BEST TIME TO REMOVE

WISDOM TEETH

Facilitator :
Dr Mohammad Khursheed Alam

OUTLINE
Objective :
To explain the best time for removal of third molars

Content :
Third molars & Orthodontics
Ideal time to remove wisdom tooth

THIRD MOLARS AND

ORTHODONTICS
General dental
standpoint1

Does not pose an issue until

between 18-25 years of age.

Issue should be acknowledged

Orthodontics
as early as 12-13 years old.
standpoint1
Orthodontist tends to remove it at an early stage,
without waiting for its eruption potential to fully
express.
3

THIRD MOLARS AND

ORTHODONTICS
Influence of third molars in lower arch crowding and
post-treatment stability? Controversial.
According to several long-term follow-up evaluations
and experimental studies, unerupted third molars
may play a role in the post-retention changes seen
after orthodontic alignment. 2, 3, 4

LITERATURE FINDINGS
Bergstrom and Jensen examined 30 dental students with
unilateral aplasia of lower third molars and found that
there was more crowding on the side with the third
molar present as compared with the side in which it was
missing.
Vego compared 40 cases with and 25 cases without third
molars (ages between 12 and 17 years) and found that
more crowding developed in the group with third
molars present.

LITERATURE FINDINGS
Schwarze compared a group of 56 patients with third
molar germectomy to 49 subjects whose third molars
were allowed to develop. He found a significantly
greater forward movement of first molars associated
with increased lower arch crowding in the nonextraction group.

Lindquist and Thailande extracted third molars

unilaterally in 52 patients and found more stable space
conditions (less increase in crowding) on the
extraction side compared with the control side in 70%
of cases.
7

LITERATURE FINDINGS
Kaplan found that presence of third molars does not
produce a greater degree of lower anterior crowding or
rotational relapse when retention is ceased after
orthodontic treatment.
Pirttiniemi et al. concluded that the extraction of an
impacted third molar allows at least the second molar
drift posteriorly and laterally, but it has minimal effect
on the anterior part of the dental arch.
There is not enough evidence in present study to prove
that third molar being the only etiologic factor in lower
dental arch crowding.
8

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PROPHYLACTIC GERMECTOMY
Germectomy :
the removal of a tooth whose
root is less than one third
formed.

Henry & Morant in 1936

Enucleation at calcification
stage of the third molar
9-11 years

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PROPHYLACTIC GERMECTOMY
WHY?
Orthodontic treatment is enhanced
Creates space for lower dentition
Anchorage preparation
Distal movement of the first and second molars
Ricketts and his co-authors further indicated that
removal of the third molar bud at the age of 7 to 10
years is surprisingly simple and relatively atraumatic.
This contrasts to the difficulty of extraction of deeply
impacted teeth in adults.
14

MANAGEMENT OF THIRD
MOLARS IN ORTHODONTICS
To delay the decision for the removal of third molars in
patients with malocclusions until the orthodontic
treatment plan is completed (if no other indications)
Recall former orthodontic patients at intervals of 2 years
to evaluate the alterations of the condition and position
of erupting or impacted third molars. 5
To monitor growth and development with panoramic
radiographs at 2-3 years interval to assess
developmental status
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MANAGEMENT OF THIRD
MOLARS IN ORTHODONTICS
Consensus Development
Removal 1979 :

Conference

on

Third

Molar

Indication to remove third molar in orthodontic treatment :

when distal movement of first or second molars could
lead to impaction or complicate orthodontic care.
Contradindication :
to prevent crowding of lower incisors, either postorthodontic treatment or in nontreated individuals
There was also no consensus achieved on the removal or
retention of asymptomatic, disease-free, impacted teeth.
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SUGGESTED PROTOCOL9 :
9-16 Y.O.
determine the presence or absence of third molar crypts and crown
formation during routine orthodontic record-taking and radiographic
examination.
If a pathologic condition is detected, refer for removal.
If there are adjunctive treatments such as orthognathic procedures,
prosthetic procedures, or orthodontic movements that will require
removal as mentioned above, refer for removal according to timing
requirements.
Otherwise, monitor development during orthodontic treatment using
routine diagnostic panoramic radiograms. Note the position of the third
molars and the stage of crown and root development to assess dental
maturation for timing of future radiographs.
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SUGGESTED PROTOCOL9 :
17-24 Y.O.
During routine orthodontic record taking or progress radiographs,
evaluate tooth position, crown formation, and root formation.
If a pathologic condition is detected, refer for removal.
If the root is one-half to two-thirds complete, determine space
requirements. If space is inadequate, consider referral for consultation
or monitor development if tooth position looks normal.
If the occlusal table of the third molar is angled > 60 to the occlusal
plane of the first and second molars, and is in close proximity to the
second molar roots, refer for consultation or removal. If the tooth is in
a distoangular position, refer for consultation or removal.

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CURRENT RECOMMENDED
IDEAL TIME
Extraction should be performed as soon as it is
diagnosed to be impacted.
Consideration factors :
Age
Root development

19

FACTOR 1 : AGE
17-20 years old18
18-24 years old19
Generally 25 years old
Removal is more difficult with advancing age
Sequelae???

20

FACTOR 1 : AGE

local tissue morbidity

Loss or damage to adjacent teeth & bone
Injury to vital structures
Denser bones
Complicated due to systemic disease

21

FACTOR 1 : AGE
Study of 4000 patients showed that patient 25
years old has 1.5 times likelihood of complications,
with generalized increasing risks with age. 21,22,23

22

FACTOR 1 : AGE
Periodontal healing & nerve recovery is
better.18
Older patient 25 years old :
more post-surgery visits due to
complications after surgery. 20
More bone removal
Closer proximity to vital
anatomical structures
Increase bone density

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FACTOR 2 : ROOT
DEVELOPMENT
Ideal to remove when :

< ROOT LENGTH <

24

FACTOR 2 : ROOT
DEVELOPMENT
<:
surgical manipulation is traumatic
difficult to secure a foothold for extraction
contributes to risk of displacement
>:
Proximity to vital structures
Indirectly related to increasing age
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CONCLUSION
Contradicting opinions on whether presence of third molar
complicates crowding in the arch.
Prophylactic removal AND prophylactic germectomy should no
longer be practiced.
Orthodontic planning according to the protocol. Development
monitoring is recommended post-treatment in asymptomatic
impacted third molars.
Remove upon diagnosis and with proper indications.
Best to remove 18-24 years old, when root formation is between
and length.
Removal of wisdom
complications.

after

25

year

old

causes

more
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REFERENCES
1. Morehouse, H. L. (1918). Third molar influence in orthodontic cases.International Journal of Orthodontia, 4(7),
345-354.
2. KAHL B. Long-term results of a clinical follow-up evaluation of orthodontically and orthopaedically treated
patients stability, relapse or new anomaly. Thesis: University of Cologne 1994 (in preparation).
3. RICHARDSON ME. The role of the third molar in the' cause of late lower arch crowding: a review. Am J Orthod
Dentofacial Orthop 1989: 95:79 83.
4. SCHWARZE CW. The influence of third molar germectomy a comparativelongterm follow-up study. In: COOK
JT, ed: Transactions of the Third International Orthodontic Congress. London: Staples, 1975:551 62.
5. Kahl, B., Gerlach, K. L., & Hilgers, R. D. (1994). A long-term, follow-up, radiographic evaluation of
asymptomatic impacted third molars in orthodontically treated patients. International journal of oral and
maxillofacial surgery, 23(5), 279-285.
6. NIH Consensus Development Conference for Removal of Third Molars. J Oral Surg 38:235, 1980
7. Waite PD, Reynolds RR: Surgical management of impacted third molars. Semln Orthod 4: 113, 1998
8. Henry, C. B., and Morant, G. M.: A preliminary study of the eruption of mandibular third molar teeth in man
based on measurement obtained from radiographs with special reference to the problem of predicting cases of
ultimate impaction of the tooth, Biometrika 28: 378-427, 1936.

9. Hicks, E. P. (1999). Third molar management: a case against routine removal in adolescent and young
adult orthodontic patients. Journal of oral and maxillofacial surgery, 57(7), 831-836.
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REFERENCES
10. Lindquist B , Thilander B Extraction of third molars in cases of anticipated crowding in the lower jaw. AM
J ORTHOD 1982; 81:130-9. Richardson
11. C Bowdler Henry, Prophylactic odontectomy of the developing mandibular third molar: A new operation,
American Journal of Orthodontics and Oral Surgery, Volume 24, Issue 1, January 1938, Pages 72-84,
ISSN 0096-6347.
12. Friedman, J. W. (2007). The Prophylactic Extraction of Third Molars: A Public Health Hazard. American
Journal of Public Health, 97(9), 15541559. doi:10.2105/AJPH.2006.100271
13. Bergstrom K, Jensen R. The significance of third molars in the aetiology of crowding. Trans Eur Orthod
Sot 1960:84-96. 7.
14. Southard TE. Third molars and incisor crowding: when removal is unwarranted. J Am Dent Assoc.
1992;123: 7579.
15. Harradine NW, Pearson MH, Toth B. The effect of extraction of third molars on late lower incisor
crowding: a randomized controlled trial. Br J Orthodont. 1998;25:117122.\

16. Kaplan RG. Mandibular third molars and post-retention crowding.Am J Orthodont.
1974;66:411430.
17. Vego L. A longitudinal study of mandibular arch perimeter. Angle Orthod 1962;32:
187-92.
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REFERENCES
16. Hupp, Myron Tucker, Edward Ellis. Contemporary Oral & Maxillofacial Surgery, 6th Edition, 2013. Mosby
Publication.
17. NICE guidance on the Extraction of Wisdom Teeth, National Institute for Health & Clinical Excellence,
March 2000.
18. R.A. Bruce, GC Frederickson, GS Small. Age of patient & morbidity associated with mandibular third
molar surgery. J Am Dent Association, Vol 101, 1980
19. Srinivas & Dodson T. Age a a risk factor for third molar surgery complications. In preparation 2007.
20. Bui CH, Seldin EB, Dodson TB. Types, frequencies and risk factors for complications after third molar
extraction. J Oral Maxillofacial Surgery 61:1379, 2003.
21. Valmaseda-Castellon E, Berini Aytes L, Gay-Escoda. Inferior alveolar nerve damage after lower third
molar surgical extraction: A prospective study of 1117 surgical extractions. Oral surgery, Oral medicine,
Oral pathology, Oral radiology and endodontology 92:377, 2001.
22. Primo, B. T., Stringhini, D. J., Klppel, L. E., Da Costa, D. J., Rebellato, N. L. B., & de Moraes, R. S.
(2014). Delayed removal of maxillary third molar displaced into the infratemporal fossa. Revista Espaola
de Ciruga Oral y Maxilofacial, 36(2), 78-81.

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