_____________________________________________________ DCA03TM Third Molar Surgery, 5th Edition
such as pericoronitis (Cosala et al., 2020). The roots of the impacted lower third molar in close proximity to the IAN are left intact. In the future, these roots may either slowly “erupt” or move up and toward an unobstructed gingival surface, away from dangerous proximity to the IAN, or they may be encased by bone formation deep in the retromolar area without symp- toms or damage to the IAN. If the roots do erupt with time, they can be removed with a decreased risk of IAN nerve injury (Lamiae et al., 2022). The key principles of successful surgical treatment are: • Surgical access • Knowledge of the regional anatomy
Patients with these problems may opt to forgo the removal of the teeth because of dental fear or dental phobia, financial concerns, social factors, concerns with postsurgical pain, and/ or complications, or a temporary dissipation of symptoms (Starch-Jensen et al., 2023). It is essential that the treating clinician (usually an oral surgeon) and the referring general dentist discuss the risks and benefits of extracting asymptom- atic impacted third molars compared with the risk of retaining impacted third molars that are asymptomatic and developing a problem of greater morbidity at a later time. PREVENTIVE APPROACH TO IMPACTED THIRD MOLARS It appears that an early extraction of impacted third molars (during the teenage years and early 20s) can prevent the fol- lowing. • A chronic inflammatory condition (pericoronitis) in the retromolar areas (especially in the lower wisdom teeth areas) with periodic exacerbations • Difficulty in oral hygiene of the posterior dental regions • Local periodontal bone loss between the second and impacted third molars • Possible development of severe infection that can spread to the adjacent structures and become life- threatening • Risks and complications inherent to the extraction of third molars that are more frequent in adults (age 30+) • Development of cystic lesions and tumors from impacted third molars It is known, for example, that many odontogenic and non- odontogenic cysts and tumors (e.g., odontogenic keratocyst, dentigerous (follicular) cysts, odontogenic ameloblastoma, myxoma) more often develop in the posterior regions (body and ramus) of the mandible and are usually associated with man- dibular third molars. Dentigerous cysts are the second most common odontogenic cyst, and 70% occur in the mandible with the impacted mandibular third molar, the tooth that has the highest frequency of occurrence with this benign lesion (Gaurkar et al., 2022). The incidence of the development of cysts and tumors around impacted wisdom teeth has varied among studies, with a range of 2.8% to 6.2% potential for the development of these pathologic lesions (Lee et al., 2024). The protracted development of cystic lesions allows their early identification, diagnosis, and treatment.
• Good visibility • Delicate surgery • Attention to detail • A team approach
CRITERIA FOR THE REMOVAL OF THIRD MOLARS Debate is ongoing over whether to leave asymptomatic third molars in place or extract them to prevent future problems. No definitive answers exist. As noted, risks are associated with extracting wisdom teeth, and these must be tempered by the medical necessity of removing the teeth, especially in patients who are asymptomatic. The American Public Health Associa- tion has not endorsed the prophylactic extractions of impacted third molars since (Haddad et al., 2021; Schroeder et al., 2022). Other national health systems, such as the National Health Service (NHS) in the United Kingdom, have recommended the retention of impacted third molars unless a pathological condition develops involving them (Saeed et al, 2024). The most common indications for the removal of impacted third molars are: • One or more episodes of pericoronitis • Unrestorable caries in the third molar tooth • Distal caries and root resorption in the adjacent tooth (second molar) • Periodontal disease (resulting in bone destruction) • Evidence of follicular enlargement and the potential formation of a cyst • Resorption of the third molar or adjacent tooth • Preventive or prophylactic removal to facilitate orthodontic tooth movement and promote dental stability, the presence of orthodontic abnormalities, a tooth interfering with orthognathic surgery, or insufficient space to accommodate the erupting tooth or teeth (Saeed et al., 2024; Choi et al., 2025)
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