Join me for a podcast summary looking at the grey topic oflower third molar management. The podcast explores the different guidelines of removal,factors for consideration for removal as well as the effect orthodontics canhave on third molar pathology. The lecture was given by Flavia Artese at thisyear’s British Orthodontic Conference in my city London.
Flavia Artese began with asking the clincal question weface, what would you do with an impacted 3rd molar?
Difference in international practice
· UK NICE guidelines 2000: Surgical removal ofimpacted third molars should be limited to patients with evidence of pathology
· AAOMS White paper USA 2016: currently or likelyto be non-functional associated with disease or at a high risk of developingdisease
What factors in decision making
· Mandible = mesial, whereas Maxilla = distal
o Rate of impaction Mandible 25%, maxilla 14%Worthington 2016
· A pathway created by the dental follicle
o Triggers eruption of intraosseous eruption
o Genetic control of cell differentiation indental follicle
§ Requires root elongation, vascular pressure andDL ise 2008
Orthodontic influence = SPACE
· Decrease with distal movement of posterior teeth
o Distalisation, elastics
§ Kim 2014 = limit of lower molar distalisation
§ 35% of cases already have contact with lingualcortical plate
· Increase through mesial movement
o 80% of 3rd molars erupted in premolarextraction cases Kim 2003
o Increase in retromolar area
o 2nd molars – removal of guidance =unpredictable alignment of 3rd molars, tipped, therefore will likelyrequire orthodontic alignment Gooris 1990
§ Flavia suggested if 7s impacted, removal of 8sand 2nd molar uprighting, as no delay until full root development
Prediction method
· Mandibular morphology
o Longer the mandible = greater chance of 3rdmolar eruption: Begtrub 2012
· Retromolar space
o OPG - size of crown and space available: If space greater then size of thetooth = 75% eruption, if less space available than the tooth size = 75% ofimpaction Olive
Prediction of orthodontists and surgeons Bastos 2016
· Orthodontists 38% extract
· Surgeons 50% extract
· Surgeons extract more
o Surgical morbidly 10% Yamada 2022
o Greater pathology: 82% when erupted, 74% in softtissue, bone 33%
Surveillance protocol
· No complaints from patients
Fully erupted
· No consensus of protocol pathology
Review of guidelines Gadiwalla 2021
Only 2guidelines were recommended , RCS and SIGN
· Recommended guidelines
Conclusion
· Limited evidence
· Orthodontists can influence the space
· If second molars require extraction, willrequire time to erupt as well as
· CBCT should be used for diagnosis
· Refer to oral surgeon for assessment ofdifficulty in removal
Please join Flavia Artese at the 2025 InternationalOrthodontic Conference in Rio De Janeiro
Contributions
Contents: AbdAllah Sharafeldin
Contents edited andproduced: Farooq Ahmed