Extraction versus nonextraction management of third molars

Incidence of caries and pathological findings in different positions of impacted third molars: A retrospective analysis

OBJECTIVES

Impacted third molars(3 M), commonly known as wisdom teeth, are prone to caries and pathological formations depending on their position in the jaw. This study aimed to determine and compare the incidence of caries, pathological formations, and the superposition of the roots of the mandibular impacted third molar over the mandibular canal in different positions of impacted 3Ms.

METERIALS AND METHODS

This retrospective study was conducted on orthopantomographs of patients who presented with 3 M complaints at the Tokat Gaziosmanpaşa University Oral and Maxillofacial Surgery Department between 2019 and 2023. The 3 M were classified according to their position by two researchers independently and were evaluated for caries, pathology, and nerve superposition. The position of the 3Ms classified using Pell and Gregory and Winter's classifications. The primary outcome variable was the presence of caries in the 3 M The secondary outcome variable was the presence of pathological formations around the 3 M The tertiary outcome variable was the superposition of the roots of the mandibular 3 M over the mandibular canal.

RESULTS

A total of 7,038 patients were included in the study, with 53.74 % being female. The mean age was 32.15±7.2 years. The highest incidence of caries was associated with the vertical position in both maxillary and mandibular 3Ms (right maxillary: 9.98 %, P < 0.001; left maxillary: 12.74 %, P < 0.001; left mandibular: 11.66 %, p = 0.003; right mandibular: 11.69 %, p = 0.031). Pathological formations were most commonly observed in the vertical position, but the highest incidence was found in the horizontal or mesioangular positions (right maxillary: 36.84 %, p < 0.001; left maxillary: 40 %, p < 0.001; left mandibular: 62.04 %, p < 0.001; right mandibular: 62.25 %, p < 0.001). Nerve superposition was most common in the vertical position but was highest in the distoangular position (left mandibular: 74.69 %, p < 0.001; right mandibular: 76.66 %, p < 0.001).

CONCLUSIONS

The position of 3Ms plays a critical role in the development of complications such as caries and pathological formations. Prophylactic extraction may be considered more seriously in cases where the position of the tooth poses a higher risk of complications.

Assessment of the Relation Between Patterns of Third-Molar Impaction and Blood Group: A Retrospective Study

Background The prevalence of impacted third molars is high in the global general population. The etiology of impacted third molars is not fully understood, but it is thought to result from combined genetic and environmental factors. Some studies have suggested a link between the blood group and the risk of impacted third molars. This study aimed to investigate the association between the blood group and the presence of impacted third molars and its pattern. Method A total of 856 panoramic radiographs were included in the study. The third molars were evaluated for the pattern of third-molar impaction and blood characteristics recorded as ABO group and presence or absence of Rhesus antigen. Results The results showed no significant association between the blood group and the presence of impacted third molars. The prevalence of at least one impacted the third molar was 34.6%. The most common angulation of impacted third molars was vertical (V) (45.1%), followed by mesioangular (MA) (33.7%), distoangular (DA) (13.8%), and horizontal (H) (7.4%). There was no significant association between the blood group and the number of impacted third molars nor between the blood group and the angulation of the impacted third molars. Conclusion This study suggests that the blood group is not a major factor in the development of impacted third molars. However, further studies with larger sample sizes are needed to confirm these findings.

Prognosis for the impacted lower third molars: Panoramic reconstruction versus tomographic images

OBJECTIVE

The aim of this cross-sectional accuracy study was to compare panoramic reconstruction (PR) and multiplanar reconstruction (MPR) images, which are used to establish the prognosis for impacted mandibular third molars in relation to professional decision making.

STUDY DESIGN

Images of 10 patients who had undergone cone beam computed tomography (CBCT) examination were selected, resulting in 2 distinct groups of images, with 10 in each group: PR and MPR. To check prognostic accuracy, 2 images from each group were randomly selected and reinserted into the sample, totaling 24 images. A questionnaire was completed by 54 professionals: 27 orthodontists and 27 oral and maxillofacial surgeons (OMFSs). Data were evaluated by using the χ² and McNemar's tests and Kappa statistics at P < .05.

RESULTS

There were no statistically significant differences when isolated PR images were compared with MPR images by orthodontists (P = .72) or OMFSs (P = .45). However, there were significant differences in the professional decision regarding the prognosis for impacted teeth, where OMFSs indicated the need for more extractions compared with orthodontists (P < .0001).

CONCLUSIONS

There are no differences between PR and multiplanar CBCT images with regard to the determination of the prognosis for impacted mandibular third molars. However, there was a difference in the decision making between the different specialties.

Prophylactic removal of impacted mandibular third molars: a systematic review and economic evaluation

BACKGROUND

Impacted third molars are third molars that are blocked, by soft tissue or bone, from fully erupting through the gum. This can cause pain and disease. The treatment options for people with impacted third molars are removal or retention with standard care. If there are pathological changes, the current National Institute for Health and Care Excellence guidance states that the impacted third molar should be removed.

OBJECTIVE

The objective of this study was to appraise the clinical effectiveness and cost-effectiveness of the prophylactic removal of impacted mandibular third molars compared with retention of, and standard care for, impacted third molars.

METHODS

Five electronic databases were searched (1999 to 29 April 2016) to identify relevant evidence [The Cochrane Library (searched 4 April 2016 and 29 April 2016), MEDLINE (searched 4 April 2016 and 29 April 2016), EMBASE (searched 4 April 2016 and 29 April 2016), EconLit (searched 4 April 2016 and 29 April 2016) and NHS Economic Evaluation Database (searched 4 April 2016)]. Studies that compared the prophylactic removal of impacted mandibular third molars with retention and standard care or studies that assessed the outcomes from either approach were included. The clinical outcomes considered were pathology associated with retention, post-operative complications following extraction and adverse effects of treatment. Cost-effectiveness outcomes included UK costs and health-related quality-of-life measures. In addition, the assessment group constructed a de novo economic model to compare the cost-effectiveness of a prophylactic removal strategy with that of retention and standard care.

RESULTS

The clinical review identified four cohort studies and nine systematic reviews. In the two studies that reported on surgical complications, no serious complications were reported. Pathological changes due to retention of asymptomatic impacted mandibular third molars were reported by three studies. In these studies, the extraction rate for retained impacted mandibular third molars varied from 5.5% to 31.4%; this variation can be explained by the differing follow-up periods (i.e. 1 and 5 years). The findings from this review are consistent with the findings from previous systematic reviews. Two published cost-effectiveness studies were identified. The authors of both studies concluded that, to their knowledge, there is currently no economic evidence to support the prophylactic removal of impacted mandibular third molars. The results generated by the assessment group's lifetime economic model indicated that the incremental cost-effectiveness ratio per quality-adjusted life-year gained for the comparison of a prophylactic removal strategy with a retention and standard care strategy is £11,741 for people aged 20 years with asymptomatic impacted mandibular third molars. The incremental cost per person associated with prophylactic extraction is £55.71, with an incremental quality-adjusted life-year gain of 0.005 per person. The base-case incremental cost-effectiveness ratio per quality-adjusted life-year gained was found to be robust when a range of sensitivity and scenario analyses were carried out.

LIMITATIONS

Limitations of the study included that no head-to-head trials comparing the effectiveness of prophylactic removal of impacted mandibular third molars with retention and standard care were identified with the assessment group model that was built on observational data. Utility data on impacted mandibular third molars and their symptoms are lacking.

CONCLUSIONS

The evidence comparing the prophylactic removal of impacted mandibular third molars with retention and standard care is very limited. However, the results from an exploratory assessment group model, which uses available evidence on symptom development and extraction rates of retained impacted mandibular third molars, suggest that prophylactic removal may be the more cost-effective strategy.

FUTURE WORK

Effectiveness evidence is lacking. Head-to-head trials comparing the prophylactic removal of trouble-free impacted mandibular third molars with retention and watchful waiting are required. If this is not possible, routine clinical data, using common definitions and outcome reporting methods, should be collected.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016037776.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 30. See the NIHR Journals Library website for further project information.

A retrospective cohort study on reasons to retain third molars

The primary goal of this study was to identify and quantify indications for retaining third molars. This retrospective cohort study included 1682 patients (818 male, 864 female; mean age 31 years) who were referred to the University Hospitals Leuven for third molar removal. Eight reasons for retaining the third molars were identified: (1) risk of damaging adjacent structures, (2) compromised health status, (3) adequate space for eruption, (4) third molar serves as abutment tooth, (5) orthodontic reasons, (6) eruption into proper occlusion, (7) symptomless third molars in patients >30 years old, and (8) patient preference. To compare these categories between sex and age groups, a generalized linear model for binary data was fitted with a logit link. A total of 1149 third molars in 548 patients were not extracted. The most frequent reasons for retaining third molar teeth were: eruption into proper occlusion (31.9%), patient preference (31.5%), and symptomless third molars in patients >30 years old (17.5%). Compromised health status and advanced age were often included in the decision regarding whether to retain the third molars. One third of the referred patients had reasons to retain one or more third molars. These findings might facilitate the future development of a consensus statement.

Influence of the impacted mandibular third molars on fractures of the mandibular angle and condyle - A prospective clinical study

AIMS

This study was set out to evaluate the relationship between the presence and absence of unerupted mandibular third molar and fracture of mandibular angle/condyle, and to analyse if prophylactic removal of symptom-free unerupted mandibular third molar is beneficial.

METHODS

Hundred patients of mandible fracture were selected randomly irrespective of age, sex, caste, creed and socio-economic status. Data were collected from the patients on the basis of history, clinical examination and radiographs for the following information: age, sex, aetiology of fracture, presence and status of the mandibular third molar and location of mandible fracture.

RESULTS

In group A (partially/completely unerupted mandibular 3rd molar), the incidence of angle and condylar fracture was 44.44% and 13.33%, respectively, whereas in group B (fully erupted/missing mandibular third molar), the incidence of angle fracture was 14.45% and the incidence of condylar fractures was 31.77%.

CONCLUSION

Practice of prophylactic removal of mandibular third molar and resultant strengthening of angle region should be reconsidered, as it increases the risk of fracture at condylar region which is difficult to treat and associated with more morbidity.

The incidence of cysts and tumors associated with impacted third molars

Incidence of cysts and tumors associated with lower impacted third molars are very low prevalence, which might be because of the fact that most pathologies go unnoticed as many practitioners discard the erupted tissue after surgical removal of the impacted teeth rather than sending the tissue for histopathological examination. Our aim was to evaluate the patients who came for third molar surgical removal with due therapeutic prophylacis and an incidental finding. A proper study protocol both inclusion and exclusion criteria was strictly followed for all the cases, which were included in the study. The period of study was 6 years and the total number of cases assessed were 2778 patients out of which 70 cases reported pathology associated with the impacted third molars. Among 70 cases 61.4% were reported as cyst and tumors and 38.6% of the cases had chronic inflammatory reaction, including two cases with normal dental follicle. High incidence rate of pathology associated with third molar occurred between age group of 20 and 30 years older age groups showed very low incidence. Most common site of impaction was found to be left side of mandible and positions were vertical and distoangular impactions. Thus was male predominance in the younger groups. The examination is necessary whether the third molars impacted cases were symptomatic or asymptomatic

Is overweight a risk factor for adverse events during removal of impacted lower third molars?

Being overweight is recognised as a significant risk factor for several morbidities; however, the experience of the dentistry faculties focusing on this population is still low. The aim of the present study was to determine the occurrence of adverse events during removal of impacted lower third molars in overweight patients. A prospective cohort study was carried out involving overweight patients subjected to surgical removal of impacted lower third molar as part of a line of research on third molar surgery. Predictor variables indicative of the occurrence of adverse events during surgery were classified by their demographic, clinical, radiographic, and surgical aspects. Descriptive and bivariate statistics were computed. In total, 140 patients fulfilled the eligibility criteria, and 280 surgeries were performed. Patients' mean age was 25.1±2.2 years, and the proportion of women to men was 3:1. Eight different adverse events during surgery were recorded. These events occurred in approximately 29.3% of cases and were significantly associated with predictor variables (P<0.05). Excess weight is recognised as a risk factor for the high rate of adverse events in impacted third molar surgery. The study suggests that overweight patients are highly likely to experience morbidities.

High weight standard and removal of third molars: a prospective randomized study

OBJECTIVE

Compare the degree of exposure to adverse events during the removal of third molars between 2 groups of patients.

STUDY DESIGN

Researchers designed and implemented a prospective randomized study. The study consisted of overweight and normal-weight patients subjected to the surgical removal of impacted lower third molars. A wide range of predictor variables was registered in the preoperative phase. Statistical calculations were computed.

RESULTS

Five hundred sixty surgeries were performed involving 2 groups (1:1). Adverse events were found in 29.3% of surgeries in overweight patients. The same procedures performed on normal-weight patients resulted in a complication rate of 10.7%. Predictor variables significant to these events were detected.

CONCLUSIONS

Overweight patients have 3 times greater risk of experiencing morbidities during the removal of lower third molars compared with patients of normal weight. Our findings have important implications for public health, given the exorbitant growth in the population of patients with high standard weight.

Assessment of factors associated with surgical difficulty during removal of impacted maxillary third molars

PURPOSE

Estimating the difficulty of removing third molars is a common dilemma. However, the estimation of the difficulty associated with maxillary third molar surgery has not yet been defined. The aim of the present study was to determine the degree of difficulty and identify predictor variables associated with the occurrence of difficulty in the removal of impacted maxillary third molars.

MATERIALS AND METHODS

A prospective cohort study was carried out involving patients who underwent at least 1 surgical removal of an impacted maxillary third molar at the Oral and Maxillofacial Surgery Unit, University of Pernambuco (Pernambuco, Brazil). Predictor variables indicative of surgical difficulty were classified by their demographic, clinical, and radiographic aspects. Degree of surgical difficulty was categorized as low, moderate, or high based on the surgical technique used. Descriptive and bivariate statistics were computed.

RESULTS

In total, 106 patients fulfilled the eligibility criteria and 204 surgeries were performed. Patients' mean age was 22.8 ± 2.2 years and the proportion of women to men was 3:1. Approximately 20% of patients were overweight. Surgical difficulty was generally low and 5 variables were significantly associated with the occurrence of a high degree of surgical difficulty.

CONCLUSION

Surgical difficulty during the removal of impacted maxillary third molars is generally low. However, for cases with a high degree of difficulty, identification of predictor variables may be useful for students and inexperienced clinicians to consider the decision not to execute the procedure, thus avoiding complications that often require complex management.

Bupivacaine 0.5% versus articaine 4% for the removal of lower third molars. A crossover randomized controlled trial

OBJECTIVE

To compare the anesthetic action of 0.5% bupivacaine in relation to 4% articaine, both with 1:200,000 epinephrine, in the surgical removal of lower third molars. As a secondary objective hemodynamic changes using both anesthetics were analyzed.

STUDY DESIGN

Triple-blind crossover randomized clinical trial. Eighteen patients underwent bilateral removal of impacted lower third molars using 0.5% bupivacaine or 4% articaine in two different appointments. Preoperative, intraoperative and postoperative variables were recorded. Differences were assessed with McNemar tests and repeated measures ANOVA tests.

RESULTS

Both solutions exhibited similar latency times and intraoperative efficacy. Statistical significant lower pain levels were observed with bupivacaine between the fifth (p=0.011) and the ninth (p=0.007) postoperative hours. Bupivacaine provided significantly longer lasting soft tissue anesthesia (p<0.5). Systolic blood pressure and heart rate values were significantly higher with articaine.

CONCLUSIONS

Bupivacaine could be a valid alternative to articaine especially due to its early postoperative pain prevention ability.

Assessment of factors associated with surgical difficulty during removal of impacted lower third molars

PURPOSE

The aim of the present study was to adjust a multivariate model to explain each of the response variables for the occurrence of surgical difficulty during the removal of impacted lower third molars.

PATIENTS AND METHODS

A prospective cohort study was carried out involving patients submitted to at least one surgical removal of an impacted lower third molar. A total of 285 patients fulfilled the eligibility criteria and 473 surgeries were performed. Preoperative variables indicative of surgical difficulty were recorded. All surgical procedures were performed under the same conditions by two surgeons who were unaware of the data collected in the pre-selection phase. Either Pearson's chi-square test or Fisher's exact test was used for the data analysis (P<5.0%).

RESULTS

Root number (P((1)) < 0.004*) and morphology (P((1)) < 0.031*), tooth position (P((1)) = 0.001*), periodontal space (P((2)) < 0.004*) and second molar relation (P((1)) = 0.001*) were significant predictors of surgical difficulty, whereas patient age (P((1)) = 0.097), gender (P((1)) = 0.470), body mass index (P((1)) = 0.719), associated pathologies (P((1)) = 0.237), relation with mandibular canal (P((1)) = 0.384) and width of 3rd molar crown (P((1)) = 0.154) were not significant predictors.

CONCLUSION

Many factors contribute to surgical difficulty, but considering these factors individually, some are only determinants of either difficulty or complications. Thus, not all significant predictors of surgical difficulty should be considered indicators of complications.