Third molar

Current Care Guidelines
Working group set up by the Finnish Medical Society Duodecim and the Finnish Dental Society Apollonia
18.12.2014

Key message

  • The primary problem related to third molars is their incomplete eruption and the associated symptoms, including local infection; this issue affects a large number of people in Finland.
  • Treatment of third molars is typically required in young adults.
  • It is important that third molars are removed at the appropriate time.
  • In selected cases, preventive removals should be considered.
  • Third molars are not associated with the crowding of lower incisors.
  • Recent and high-quality x-rays should always be available when removing third molars.
  • The risk of postoperative complications, including nerve injuries, can be minimised with careful preoperative examination of the position and location of the third molar, which may require additional imaging, followed by the decision to treat.
  • The risks of removal with respect to the surrounding periodontal tissue must be assessed before extraction.
  • The use of antibiotics is helpful in third molar surgery.
  • According to the difficulty of the extraction, attention should be paid to the division of labour and to the correct place for treatment. Difficult cases should be referred to a specialist.

Aims

  • The aims of these guidelines are as follows:
    • To promote uniformity in the clinical decision-making of dentists
    • To improve the quality of care
    • To prevent health problems related to third molars.

Target groups

  • The target groups for this guideline are as follows:
    • Healthcare professionals in basic and specialist dental and medical care
    • Patients suffering from problems with third molars
    • Other individuals requiring additional information about third molars.

Definitions

  • Fully erupted third molar:
    • Crown is completely visible. Tooth is occluded, is located at the occlusal level, and has attached gingiva along its marginal circumference (figure «Fully erupted third molar»1).
  • Partially erupted third molar:
    • Tooth is partially visible. It may also be clinically invisible, but it has a connection to the oral cavity and is detectable with a probe from the gingival pocket of the neighbouring tooth (figure «Partially erupted third molar»2).
  • Unerupted third molar:
    • Tooth is neither visible nor detectable with a probe from the gingival pocket of the neighbouring tooth (figure «Unerupted third molar»3).
  • Retained tooth (ICD10 code K01.0):
    • Tooth is unerupted after the normal age for eruption has passed (approximately after the age of 25 years).
  • Impacted tooth (ICD10 code K01.1):
    • Tooth is impacted against another tooth or bone such that further eruption is not possible.
    • Tooth may be partially erupted or unerupted.
  • Nervus mandibularis = mandibular nerve and its branches:
    • Nervus alveolaris inferior = inferior alveolar nerve
    • Nervus buccalis = buccal nerve
    • Nervus lingualis = lingual nerve.
  • Pericoronitis:
    • Pericoronitis is an infection of the soft tissue surrounding the tooth crown.
    • Pericoronitis may be acute, subacute or chronic.
    • Acute pericoronitis (ICD10 code K05.22) is associated with trismus, extra-oral swelling, and pus issuing from the gingival pocket. In most cases, there is intermittent throbbing pain, dysphagia, and fever.
    • Subacute pericoronitis is associated with local aching and continuous pain. Swelling is solely intraoral and is often associated with pus in the gingival pocket and an unpleasant taste. The action of opening of the mouth may be stiff but not restricted, and there are no general symptoms.
    • Chronic pericoronitis (ICD10 code K05.32) exhibits mild symptoms commonly associated with pus issuing from the gingival pocket.
  • Crown follicle:
  • Alveolitis (ICD10 code K10.3):
    • Alveolitis is a very painful infection of the extraction socket and usually appears approximately 3 days after the removal of a tooth. A blood clot is absent from the socket, and bone surfaces are exposed. The typical signs of infection (fever, swelling, redness) are not present.
  • Late infection:
    • There is swelling, pain, and pus in the operative area beginning more than a week after the tooth has been removed.

Prevalence of third molar problems

Predisposing factors

Diagnostics

Clinical examination

  • All third molar areas should be examined by the dentist during a routine dental examination.
  • When a patient seeks care for third molar problems, all four third molars should be examined even if the patient only complains of pain in a single molar.
  • Extra-oral examination includes the detection of facial swelling, evaluating the patient's capacity to open the mouth, and palpation of the submandibular nodes.
  • Intra-oral examination includes detection of sublingual swelling or local swelling at the gingiva around the third molar and pus discharge.
  • The state of eruption of the third molar is examined (unerupted, partially erupted or fully erupted). Caries of the third molar is examined. Attention is paid to whether the distal gingiva of the third molar is loose alveolar mucosa or attached gingiva.
  • The depth of the periodontal pocket between the second and third molar is examined with a probe. The connection between a clinically invisible third molar and the oral cavity is examined (figure «The status of the gingiva and the pocket depth between the second and third molars are examined with a probe»5).
  • Caries in neighbouring tooth is examined.
  • The patient is asked to bite the posterior teeth together to determine whether the third molar is below the occlusal plane, in occlusion or elongated. The dentist must also determine whether the third molar is traumatising the buccal mucosa or the gingiva of an opposing tooth.

Prediction of eruption

Differential diagnostics

  • Diagnosis of infection of the third molar and differentiation from other possible diagnoses is generally not difficult because the infection is typically observed in young adults:
  • An unerupted third molar may cause nonspecific facial pain. The diagnosis of a third molar problem may be confused with facial pain if the third molar area is clinically normal.
  • Pain from a third molar may be described as pain in the ear.
  • If the third molar is located close to the mandibular canal, there may be symptoms in that half of the jaw.
  • Other diseases and findings resembling symptoms from a third molar include the following:
    • Parotitis
    • Abscess of the throat
    • Caries in the neighbouring tooth
    • A cyst or a tumour
    • Temporomandibular disorders.

Microbiology of the third molar

Imaging

Panoramic radiography

Cone beam computed tomography (CBCT)

Computed tomography (CT)

  • Computed tomography, which is performed in hospitals, can also be used for the precise imaging of third molars if CBCT is not available.

Indications and contraindications for the removal of a third molar

Orthodontic considerations

Periodontal considerations

Preventive removal

  • Preventive removal is defined as the removal of a symptomless third molar prior to the development of anticipated problems.

Prevention of pericoronitis

Prevention of periodontal infection

Prevention of nerve injuries

Prevention of caries

Cost-effectiveness studies of preventive removals

Treatment of third molars

Acute care

Technique of tooth removal

Prevention and treatment of the residual pocket

Prevention of nerve injuries

Medication for third molar surgery

Postoperative instructions

  • Patients should be given both oral and written postoperative instructions.
  • Normal healing is characterised by the following «Skjelbred P, Lökken P. Pain and other sequelae af...»103:
    • Pain is most severe at 6–8 hours postoperatively and disappears in a few days.
    • Swelling of the cheek develops slowly, is at its peak 24–48 hours postoperatively and disappears within a week.
    • Trismus is most severe 12–16 hours postoperatively and disappears in approximately one week.
  • The patient can significantly accelerate his or her recovery from third molar surgery with personal care (instructions in Finnish, «Viisaudenhampaan poistoleikkauksen jälkihoito-ohjeet»1).
    • This care includes the use of compresses and ice packs, taking care with the wound, eating cold food, avoiding sports and smoking, performing chlorhexidine rinses, and using anti-inflammatory analgesics and antibiotics.
  • Indications to contact the dentist or surgeon include:
    • Continuous bleeding despite following self-care instructions
    • Intolerable pain developing on the third postoperative day
    • High fever
    • Adverse reactions to prescribed medicines.

Complications

Alveolitis (ICD10 code K10.3)

Nerve injury from mandibular nerve block (ICD10 code T80.8)

Injury of the inferior alveolar nerve related to mandibular third molar removal (ICD10 code T81.2)

Injury of the lingual nerve related to mandibular third molar removal (ICD10 code T81.2)

Mandibular fracture related to mandibular third molar removal (ICD10 code T81.8)

Sinus perforation related to upper third molar removal (ICD10 code T81.8)

  • The incidence of acute perforation of the sinus is 5% in an ordinary extraction, 10% in an operative removal of a partially erupted tooth, and 24% in an operative removal of an unerupted third molar «Rothamel D, Wahl G, d'Hoedt B ym. Incidence and pr...»131.
    • Perforation is most likely to occur when the root fractures during extraction, when the tooth is unerupted, and among elderly persons.
  • Depending upon the size of the perforation, the treatment may be the formation of a stable blood clot, sutures or the raising of the buccal flap, in addition to adequate medication, postoperative instructions for self-care, and a follow-up assessment of healing «Hupp JR. Prevention and management of surgical com...»111.
  • The proximity of the sinus should be determined preoperatively from the radiograph, and the operation should be planned considering the proximity.

Division of labour

  • The praxis for the division of labour differs from country to country, and there is no international consensus on whether the decision for removal and the actual treatment of a third molar should be made by an oral and maxillofacial surgeon, or whether general dentists should participate widely in the treatment «Christensen GJ. Dental surgery and the general pra...»132, «Knutsson K. The mandibular third molar. Dentists&#...»133, «Joynson OB, Williams SL, Brickley MR ym. Lower thi...»134.
  • In Finland, most third molars are removed by general dentists.
  • Depending upon the difficulty of removal, it is important to choose the correct place for treatment.
  • When assessing the difficulty of the removal and the division of labour, the patient should be evaluated comprehensively, and the following factors contributing to the difficulty of the operation should be assessed:
    • Patient-related factors, such as older age, male gender, diseases, medications, stiffness of the neck, bulky cheeks, a large tongue, minimal opening of the mouth, a sensitive throat, and poor ability to co-operate
    • Factors related to facilities, such as an inexperienced nurse, poor lighting, inadequate instruments
    • Tooth-related factors, such as a deeply located tooth, the vicinity of the mandibular canal or the maxillary sinus, a deep inclination of the tooth, a hooked root end, the presence of multiple roots, and an occluded tooth.
  • Greater operator experience decreases the likelihood of complications from third molar surgery «Berge TI, Gilhuus-Moe OT. Per- and post-operative ...»135, «Sisk AL, Hammer WB, Shelton DW ym. Complications f...»136, «Jerjes W, Upile T, Nhembe F ym. Experience in thir...»137.
  • Because nerve injuries (lingual nerve and inferior alveolar nerve) are the most common malpractice claims related to tooth extractions that are reported to the Finnish Patient Insurance Centre, operators should avoid the removal of third molars close to the mandibular canal when their surgical skill and experience are minimal.
  • Dental students and other inexperienced operators should begin with simple extractions of third molars that possess the following characteristics «Christensen J, Matzen LH, Wenzel A. Should removal...»138:
    • Not distally inclined
    • Not impacted deeply in bone
    • Not in close contact with the mandibular canal.
  • In Great Britain, the core curriculum of dental students does not include the removal of impacted third molars, and the student is only required to have knowledge of the indications for extraction, how to perform a clinical examination of the patient, and the treatment for impacted teeth «Macluskey M, Durham J, Cowan G ym. UK national cur...»139.
  • In the Finnish healthcare system, the extraction of unerupted or partially erupted third molars is recommended under special care in a hospital only under the following conditions «Sosiaali- ja terveysministeriön selvityksiä. Yhten...»140:
    • Infection related to the tooth presents a difficult local or general complication.
    • The general health of the patient necessitates that the operation be performed in a hospital.
    • The operation is difficult and requires special skills.
    • In other cases, the operation can usually be performed in a primary care setting.

Working group set up by the Finnish Medical Association Duodecim and the Finnish Dental Association Apollonia

Chair:

Irja Ventä, DDS, PhD, Specialist in oral and maxillofacial surgery, Institute of Dentistry, University of Helsinki

Members:

Marja Pöllänen, DDS, PhD, Specialist in periodontal diseases, Finnish Medical Association Duodecim, editor of Current Care

Tuula Ingman, DDS, PhD, Specialist in orthodontics, Department of Oral and Maxillofacial Diseases, Helsinki University Central Hospital, and Espoo Health Care Centre

Mika Mattila, DDS, Specialist in dental radiology, Pantomo, Helsinki

Ari Rajasuo, DDS, PhD, Specialist in oral and maxillofacial surgery, Etelä-Savo Hospital District, Mikkeli Central Hospital

Juha Sane, DDS, PhD, Specialist in oral and maxillofacial surgery, City of Helsinki Health Center, Unit of Specialised Oral Care in the Metropolitan Area and Kirkkonummi

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Read more
A triangular flap accelerates the initial healing phase
Additional images may be taken of the relationship between the mandibular canal and root
Course of the lingual nerve in the lingual soft tissue of the mandibular third molar
Envelope flap
Extended trapezoid flap
Follicle around the crown of a developing tooth
Fully erupted third molar
Partially erupted third molar
The status of the gingiva and the pocket depth between the second and third molars are examined with a probe
Trapezoid flap
Unerupted third molar