrated improved outcomes of pain score and reduction of dry socket development with the application of PRF to the socket or wounds.

Other complications associated with third molar surgery include periodontal complications, maxillary sinus involvement (oral antral communications, displacement of a fragment into the sinus), displacement of a tooth into adjacent fascial spaces, breakage of instruments, aspiration or swallowing of foreign objects, TMJ pain, maxillary tuberosity fractures, root fracture, injury to adjacent teeth, hemorrhage/hematoma, wound dehiscence, mandible fracture, and soft tissue emphysema. The displacement of a tooth or root fragment to the maxillary sinus may be managed by attempted retrieval from the site of perforation. If this unsuccessful, then consideration for Caldwell Luc access to retrieve a fragment and concurrent use of antibiotic therapy to minimize risk of sinus infection. The oroantral communication may be addressed by a variety of localized pedicled flaps based on branches of the maxillary artery (from rotational flap to advancement flap to buccal fat advancement flap and primary closure). The surgeon will be adept in the management of these complications.

Discussion

Two major professional organizations have made contradictory recommendations on the prophylactic removal of impacted third molars. The researchers for AAOMS Third Molar Clinical Trials published several scientific articles that linked third molars to future health problems in adults. In light of these findings, in 2005, the AAOMS suggested that removal of the third molars during young adulthood may be the most prudent option. In contrast, the National Health Service (NHS) of Great Britain and an associated agency, the National Institute of Clinical Excellence (NICE), published a series of guidelines recommending that “the practice of prophylactic removal of pathology-free impacted third molars should be discontinued in the NHS.” These guidelines, made public in 2000, did acknowledge the ongoing AAOMS Third Molar Clinical Trials. In 2012 Renton and colleagues published an article chronicling the United Kingdom’s experience with retention of third molars. They concluded that “admissions for M3

In some regions of the world, socioeconomic and available resources play a major role in the determination of guidelines for third molar extractions, and current scientific evidence remains unchanged. The cumulative financial costs of treating the health complications of retained third molars in the older population should be considered. Although there is cost associated with the procedure to remove third molars, there is also the cost of monitoring retained third molars. Subsequent removal at an older age may also be associated with the cost of lost income in recuperation time in addition to the greater risks of removal at an older age. In a systematic review and economic evaluation of the prophylactic removal of mandibular third molars, Hounsome et al. developed an exploratory model based on evidence of symptom development and the rates of extraction of retained impacted mandibular third molars and suggest that “prophylactic removal may be the more cost-effective strategy.”

It is clear that the extraction of third molars poses some risks to the patient. However, the determination of extraction versus nonextraction of asymptomatic third molars must compare the cost and risks of surgical extraction with the lifetime health and cost benefits of preventing and eliminating any pathologic processes associated with retention of the third molars. More recent studies continue to bolster these concepts.

The effectiveness, safety, and relatively minimal cost of extraction of third molars using outpatient, office-based anesthesia, along with the currently available scientific evidence linking asymptomatic third molars to multiple health hazards, generally support the extraction of asymptomatic third molars in young adults; however, as mentioned, the patient’s preference and an informed decision arrived at by the surgeon and patient are the most important deciding factors.

Indications for the removal of third molars are variable and influenced by many factors, as previously outlined. Insufficient room for adequate eruption of the teeth can create difficulty with maintenance of oral hygiene in these areas, affecting the adjacent soft tissues and teeth. The increased difficulty and risks of third molar removal with increasing age, inadequate oral hygiene, and tooth position, in addition to periodontal health and orthodontic considerations, should be taken into account. Erupted or partially erupted third molars have been shown to have a negative impact on periodontal health. In a study by Dodson, attachment levels and probing depths improved after third molar removal. Pogrel reported that a periodontal condition may persist or may be created on the distal aspect of the second molar after third molar removal, especially in some older patients. Dodson has suggested that in this subgroup of patients, immediate reconstruction may be beneficial in the long term. However, the relationship between third molars and periodontal disease pathogenesis requires further study. There is no clear consensus on the ability of mandibular third molars to cause crowding of the anterior teeth. Although some investigators have shown a statistical association of third molars and late anterior crowding, this association is not strong. The majority of the literature does not support this hypothesis.

Offenbacher and colleagues published a study on periodontal disease and the risk of preterm delivery. The study involved 1020 pregnant female patients who received antepartum and postpartum periodontal examinations. The findings clearly demonstrated that maternal periodontal disease increases the relative risk of preterm or spontaneous preterm birth. The mothers with third molar periodontal pathology had elevated serum markers of systemic inflammation (C-reactive protein, isoprostanes). Periodontal disease was also a predictor of more severe adverse pregnancy outcomes.

For extraction of third molars, there is a wide range of choices of anesthetic and surgical techniques related to the surgeon’s training and experience. As the common dictum proclaims, “There is more than one way to do it.” Many different surgical flaps and instruments have been developed over the years. A variation of the buccal hockey stick incision appears to be the most commonly used and has the lowest incidence of permanent neurosensory injury. Similarly, the choice of anesthesia can vary from local anesthesia, to intravenous sedation using a variety of medications, to general anesthesia with endotracheal intubation. This choice is influenced by many factors, including the patient’s preference, available resources, surgeon’s training, and practice patterns in the region. Various regimens of perioperative care are also followed. Common practices include the use of a long-acting local anesthetic (e.g., 0.5% bupivacaine or 1.3% bupivacaine), corticosteroids, and NSAIDs to improve postoperative pain management. Bailey et al. performed a meta-analysis of the various databases comparing various surgical techniques for the removal of mandibular third molars teeth in randomized controlled trials and found no meaningful conclusive recommendations to guide surgeons in their technique for this removal surgery. The surgeon should be guided by their training, use of sound surgical principles, and evidence that best supports their chosen technique of care and, of course, the patient’s preference of care having been explained the risks and benefits.