Oral Surgery ISSN 1752-2471

ORIGINAL ARTICLE

Current practice in mandibular third molar surgery. A national

survey of British Association of Oral Surgeons membership
M. Devine1, G. Gerrard2 & T. Renton1
1
Department of Oral Surgery, Kings College Dental Institute, London, UK
2
Oxford Health NHS Foundation Trust, London, UK

Key words: Abstract

Surgery, oral Molar, third Cone-Beam
computed tomography, Informed consent, Objective: The aim of this survey was to evaluate current practice in
Trigeminal nerve injuries, Risk assessment mandibular third molar (M3M) surgery within the British Association of
Oral Surgeons (BAOS) membership against current evidence and
Correspondence to: relevant guidelines.
Dr M Devine
Method: An online questionnaire survey was active from March to June
Department of Oral Surgery
2015.
Kings College London Dental Institute
Bessemer Road Results: A total of 250 BAOS members (48%) responded to the survey.
Denmark Hill About 52% were registered Oral Surgery specialists. Exactly, 36% stated
London SE5 9RS that M3M surgery comprised 5075% and 17% stated that M3M
UK surgery comprised over 75% of their workload. About 73% would
Tel.: +02032991068 recommend coronectomy for high-risk M3Ms; however, 53% had
Fax: +02032991210
difficulty in accessing cone beam CT (CBCT) scanning. Most
email: maria.devine@nhs.net
practitioners undertook a two-stage written consent informing patients
Accepted: 29 January 2016 of the possibility of numbness, altered sensation or pain as a result of
inferior alveolar or lingual nerve injury; however, there were significant
doi:10.1111/ors.12211 variations in how this was communicated. Most surgeons operated
mainly under local anaesthesia, using a triangular buccal flap access;
27% routinely used lingual retraction. Buccal and distal bone removal
followed by sectioning of the tooth was the most common approach,
although 1% routinely used the lingual split technique. Over the last
5 years, each responder reported an average of 2 temporary and 0.4
permanent inferior alveolar nerve injuries (IANI), 1 temporary and 0.1
permanent lingual nerve injuries (LNI).
Conclusion: This survey has highlighted the lack of access to CBCT
scanning and the differences in approach to consent and surgical
technique. The reported rates of nerve injury caused by M3M surgery
were low; however, this may be due to a lack of post-operative follow up.

Clinical relevance and differences in approach to planning, consent and

Mandibular third molar surgery is one of the most
common outpatient procedures in the UK. However,
there is a lack of high-quality evidence regarding best
practice; leaving the optimisation of surgical training
difficult. This survey evaluates current practice and
post-operative nerve injury rates against available evi-
dence and guidelines. The results highlight lack of
access to cross-sectional imaging for high-risk cases
surgical technique. The rates of inferior alveolar and
lingual nerve injuries varied widely; possibly due to a
lack of follow-up preventing surgeons from accurately
recording their outcomes.
Introduction
Mandibular third molar (M3M) impaction repre-
sents the most common developmental condition

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2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Current practice in third molar surgery
in humans1. The prevalence of impacted mandibu-
lar third molars varies widely in the literature due
to differences in the age of populations studied,
failure to distinguish between one or multiple
impacted third molars, and pre- and post-surgery
cohorts2. However, surgical removal of M3Ms is
one of the most commonly performed outpatient
procedures in the UK National Health Service1.
M3M surgery in the UK is provided by diverse
services and practitioners, ranging from primary
care dental surgeons to consultant-led oral surgery
services in district general hospitals and dental
teaching hospitals.
An impacted tooth is defined as one whose erup-
tion is impeded by a lack of sufficient space in the
arch, ectopic position of the developing tooth germ,
or presence of an obstruction such as a supernumer-
ary tooth, retained deciduous tooth, tumour, cyst or
scar tissue3. The mandibular third molar is the most
commonly impacted tooth in the arch. The presence
of an impacted M3M can lead to difficulty in main-
taining oral hygiene, periodontal inflammation and
pericoronitis, dental caries in the third molar, distal
cervical caries in the second molar and less com-
monly cyst or tumour development4. Surgical
removal of M3Ms, where indicated, will alleviate
symptoms of pain and swelling to restore oral health
and normal function5. Frequent post-operative
sequelae of M3M surgery include pain, swelling and
restricted mouth opening (trismus). Complications of
surgery include infection, alveolar osteitis (dry
socket), injury to the inferior alveolar and lingual
nerves and occasionally mandibular fracture6.
Morbidity related to M3M surgery can be signifi-
cant to the individual patient and there has been an
increase in litigation associated with dentoalveolar
procedures in recent years7. However, unfortunately
best practice is still not clearly defined or identified
leaving the optimisation of surgical training in this
area difficult.
Evidence-based guidelines can be a very useful
support for clinicians and patients in making clinical
decisions and for optimising treatment, where evi-
dence may exist8. However, clinical guidelines
should be based upon the best available evidence,
which is often scant even for such a high-volume
surgical practice. The National Institute of Clinical
Excellence (NICE) introduced guidelines relating to
M3M surgery in 20009, discouraging the prophylac-
tic removal of M3Ms. However, there is growing evi-
dence that this may not be in the best interest of the
patient resulting in delay of inevitable surgery, an
increase in risks of surgery with increasing age and
12
Devine et al.
development of distal cervical caries in the adjacent
second molar teeth4.
The British Association of Oral Surgeons repre-
sents one of the main workforces providing M3M
surgery in the UK. The aim of this survey was to
evaluate current practice within BAOS membership
of pre-operative planning, consent, surgical tech-
niques and post-operative nerve injury rates in M3M
surgery against current evidence and relevant guide-
lines.
Methods
The survey was written using the web-based Survey
Monkey (Palo Alto, CA, USA) platform and con-
tained 20 questions. These were extensively piloted
with a group of 12 senior oral surgeons who pro-
vided feedback and suggestions for improvement.
The final survey was emailed to all 520 members of
BAOS in March 2015 with a reminder email sent
2 weeks later. The survey was closed to respondents
in June 2015. The data were then analysed using
Microsoft Excel (Redmond, WA, USA).
Results
Of the BAOS membership (n = 520), 250 responded
to the survey (48.1%).
Grade and surgical experience
Operator seniority in general was high, with 42% of
responders qualifying over 20 years ago (Fig. 1).
Of the responders, the most common grade was
specialty doctor (25%), followed by primary care
oral surgeon (18%), associate specialist (18%) and
oral surgery consultant (13%) (Table 1). Overall,
52% of responders were registered Oral Surgery spe-
cialists with the General Dental Council.
Years since qualification
120
100
80
60
40
20
0
0-5 6-10 11-15 16-20 >20
Figure 1 Years since qualification as a dental surgeon.
Oral Surgery 10 (2017) 11--19.
2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Devine et al. Current practice in third molar surgery

About 36% of responders stated that M3M surgery 28% of responders would want to schedule a CBCT
comprised of 5075% of their workload and 17% of but had limited access and 34% cited that there was
responders stated that M3M surgery comprised of over not sufficient indication for CBCT.
75% of their workload (Fig. 2). The average surgical Analysis of individual responses showed that some
case load of patients undergoing M3M surgery per clinicians would not request a CBCT scan if a deci-
week was eight local anaesthetic cases, five intravenous sion had been made to perform a coronectomy based
sedation cases and six general anaesthetic cases. on the appearance on plain radiography. Of respon-
ders, 73% would routinely recommended coronec-
tomy for high-risk M3Ms based upon CBCT
Pre-operative assessment and consent
assessment; however, many practitioners in primary
When asked about access to CBCT for risk assessment care would refer the patient to secondary care if they
of M3M, 47% of responders had no problems in felt coronectomy was indicated.
accessing a CBCT scanner. Obstacles to CBCT access Only 4% of responders do not routinely gain
were most commonly attributed to distance (28%), written consent for M3M surgery. About 57%
cost (27%), time constraints (22%), no available undertake a two-stage consent process which is initi-
reporting (10%) and difficulty in interpreting the scan ated at the consultation visit and confirmed on the
(6%) (Table 2). Individual responses also indicated day of surgery. Of responders, 33% gain written
that scans were not always available on the NHS in
primary care, which resulted in some individuals Table 2 Access to CBCT scanning for high-risk M3M
either referring for a private scan or to secondary care. Obstacles to CBCT scanning of high-risk M3M %
In some hospitals, CBCT was not available however
No obstacle easy to access scanner 46.6
spiral or medical CT was offered to high-risk cases.
Distance 28.2
Based upon the presented high-risk example case Cost 27.2
(Fig. 3), 39% of responders would request a CBCT, Time taken to arrange scan 21.8
No arrangement for reporting of scan 9.7
Difficulty interpreting scan 6.3
Table 1 Operator grade
Other 11.7
Which of the following best matches your job title? %

Specialty dentist 25.2

Primary care oral surgeon 18.4
Associate specialist 18.0
Consultant oral surgeon 13.2
Specialty registrar (Oral Surgery) 8.8
Dentist with special interest (Oral Surgery) 8.8
Dental core trainee 3.6
General dental practitioner 2.0
Consultant maxillofacial surgeon 2.0

Figure 2 Proportion of responders work which involves M3M

surgery. Figure 3 Radiograph of impacted M3M.

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2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Current practice in third molar surgery Devine et al.

consent on the day of surgery. Individual responses
indicate that some practitioners are not able to see
patients for a consultation before the day of surgery
but written information on the procedure is sent out
in advance of the appointment.
During the consent process, 64% of responders
routinely warned of inferior alveolar and lingual
nerve injury including numbness, altered sensation
and pain, 7% and 6% warned of only altered sensa-
tion or numbness respectively. About 0.5% of
responders only warned patients of nerve injury if
the surgery was deemed to be high risk. When quali-
fying warnings of nerve injury during consent,
patients were advised of anatomical areas which
could be affected, including the lower lip (97%),
tongue (93%), chin (79%), gums (31%), lower teeth
(38%) and other (6%) (Fig. 4A, B).
Surgical and anaesthetic technique
Standard local anaesthetic practice involved using
lidocaine inferior dental block (IDB) supplemented
by a buccal infiltration with lidocaine (50%) or arti-
caine (39%). Exactly, 6% of responders use articaine
IDB regularly and 2% use infiltration only or
intraligamental techniques (Table 3).
Based upon the case presented (Fig. 5), 46% of
the responders would use a buccal triangular (3
sided) flap, 41% a buccal approach with distal reliev-
ing incision, 11% buccal approach with retraction of
distal soft tissues using a periosteal elevator and 2%
other approaches.
On questioning about indications for lingual
access, 50% of responders stated they would only
Table 3 Local anaesthetic technique for M3M surgery
LA technique %
Lidocaine IDB + lidocaine buccal infiltration 49.5
Lidocaine IDB + articaine buccal infiltration 39.3
High concentration agent (e.g. articaine) IDB + buccal infiltration 6.1
Infiltration only technique (no IDB) 1.4
Intraligamentary infiltration 0.9
Other 2.8

A Consent for risk of inferior alveolar and lingual nerve

injur y

B Which anatomical areas do you specify may be aected

by nerve injury following M3M removal?
Lower lip
Tongue
Chin
Lower teeth
Gingivae
Other

0 20 40 60 80 100
Figure 4 (A) Consent for risk of inferior alveolar and lingual nerve injury. (B) Areas affected by nerve injury.

14 Oral Surgery 10 (2017) 11--19.

2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Devine et al. Current practice in third molar surgery

Figure 5 Image of impacted M3M.

use the buccal approach and 27% would use a

Howarths (or similar) retractor to protect the lingual
nerve during bone removal. However, analysis of
individual responses revealed that although most sur-
geons would not use lingual access routinely, it was
largely case dependent, and may be required in diffi-
cult cases to aid visualisation and bone removal. Most
surgeons would use a retractor to reflect the lingual
tissues at the level of the alveolar crest to aid visualisa-
tion but would not raise a lingual flap or place a
retractor between the lingual periosteum and bone.
For the presented case (Fig. 6), the majority of
responders (65%) would use buccal and distal bone
removal and 24% would only remove buccal bone.
About 1% would use the lingual split technique. Of
the responders, 92% stated that they would section
the tooth in preference to further bone removal, while
8% would aim to elevate the tooth whole, removing
as much bone as was necessary to facilitate this.
Of the responders who regularly operate under
general anaesthesia (GA), 38% commonly undertake
M3M surgery with a laryngeal mask airway (LMA),
with 12% and 18% operating with orotracheal and
nasotracheal tubes respectively.
Post-operative telephone contact to check progress
and recovery within 2 days of M3M surgery was
regularly undertaken by 18% of responders. The
remaining 82% of surgeons did not arrange routine
proactive patient contact after M3M surgery and
patients were only reviewed if they developed
complications.
Figure 6 Radiograph of distoangular impacted M3M (also shows
caries in the mesial and distal aspects of the lower left second molar
tooth).
responder of permanent IANI and LNI was low
(0.4% and 0.1% respectively). However, experience
of nerve injuries varied widely between responders
(Table 4). About 19% reported no experience of any
nerve injury over 5 years. Many responders com-
mented that they were unaware of how many nerve
injuries they may have caused due to lack of routine
follow-up of patients, working in a large department
where other members of the team may review the
patient and/or working in multiple centres.
Of those who had known nerve injuries, 21%
were referred to a specialist nerve injury clinic, 8%
to oral and maxillofacial surgery departments and
1% to oral surgery departments for further
assessment and management. About 51% of patients
with nerve injury were not referred for further
assessment.
Table 4 Experience of nerve injury in relation to M3M surgery in the
past 5 years
Nerve injury Average Minimum Maximum Total Number of
number number responders
per reported
responder

Temporary 2 0 18 339 175

Experience of nerve injury in relation to M3M IANI
Permanent 0.4 0 5 64 162
surgery
IANI
Over the last 5 years, each responder reported an Temporary 1 0 15 164 160
average of two temporary inferior alveolar nerve LNI
Permanent 0.1 0 4 23 155
injuries (IANI) and one temporary lingual nerve
LNI
injury (LNI). The average reported incidence per

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2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Current practice in third molar surgery
Discussion
It is clear that the majority of those responding to
this survey are clinicians with considerable experi-
ence in M3M surgery; therefore, the data collected
are of particular interest in evaluating the current
practice of pre-operative planning, consent, surgical
techniques and post-operative nerve injury rates in
M3M surgery.
Clinician grade and experience
The largest group of responders were Specialty Den-
tist grade (25%), closely followed by primary care
oral surgeons (18%). With changes in dental com-
missioning, there is a move to increase the provision
of minor oral surgery services within primary care,
therefore reducing the demand for secondary care
oral surgery10. Pilot schemes have shown the success
of primary care intermediate minor oral surgery ser-
vices, with M3M surgery accounting for up to one-
third of the workload11,12. It is therefore likely that
increasing numbers of the BAOS membership will be
performing M3M surgery within primary care. There
is a recognised need for an increased number of
Consultant grade oral surgeons in order to deliver
Consultant-led provision of care both within primary
care managed clinical networks and secondary
care10.
Pre-operative planning
Of responders 53% experienced difficulty in
accessing CBCT scanning facilities for assessment of
high-risk M3Ms, which appeared to be a particular
problem for those in primary care. While surgical
management of high-risk M3M is mainly undertaken
in secondary care, distance and cost are often pro-
hibitive factors for patients who may elect to have
the tooth removed without further imaging, accept-
ing the increased risk of nerve injury. Evidence-
based guidelines for the use of CBCT in dentistry
were published in 2012 by the SEDENTEXCT
project13 and suggest that where conventional
radiographs suggest a direct inter-relationship
between a mandibular third molar and the mandibu-
lar canal, and when a decision to perform surgical
removal has been made, CBCT may be indicated13.
The authors indicate that where coronectomy has
been selected, CBCT is not required, although they
do acknowledge that cross-sectional imaging is useful
in determining the buccal/lingual position of the
canal, which may be useful in cases where the ID
16
Devine et al.
canal is radiographically close to the cemento-
enamel junction. A study by Matzen et al. concluded
that CBCT influenced the decision between surgical
removal and coronectomy for only 12% of M3M
cases included14, therefore it is important that CBCT
is used for selected cases showing high-risk features
only rather than becoming the routine. High-risk
features on panoramic radiography are widely
accepted as darkening of the root, interruption of
the canal wall and diversion of the canal15. Cross-
sectional imaging may be useful for surgical planning
of cases with complex root morphology; however,
the SEDENTEXT guidelines also state It is important
to ensure that the above recommendation (CBCT for
complex root patterns) does not lead to a drift
towards routine use13; therefore, the decision on
CBCT must be made on a case by case basis consid-
ering the risks and benefits to each patient.
Coronectomy versus surgical removal
Of responders, 73% would offer the option of coro-
nectomy for high-risk cases where the tooth is vital.
A systematic review and meta-analysis found that
surgical removal carried a 10-fold increased risk of
inferior alveolar nerve injury compared with
coronectomy for high-risk M3Ms16. The rates of
post-operative pain and infection were similar for
both procedures. Although all studies reported fairly
high incidence of root migration following coronec-
tomy, the cumulative distance was only 3 mm, with
a re-operation rate of 05%16. This survey did not
explore the criteria used by clinicians to categorise
M3Ms as high risk, or indications for coronectomy;
however, studies have indicated that teeth with
high-risk radiographic features (as described above),
in addition to complex root morphology such as api-
cal curvature, hypercementosis and divergence
should be considered17. Patients who are immuno-
compromised and non-vital, third molars should not
be considered for coronectomy due to the risk of
post-operative infection17. Our results indicated that
many primary care practitioners would refer patients
to secondary care for consideration of coronectomy
in high-risk cases. The reasons for this are unclear;
however, it may be related to limited access to CBCT
scanning, therefore practitioners refer patients both
for assessment of risk and treatment to secondary
care. It may also be due to a lack of training or clini-
cal exposure to the coronectomy procedure. As yet,
evidence-based guidelines on indications for coro-
nectomy do not exist, therefore the clinician must
use their own judgement to weigh the risks and ben-
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2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Devine et al.
efits of the procedure for each individual case and
discuss this with the patient involved.
Consent
The majority of responders (57%) undertake a two-
stage consent process for M3M surgery, with only
4% failing to gain any form of written consent. This
is in line with guidance from the Department of
Health which recommends confirmation of consent
at a separate visit for significant procedures, which
in the case of M3M surgery would include any
treatment undertaken with intravenous sedation or
general anaesthesia18. It is recognised that patients
memory of information given by doctors is poor,
therefore the provision of written information
regarding the risks and benefits of the procedure
and the opportunity to discuss these at a second
consultation is of benefit to those undergoing M3M
surgery19. There was significant variation between
responders in the information given during the con-
sent process to describe the risk of injury to the
inferior alveolar and lingual nerve. There is cur-
rently no guidance on exactly what should be
included in the consent process for M3M surgery.
Both the General Dental Council and General Medi-
cal Council guidance on consent state that patients
should be informed of all frequently occurring and
rare serious complications which would significantly
impact on the patients life, rather than only men-
tioning those which the clinician deems likely to
occur20,21. The law relating to consent for medical
treatment has changed following the Supreme
Court judgement in Montgomery versus Lanarkshire
Health Board in March 2015, bringing it in line
with GDC and GMC guidance22. In the case of third
molar surgery, nerve injury should be considered a
significant complication to the individual patient,
with many studies confirming the serious psychoso-
cial impact these injuries can have23. There is a
need for further guidance and clarity on the
consent process for third molar surgery, with the
possibility of standardised consent forms being made
available to clinicians.
Choice of anaesthesia/anxiety management
On average, each responder was carrying out 19
M3M cases per week (eight local anaesthesia, five
intravenous sedation and six general anaesthetic
cases). This survey did not explore the criteria used
by responders in choosing an anxiety management
technique. There is evidence that around 7% of the
Oral Surgery 10 (2017) 11--19.
2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Current practice in third molar surgery
population will require IV sedation for dental treat-
ment and it is recognised that this number could be
much higher for invasive procedures such as M3M
surgery24. The Index of Sedation Need (IOSN) has
been proposed and evaluated as a tool for identifying
patients who require sedation or general anaesthesia
for treatment25. It has been shown to be a useful aid
for clinicians in identifying patients who should be
referred for sedation or GA, taking into account fac-
tors such as anxiety and treatment complexity25.
However, whether or not this tool is used, the final
decision should rely on agreement between the
patient and clinician taking into account the views
and opinions of both parties. Individual responses to
this survey stated that the choice between IV seda-
tion and GA was often dictated by the clinical envi-
ronment and facilities with maxillofacial units
tending to treat higher numbers of patients under
GA26. Recent guidance from the GDC emphasises
that due to the risks associated with GA, all beha-
vioural and anxiety management techniques should
be considered before prescribing treatment under
GA27.
Surgical technique
The majority of responders (90%) would use an
inferior dental block with lidocaine, supplemented
with a buccal infiltration with lidocaine or articaine
for M3M surgery, in line with current UK practice.
About 6% used articaine or another high concen-
tration agent for IDB, which has been associated
with a higher incidence of inferior alveolar nerve
injury28. Flap design was fairly evenly split between
buccal triangular (46%) and buccal envelope (41%)
for the M3M shown. A recent systematic review
reported moderate evidence that triangular flaps are
associated with a reduction in alveolar osteitis at
1 week and pain at 24 hours compared to envelope
flaps. There was low-quality evidence of increased
swelling at 1 week with triangular flaps when com-
pared to envelope flaps6. Routine use of lingual
retraction was reported by 27% of responders,
while others would use it for selected complex
cases to aid visualisation and bone removal. Use of
lingual retraction has been shown to increase the
risk of temporary lingual nerve injury, although an
increased risk of permanent lingual nerve injury
has not been demonstrated6. Therefore, if surgeons
are using this technique, patients should be
informed during the consent process of the
increased risk of lingual nerve paraesthesia which
may last for several weeks following surgery. Most
17
Current practice in third molar surgery
responders (92%) would use a sectioning technique
to conserve alveolar bone during M3M surgery. To
the authors knowledge, there is no evidence on
the post-operative complications of bone removal
versus tooth sectioning; however, intuitively con-
serving bone should be in the best interests of the
patient.
Post-operative follow-up
Post-operative follow-up for patients undergoing
M3M surgery was rare with only 18% of those sur-
veyed making any type of proactive contact with the
patient within 48 h of surgery. Studies have shown
that home-check telephone contact is favoured by
patients over a clinic review following M3M sur-
gery29 and is a useful way for surgeons to record
their own outcomes and identify complications early.
Telephone follow-up has also been shown to
increase patient satisfaction with treatment received
and reduce re-attendance rates30.
Experience of nerve injury
The average rate of self-reported inferior alveolar
nerve injury (2 temporary, 0.4 permanent) and lin-
gual nerve injury (1 temporary, 0.1 permanent) in
the past 5 years is low among this group of respon-
ders; however, the numbers vary widely between
clinicians. This may be due to some clinicians taking
on a greater number of high-risk cases in secondary
care units. The incidence of IANI following M3M
surgery has been reported to vary from 0.35% to
8.4%31. A similar questionnaire study of Oral and
Maxillofacial Surgeons in the USA reported average
rates of 4 per 1000 (IANI) and 1 per 1000 cases
(LNI)32. The lack of routine follow-up or continuity
of care following M3M surgery mean that many
clinicians in this group are unaware of the numbers
of nerve injuries caused and therefore the results
of our survey should be interpreted with some
caution.
Conclusion
Mandibular third molar surgery is one of the most
common outpatient procedures carried out in the
UK NHS. BAOS members represent one of the main
workforces providing this service. Just over half of
the membership is on the GDC specialist list, how-
ever the proportion of consultant grade surgeons
was only 13%. This survey has highlighted the lack
of access to CBCT scanning for pre-operative plan-
18
Devine et al.
ning of high-risk cases and the differences in
approach to pre-operative planning, consent and sur-
gical technique between responders. The reported
rates of inferior alveolar and lingual nerve injuries
caused by M3M surgery varied widely between sur-
geons; however, this may be due to a lack of post-
operative contact or follow-up with patients there-
fore preventing surgeons from accurately recording
their surgical outcomes. There is a need for further
high-quality research and evidence-based guidelines
on radiographic features of high-risk M3Ms, indica-
tions for coronectomy and incidence of neuropathy
to inform best practice in this high-volume surgical
procedure.
Funding
None.
Conflict of Interest
The authors confirm that there are no conflicts of
interest.
Ethical Approval
None required.
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