The surgical removal of mandibular third molars: A study in decision making

AnwarB, Bataineh, BDS, MScD, MDSc, CSOSVZakereyyaS-Albashaireh BDS MSc Abdalla M, Hazza'a, BDS, MSc, DDS^
Objective: The aim of this study was to investigate and analyze the angulation of and the various indications for removal of mandibular third molars in Jordanians as a representativa Arab sample. Method and materials: The data included in this retrospective study were obtained from the clinical and radiographie records of 1,282 patients undergoing mandibular third molar surgery during a 5-year period from 1994 to 1999, The indications for removal of the mandibular tbird molars were classified in accordance with age and gender. The angular position of mandibular third molars was registered. Results: A total of 2,252 mandibular third molars were removed from 740 male patients (57,7% and 542 emale patients (42,3%) aged 14 to 67 years. Pericoronitis was the most common indication for surgery, affecting 1,055 teeth (46,8%), Caries was observed in 519 third molars (23,0%). The vertical angular position was most commonly found (1,383 teeth; 61.4%) followed by the mesioangular position (407 teeth; 18,1%), Conclusioti: The results obtained in this study are similar to those reported in earlier studies carried out elsewhere, although the incidence of periodontitis among Jordanians was significantly higher and occurred in older patients, and prophylactic removal was performed less frequently than has been reported in other countries. (Quintessence Int 2002:33:813-617)

Key words: decision-making process, mandibular teeth, third molars

CLINICAL RELEVANCE: Surgical removal of mandibular third molars can only be justified when a clear indication is present and long-term benefit to the patient is expected.

etnoval of impacted mandibular third molars is one of the most frequently perfonned oral surgical procedures, and there is some evidence that the incidence of impaction of third molars is increasing,'^ A recent literature review revealed that surgical removal of third molars in the United liingdom increased by 113% hetween 1974 and 1984,^ In the United Kingdom during 1989 to 1990, 67,000 patients had third molars removed by general dental practitioners working in the National Health Service at a cost of
'Associate Professor, Department o Oral a r d Maxillofaciai Surgery, Faculty ot Dentistry, Jordan university o! Science and Technology, Irbid, Jordan, ^Assistant Professor, Department ot Conservative Dentistry, Faculty of Denstry, Jordan University ol Science and Tectinology, irbid, Jordan. ^Assistant Professor, Department ot Oral and MaxiNofaoial Radiology, faculty ot Dentistry, Jordan University ol Science and Technology, libid, Jordari, Reprint requests: Dr Anwai B. Bataineh, Associate Professor, Department of Oral and fulaxillotacial Surgery, Facjily of Dentistry, Jordan University of Science and Technology, Irbid 22110, Jordan, E-mail: anwar@just.edu,jo

23.3 million, while 22,000 patients were treated in the private sector at a cost of 22 million, In the United States, third molar surgery has heen estimated to cost up to $2 billion per vear,-" Not every impacted third molar causes a clinical problem, and an unknown percentage of unerupted third molars may remain asymptomatic throughout life,^ However, they have the potential to be associated with pathoses, including pericoronitis. periodontal disease, or caries, when a communication, however miniscule, exists between the tooth follicle and the oral cavity proper. They may also be associated with rsorption of the adjacent second molar or the presence of cysts or tumors,^' Dentists often experience difficulty in deciding whether an asymptomatic third molar should be removed. Although third molars serve no useful purpose and have the potential to cause problems, some authorities believe that prophylactic surgery is not an appropriate management strategy,*' Others believe that, if third molars are removed only when symptoms and pathologic changes occur, the patients may be older and therefore may have a very real risk of serious complications following surgery,'"" Many asymptomatic third moiars arc removed while the patient is under general anesthesia when the asymptomatic third molar on the opposite side is removed, thus reducing
613

Quintes seat

3ataineh et ai Fig 1 Distribution ol impacted n-rj lars by the patient's age and gen^i' r third mo-

14-19

20-25

26-30 Age (y]

the risk that a second operation may have to be undertaken later. There are variations in third molar removal rates across relatively small areas'^ and in understanding of the evidence on which decisions whether to operate or not are tnade.'^ Because treatment decisions concerning mandibular third molar removal have important clinical and cost implications,' it was decided to investigate and analyze the various factors governing such decisions using Jordanians as a representative Arab sample.
METHOD AND MATERIALS

ered regardless of whether the tooth was impacted in bone, soft tissue, or both. To ensure diagnostic reproducibility, a single examiner, an oral radiologist, examined the same 30 panoramic radiographs in random order on 5 consecutive days. The study criteria for diagnosis of each lesion, indication, and position were determined after group discussion among the authors.
RESULTS

This retrospective study was carried out by means of a review of clinical records and panoramic radiographs. These records formed part of a clinical workup of 1,282 patients referred for third molar surgery during a 5-year period, from 1994 to 1999, at the Oral and Maxiilofaciai Surgery Clinic, Faculty of Dentistry, Jordan University of Science and Technology, Gender, age, and symptoms were recorded from the patients' records. The following reasons were considered valid for removal of mandibular third molars: recurrent pericoronltls, caries of either the third or the adjacent second molar, periodontai disease, orthodontic or prosthodontic indications, associated pathosis, chronic facial pain, and prophyiactic removal. The indications for removal of the mandibular third molars were anaiyzed according to age and gender. Patients were divided into four 5-year groups ranging from 14 to 36 years and a single group of those aged 37 years or older. The angular position of the mandibular third molars was classified using a modification of Winter's classification'+: verticai, horizontal, mesioangular, distoangular, or aberrant position. Vertical position and carious involvement of the third molar were consid614

The results were based on both radiographie and clinical findings in a total of 2,252 mandibular third molars, A tota! of 970 patients had bilateral third molar removal and 312 had only unilateral third molar removal. There were 740 male patients (577%) and 542 female patients (42.3''/o), ranging in age from 14 to 67 years. Figure 1 shows distribution of impacted mandibular third molars by the age and gender of the patients. The largest group of impacted third molars (889; 39,5%) was found in patients aged 20 to 25 years; of these, 472 (21,00/0) were in male patients and 417(18,5%) were in female patients. The indieations for mandibular third molar removal are detailed in Table I. Pericoronitis was the most common indication for surgery, afi'ecting 1,055 (46.8%) of the mandibular third molars. Caries was present in 519 third molars (23.0%), Rare indications included orthodontic indications (five teeth; 0,3%); caries of second molar (11 teeth; 0,5%); and associated pathoses, such as cysts, tumors, and root rsorption (37 teeth; 1.6%), The indications for surgical removal by age of the patient are shown in Table 2. More than one third of the mandibular third molars (889; 39,5%) were removed from patients in the 20-to-25-year age group. The incidence of caries in the third molar (152; 6.8%), was also greatest in this group. Table 3 details the angtilar
Voiume 33 B, 20O2

Bataineh et ai -

position of the impacted mandibular third moiars by patient age group. The vertical position was the most common position for the third molars (555; 24,6''/o) among 20 to 25 year olds. Figure 2 shows the angular position of the mandibular third molars by the patients' gender. The vertical position was the most common, accounting for 1,383 (61,4%) of all the mandibular tbird molars; of these, 807(35,8%) were in male patients and 576 (25.6'io) were in female patients. The mesioanguiar position was a distant second, found in only 407(18,1") of mandibular third molars.
DISCUSSION

Treatment decisions concerning mandibular third molar removal are still a matter of opinion. Some indications for third molar removai are well established and widely agreed on, althougb controversy still exists concerning the validity of prophylactic removal,'* Althougb the prevalence of pathoses involving mandihuiar third molars subjected to removal is well documented in some areas of the worid,'' very few
TABLE 1 Indications for mandibular tbird molar removal
Indications Recurrent pericoronitis Caries of third rnolar Periodontitis Prophylactic Chronic facial pain Prosthodontic reason Associate pathosis Canes ol second molar Orthodontic reason
Totai No. %

1055
519 307 172 103 43 37 11 5

Disease patterns and the prevalence of impacted third molars vary among populations, Unerupted third molars are present in 77% of Finnish university students,' in a previous study of 20-year-oid Jordanian university students, in contrast, 5S% of third molars were fully erupted, 16% were partially erupted, and 26% were unerupted; one or more impacted molars were found in 34''/o of the Jordanian students, '^

46,8 23,0 13,6

7.7 4.6 1,9 1.6 0,5 0,3

2252

too.o

TABLE 2 Indications for mandibular third molar removal, by patient's age

Age (y Indications Recurrent pericoronitis Caries of third molar Periodo ntiti s Prophylactic Chronic facial pain Prosthodontic reason Associated pathosis Caries of second molar Orthodontic reason
Totai

14-19
133 31 5 23 6 0 6 5 0 209 9.3

20-25
510 152 33 108 75 2 4 0 5 889

26-30
183 113 51 12 4 8 0 0 0 371

31-36
100 38 30 19 2 0 4 6 0 249 U.O

>37 129 135 ia8 10 16 33 23 0 0 534

39 5

16.5

23.7

TABLE 3 Angular position of mandibular third molars, by patient's age

Age (y) Angular position Vertical Mesioanguiar Distoangular Horizontal Aberrant 14-19
104 56 18 IB 13 209 % 9.3

20-25
555 196 71 29 38 889

26-30
232 79 20 26 371

31-36
143 28

>37 349 47

13 249

90 534

39.5

16.5

11.0

23.7

Quintessenc Ifi

615

3ataineh et ai Fig 2 Distribution of angular gender tha patient's

1400
d

t383

1200-

1
807

jiar third rr

1
1

DMale
H Female

800

6004002000

ra

"D Impact

1
407

Total

Vertical

I LH
W
229 H
angular Mesio-

180

mm '''
Angulation

Disto- Honzontai anguiar Aberrant

n^

Studies are available from other areas. One study reported that pericoronifis was encountered in SO"/ of partially erupted mandibular third molars and in 20% of unerupted third molars,'*' Another study found an incidence as high as 94% in partially erupted mandibular third molars.''' In the present study, pericoronitis was the most common indication (46.0%) for mandibular third molar surgery. The frequency of pericoronitis in this series was low in comparison to that found in some studies (more than 60%) "''^ but higher than that reported in others (30W"; 36%i; 37%=; and 64%''). In a retrospective examination of panoramic radiographs of 2,872 third molars, the condition observed most frequently was caries, 71% in impacted teeth but 42.7% in adjacent leeth; the incidence of caries decreased to 5.4% in erupted molars.^' In the present study, the incidence of caries in tbe tbird molars was 23%, the second most frequent indication for removal. This incidence was similar to that reported in an American study (26%)^ but almost twice as high as the 13% registered in both Swedish^" and Thai'* samples. Because very few impacted third molars seem to cause caries of the second molar, estimates varying between 1% and 5%,*'^^*' the O.S^/o found in the present study cannot justify removal of third molars to prevent second molar caries. The incidence of periodontitis associated with third molars in this study was 13.6%, much higher tban that reported by others (3%20; 3.3%'^; and 6,7%'^), In other studies, the patients affected were younger than 25 years of age and the third molars had just erupted; in the present study, however, 23.7% of the patients were 37 years of age or older. The proportion of third molar surgery that is carried out prophylacticay in asymptomafic patients is
616

difficult to estimate precisely and is dependent on the definitions used and the type of anesthesia employed. The frequency of prophylactic removal of mandibular third molars in this series was 77''/D, much less than that reported in Sweden (27%).2'' There are many reports of an associafion between chronic facial pain and the presence of impacted third molars. It is a common complaint, particularly in young adults.' A survey by Samsudin and Mason'' found that 73,7% of new patients waiting for third molar surgery suffered from pain. However, Lyseil and Rohlin^" reported pain in only 59% of patients. In the present study, pain was associated with 4.6% of impacted third molars. This rate is lower than the rates reported by others'''^"^^ and lower than the rate for pain not attributed to infecfion (23%}.^ In a retrospective examination of panoramic radiographs of 1,756 patients with 3,702 impacted third molars, Stanley ef aF^ found tbat cysts were associated with 0.81% and that 3.05% were associated with rsorption of the distal root of the second molar. Although the incidence of pathologic sequelae to impacted third molars apparently is low (1.9%^; 3%^"; and 4%"), the incidence in the present study (1.6%) was in agreement with previous reports,^^ The majority of pathologic conditions can be expected eventually in approximately 12% of impacted third molars; therefore, removal is recommended.^^ The incidence of removal for orthodontic reasons, another indication for removal of an asymptomatic third molar besides prophylactic removal, was very low in the present study (0.2%), especially in comparison with the incidences reported in other studies (2%"; 12%22; and 14%^"), The association between anterior incisor crowding and impacted mandibular third
sr 8, 2 0 0 2

3a1aineh et al

molars does not seem to be significant and does not warrant the removal of asymptomatic third tTiolars. The association between angular positioning of mandibular third molars and pathoses has been reported by many authors.'"'^-'' The frequency of mesioangular positioning in this series was 407 (18.2''/o), lower than that repotted by others (30%---^ and 24%"). Mesially inclined third tnoiars are usually associated with pathoses, including pericoronitis, caries, and root rsorption of the second molar.'' In this study, the incidence of mesioangular positioning of third molars decreased from the 20-to-25-year group to the 31-to36-year group. This corroborates other studies, which have found that a significant proportion of mesially impacted third molars change their position and become fully erupted after patients reach the age of 20 years.-^-^

CONCLUSION

The results obtained in this study were in agreement overall with those of other studies. The largest number of impacted mandibular third molars in this study was found in individuals between the ages of 20 and 25 years; the second largest incidence was found in the group aged 37 years and older. Pericoronitis was the most common indication for surgical removal of mandibular third molars, affecting 46.8''.'o of removed mandibular third molars, twice as many as were affected by caries {23.0'>'o). The most common positioning of the of the mandibuiar third molar was vertical However, the incidence of periodontitis, 13.6%, was higher, and the patients involved were older (usually older than 37 years old) than has been reported in previous studies. The frequency of prophylactic removal, 7.7".o. was just over a quarter of that reported in Sweden (27^o). Surgical removal of mandibular third molars can only be justified when a clear indication is present and long-term benefit to the patient is expected.
REFERENCES
1. Shepherd JP. Surgical removal of third molars. BMJ 1994: 309:620-621. 2. Rajasuo A, Murtomaa H. Meurman JH. Comparison of fhe clinical status of third molars in young men in 1949 and in 1990. Oral Surg Oral Med Oral Pathoi 1993:76:694-698. 3. Shepherd JP. The third molar epidemic. Br Dent J 1993;178:85. 4. Fiick WG. The third molar controversy: Framing the controversy as public health policy issue. J Oral Maxillofac Surg 1999j57:438-444. 5. Lopes V, Mumenya R, Feinmann C, Harris M. Third molar surgery: An audit of the indications for surgery, post-operative complaints and patient satisfaction. Br J Oral Maxillofac Surg 995;33:53-35.

6. Ailing CC, Helfrick IF, Ailing RD Impacted Teeth. Philadelphia: Saundcrs, 1993. 7. Peterson L. Rationale for removing impacted teeth: When to extract or not to extract. J Am Dent Assoc 1992; 123:198-204. 8. Mercier P, Precious D. Risks and benefits of removal of impacted third molars. ] Oral Maxillofac Surg 1992;21:17-27. 9. Brokaw WD. The third molar question: When and why should we recommend removal? Va DentJ 1991:68:18-21. 10. Stavisky DE. Chnical justification for the prophylactic removal of impacted third molars. Pa Dent J 1989:56:8-9. 11. Tte TE. lmpactions: Observe or treat? J Calif Dent Assoc 1994:22:59-64. 12. Toth B. The Appropriateness of Prophylactic Extraction of Impacted Third Molars. A Review of the Literature [thesis]. Bristol, England: Health Care Evaluation Unit, University of Bristol, 1993. 13. Lysell L, Brehmer B, Knutsson K, Rohlin M. |udgement on removal of asymptomatic mandibular third moiars: Influence of perceived likelihood of pathology. Dentomasillofac Radio! 1993:22:173-178. 14. Winter GB. Impacted mandibular third molar. St Louis: American Book, 1926. 15. Hattab FN, Rawashdeh MA, Fahmy MS. Impaction status of third molars in Jordanian students. Oral Surg Oral Med Oral Pathoi Oral Radiol Endod 1995;79:24-29. 16. Brickley M. Shepherd J, Mancini G. Comparison of clinical treatment decisions with US National Institutes of Health consensus indications for lower third molar removal. Br DentJ 1993:175:102-105. 17 Knutsson K. Brehmer B, Lysell L, Rohlin M. Pathoses associated with mandibular third molars subjected to removal. Oral Surg Oral Med Oral Pathoi Oral Radiol Endod 1996;82:10-17 18. Punvvutikorn J. Waikakul A, Ochareon P. Symptoms of unerupted mandibular third molars. Oral Surg Oral Med Oral Patho! Oral Radiol Endod 1999:87:385-390. 19. Samsudin AR, Mason DA. Symptoms from impacted wisdom teeth. Br J Oral Maxillofac Surg 1994:32:380-383. 20. Lysell L, Rohlin M. A study of indications used for removal of the mandibular third molar. Int J Oral Maxillofac Surg 1988:17:161-164. 21. Van der Linden VV. Cleaton-Jones P. Lownie M. Diseases and lesions associated with third molars. Review of 1001 cases. Oral Surg Oral Med Oral Pathoi Oral Radiol Endod 1995 ;79:142-145. 22. Bruce RA, Frederickson GC. Small GS. Age of patients and morbidity associated with mandibular third molar surgery. J Am Dent Assoc 1980:101:240-245. 23. Stanley HR, Alattar M, Collett WK, Stringfellow Hr. Spiegel EH. Pathological sequelae of "neglected" impacted third molars. I Oral Pathoi 1988:17:113-117. 24. Leone SA, Edenfield MJ, Cohen ME. Correlation of acute pericoronitis and the position of the mandibular third molars. Oral Surg Oral Med Oral Pathoi 1986;62:245-250. 25. N o r d e n r a m A, Hultin M. Khellman 0 , Ramstrom G. Indication for surgical removal of third molars: Study of 2650 cases. Swed DentJ 1987:11:23-29. 26. Hattah FN. Positional changes and eruption of impacted mandibular third molars in young adults A radiographie 4year follow-up study. Oral Surg Oral Med Oral Pathoi Oral Radiol Endod 1997:84:604-608. 27. Venta 1, Turtola L, Ylipaavalnicmi P. Change in clinical status of third molars in adults during 12 years of observation. J Oral Maxillofac Surg 1999:57:386-389.

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