American Association of Oral and Maxillofacial Surgeons

Supporting Information to theManagement of Patients withThird Molar Teeth
The following information is intended as resource material
regarding the management of third molar teeth. As in all
matters of decision-making, the AAOMS believes that
relevant evidence should be fairly interpreted by those whoare expert, experienced and active in the management ofpatients with third molars, using an organized approach toevaluate the validity and clinical relevance of the evidence.
Where there is an absence of conclusive evidence, theavailable evidence should be interpreted and used in amanner that is most likely to benefit the patient, considering both short and long-term consequences of removal andretention strategies.

Pathologies Known to be Associated withThird Molar Teeth

Third Molars Are Different

6) Cysts

Third molars are different from other teeth in importantways, highlighted by their greater frequency and severityof disease and the fact they are typically non-functional.
The differences are, to a large degree, secondary to theirlocation, as they are the most distal teeth in the dentalarch and the last to erupt into the oral cavity, leaving lessphysiologic space for eruption and maintenance. The
result is poor quality soft tissue support that often leads
to percolation of bacteria beneath the gingival tissues
surrounding the third molar. This contributes to subclinicalinflammation that often progresses to pericoronitis andinfection. Periodontal pocketing is frequently found aroundthird molars as well as dental caries, which are difficult torestore. In addition, the roots of these teeth, particularly
with increasing age, are more likely to approximate
important anatomic structures such as the maxillary sinus,
adjacent teeth and the neurovascular canal. Additionally,
they are often positioned in places where associated infections may become more of an issue due to the position of
the myohyloid muscle and thin area of the lingual corticalplate, which can be predisposed to bacterial migration to
adjacent fascial spaces.

There are well-documented pathologies associated withretained third molars. These include but are not limited to:1) Dental caries
2) Pericoronitis
3) Root resorption4) Periodontitis
5) Infections (local and fascial space)
7) Tumors
8) Mandible fractures.

Potential Adverse Outcomes Associated withSurgical Management of Third Molars
As with any form of treatment, complications may occur
secondary to any management approach, including retention. Complications from third molar removal are generally minor and resolve within a few days. Problems that
may be associated with the removal of third molars include
inflammatory complications such as infection or osteitis,hemorrhage, injury to adjacent anatomic structures, teethor nerves, periodontal defects, fractures of maxillary
tuberosity or mandible, persistent oral-antral communication, retained roots and the need for additional treatment tomanage complications.

Consequences of Third Molar Retention
The risks and implications of third molar retention include
all the known associated third molar pathologies noted
previously. While the incidence of problems associatedwith retained third molars is not completely understood,
recent papers help clarify what happens to retained thirdmolars over time. Two papers in particular are noteworthy.

PAGE 1 Supporting Information to the Management of Patients with Third Molar Teeth

The first article reflects the work of McArdle and Renton(1),who reviewed the effects of the United Kingdom’s
N.I.C.E. Guidelines over a decade and concluded that,while initially the incidence of third molar removal
was decreased as a result of these guidelines, it is now
as common as it was before their institution. They also
found that the dynamics of removal were altered. They
reported that the mean age of patients undergoing removal
increased and the reason for extraction changed to predominately include caries, periodontal disease and pericoronitis
rather than impaction.
The second article documents the findings of a group ofexperienced clinicians who asked the question; “Amongadults who elect to retain their asymptomatic third molars,
what is the risk that one or more third molars will beextracted in the future?”(2) They conducted a systematic
review of the literature. Studies included were prospective,
had sample sizes ≥ 50 subjects with at least one asymptomatic third molar and at least 12 months of follow-up.
They found that the mean incidence rate for the extractionof previously asymptomatic retained third molars ranged
from 5% at one year to 64% at 18 years, with the predominant reasons for extraction caries, periodontal disease andother inflammatory conditions. They concluded that thecumulative risk of third molar extraction for young adults
with asymptomatic third molars is sufficiently high towarrant discussion when reviewing the risks and benefitsof third molar retention as a management strategy.
In light of the above and given that the absence ofsymptoms does not equal the absence of disease, it is clear
patients who elect to retain their third molars should befollowed with active surveillance including recommendations regarding the frequency of regular follow-up visits.
Despite the fact that most patients will eventually require
removal of their third molars, some will be able to maintain these teeth for a lifetime. At this time, we cannot say
with confidence what the future will be for all patientswith asymptomatic disease-free teeth. However, there aresome things that we do know about their behavior andmanagement.

Evidence-Based Facts about Third Molar
Behavior and Management
1) Third molars are different from other teeth in significant ways.
2) An absence of symptoms associated with third molars
does not equate to the absence of disease.

3) Retained third molars frequently and unpredictablychange position, eruption and periodontal status.
4) The microbial biofilm associated with partially
erupted third molars and pericoronitis is conducive tothe development of periodontal disease.
5) Periodontal disease in the third molar area begins
with their eruption.
6) Pocketing around third molars is an important indicator of periodontal disease, especially when bleeding
occurs on probing.
7) Third molars with probing depths greater than 4mmincrease the risk for developing anterior pocketing.
8) Extraction of a third molar reduces the risk forperiodontal disease in young adults.
9) There are identifiable risk factors for delayed healing
and surgical complications associated with thirdmolar surgery.
10) There are identifiable ways to improve post-operative
healing and recovery.
11) The majority of patients with retained, asymptomatic
disease-free third molars eventually require surgicalmanagement.
12) When patients elect to retain their third molars, thefrequency of future disease is sufficiently high that
active surveillance is a superior management strategy
when compared with symptomatic as needed
follow-up.

Evidence-Based Statements Likely Valid but
Requiring Further Study:
1) While it is likely that most third molars will develop
pathology over time, there is uncertainty in identifying those that can be maintained.
2) There are costs associated with the active surveillanceof retained third molars, which may be more expensive than extraction in the long term.

PAGE 2 Supporting Information to the Management of Patients with Third Molar Teeth3) While it makes biologic sense that systemic diseases
may be linked to the oral inflammation associatedwith third molars, current evidence for a cause andeffect link is suggestive rather than definitive.

Recommendations Supported by Clinically
Relevant Evidence:
1) Surgical management of third molars is appropriate
when there is evidence of pathology.
2) Surgical intervention or removal of third molars prior
to the development of pathology should be considered in patients who have insufficient physiologic
space for eruption and maintenance at a time when
the post-surgical healing is optimal and the risk ofcomplications low.
3) To limit the known risks and complications associatedwith surgery, it is medically appropriate and surgically prudent to remove third molars in patients withdemonstrated pathology before the middle of the third
decade and before complete root development.
4) Given that third molars have been shown to be dynamic in their behavior and position, patients choosing to monitor them are committed to a lifetime offollow-up. The known variables of active surveillance
include the cost of regular imaging and follow-up
visits, the uncertainty regarding the future behavior of
the teeth, the risk for developing inflammatory dental
disease and a statistically significant increased risk
with age for operative or postoperative complications
if extraction or other treatment becomes unavoidable.
5) Third molars that are completely erupted andfunctional, symptom-free, free of caries, in hygienic
position with a healthy periodontium and without
other associated pathologic conditions do not require
extraction, but do require routine maintenance andperiodic clinical and radiographic surveillance.
6) An impacted tooth with complete root formation thatis totally covered by bone in a patient over 30 yearsof age and is not associated with clinical or radiographic evidence of pathology can be maintained but
should be monitored for future changes in position
and/or development of clinical or radiographic
pathology, which may then indicate the need for
surgical management.

Bibiliography:
1. McArdle, L, and Renton, T: The effects of NICE guidelines on themanagement of third molar teeth, British Dental Journal, Published
online: 7 Sept 2012, E8.
2. Bouloux, G., Busaidy, K., Biern, O., Chuang, S., Dodson, T.: Whatis the risk of future extraction of asymptomatic third molars? A
systematic review. J Oral and Maxillofac Surg. 73:5, 806-11, 2015
Relevant Sources:
1. AAOMS Parameters of Care: Clinical Practice Guidelines for Oraland Maxillofacial Surgery (AAOMS ParCare 2012), Dentoalveolar
Surgery Version 5.0, DEN 1, J Oral and Maxillofacial Surg 2012.
2. “Proceedings From the Third Molar Multidisciplinary Conference”, Supplement to the J Oral and Maxillofac Surg, 70:9, 2012.
3. Mettes DTG, Ghaeminia, H, Nienhuijs MMEL, Perry, J, van derSanden WJM, Plasschaert A, “Surgical removal versus retention
for the management of asymptomatic impacted wisdom teeth”,
Cochrane Oral Health Group, Online @ cochrane.org: Jun 2012.
4. Dodson, T.B, The management of the asymptomatic, disease-free
wisdom tooth: removal versus retention. Atlas of the Oral andMaxillofacial Surg Clin N Am, 20 (2012), 169-176.
5. McCoy, M: Complications of retention: pathology associated withretained third molars, Atlas of the Clinics of Oral and Maxillofacial
Surgery, 20, 177-195, 2012.
6. White, R, Fisher, E, Magraw, C, Phero, J, Advelvaky, O, Sherwood,C, Nelson, B.: Special Contribution: Third Molar Clinical Trials
Annotated Bibliography, J Oral and Maxillofac Surg., Available
online 30, October, 2015.
7. Dodson, T.: “The management of the asymptomatic, disease-free
wisdom tooth: removal versus retention”, Atlas of the Clinics ofOral and Maxillofacial Surgery, 20 (2012), 169-176.

© 2016 American Association of Oral and MaxillofacialSurgeons. No portion of this publication may be used orreproduced without the express written consent of theAmerican Association of Oral and Maxillofacial Surgeons.

PAGE 3 Supporting Information to the Management of Patients with Third Molar Teeth