White paper on wisdom teeth published by AAOMS discussing current knowledge on wisdom teeth and treatment indications.

1. WHITE PAPER
ON THIRD MOLAR DATA
H. Ryan Kazemi, DMD Oral & Maxillofacial Surgery Bethesda, MD

2. LOSE THE WISDOM

3. LOSE THE WISDOM
BUT STILL KEEP THE
COMMON SENSE

4. Can the course of an unerupted
third molar be predicted?
Hard tissue space: space/
crown width rations < 1
Radiographic monitoring
Eruption does not imply
health or adequate
periodontal support
Change in position even after
age 25

5. Periodontal Considerations
Presence of Third molar
Pan: 3-4%
Bone loss and Root
resorption PA: 24%-42%
Probings
Visible third molar >=5mm
Disruption of of PDL, root resorption, pocket and LOA

6. Periodontal Considerations
Third molar Removal
Loss of Attachment or Age <25
increase pocket depth
Preoperative state
Adversity predicted based on preop existence of
intrabony defect, age, level off plaque control

7. Periodontal Considerations
Reduction in postop LOA
Flap design, buccal window,
GTR, approach.......
No relationship between approach and minimizing LOA
GTR helpful if there is pre-existing attachment loss
Scaling / RP and plaque control help

8. Periodontal Considerations
Risk factors
Visible third molars: Elevated levels of periodontitis and
progressive
Presence of pocket depths >=4-5 mm or bleeding on
probing may be good predictors
Third molars should be considered as a possible
predictor of periodontitis due to direct association of
periodontal disease, its progression, severity, and flora.

9. Microflora
Absence of symptoms does not indicated absence of
disease or pathology
Pathogenic bacteria exist around asymptomatic 3rds
Periodontal disease as indicated by probings of
>=4-5mm exists around asymptomatic 3rds
Indicators of chronic inflammation exists in pockets
Periodontal disease progresses in the absence of
symptoms

10. 3/2003
1/24/08

11. Effect of age
Symptomatology + Age
pain (35.3%)
swelling (21.7%)
discomfort (3.6%)
purulence (3%)
** increase with age

12. Effect of age
Periodontitis + Age
>25 33% asympt perio defects
<25 17% asympt perio defects
6793 patients, 52-74: 1.5 times the odds of
having perio defect >5mm
5831 patients, 25-34 vs 18-24, 30% greater
chance of periodontal defects

13. Effect of age
Caries + Age
342 subjects, mean age 73: increased caries
22-32 year-old: 3 years, increased caries
40% risk of caries in erupted thirds before end
of third decade

14. Effect of age
Postoperative risks + Age
Lower post op morbidity in younger patients
All risks increased from <25 to 25-35, to >35
4004 patients: 1.5 times complications if >25,
increasing through age 65
Perio defects twice as commonly (51%) in
patients >26

15. Effect of age
Germectomy + Age
(Roots one third or less developed)
no nerve injuries
no pocketing
significantly lower morbidity

16. Effect of age
Presence of 3rds + Age
increase in patients >40 needing 3rds ext
eruption of 3rds in older patients is more
frequent than may be thought
14-45 year olds found 51% of 312 late erupting
thirds had perio disease in 2.2 year f/u

17. Effect of age
Presence of 3rds + Age
Increase in presence of retained third molars:
Periodontal defects
Caries
Post operative morbidity >25
Germectomy is recommended

18. Orthodontics / Prosthodontics
Crowding
Asymptomatic impacted third
molars under existing or
planned removable prosthesis

19. Imaging Techniques
CT & IAN injury Sensitivity
Specificity
93%
77%
Panorex & IAN Sensitivity
Specificity
70%
63%
Sensitivity is the proportion of people that tested positive of all the positive people tested; that is (true positives) / (true positives + false
negatives). It can be seen as the probability that the test is positive given that the patient is sick. The higher the sensitivity, the fewer real
cases of diseases go undetected (or, in the case of the factory quality control, the fewer faulty products go to the market).
Specificity is the proportion of people that tested negative of all the negative people tested; that is (true negatives) / (true negatives + false
positives). As with sensitivity, it can be looked at as the probability that the test is negative given that the patient is not sick. The higher the
specificity, the fewer healthy people are labeled as sick (or, in the factory case, the less money the factory loses by discarding good products
instead of selling them).
Role and indications of CT is unclear and evolving

20. Coronectomy
5 papers in literature
Partial root removal when intimate relationship
between roots and IAN
No standard of care with regard to this
technique
An alternative approach until more studies

21. Socket protocol following
extraction
Age >26, perio defect, mesioangular impaction
Predictable benefit to reconstruct defect at
time of extraction

22. Nerve damage
IAN: 1-5% 1-7 days after surgery; 0.9%-low
zero after 6 months
Lingual Nerve: 0.4-1.5% 1-day after surgery;
0.5%-low zero after 6 months
Long Buccal: No specific reports
Mylohyoid nerve: 1.5% (lingual approaches)
Spontaneous Recovery: 50-100%, IAN & Lingual

23. Nerve damage
Evaluation
Mapping and photograph
Light touch (von frey’s hairs)- A beta, pressure
Two point discrimination- Larger myelinated
Direction test: A alpha and A beta fibers
Pinprick- A delta and C fibers

24. Nerve damage
Nerve repair
23 lingual nerves, earliest at 6 m: 50% with
some recovery, Poor results with dysesthesia
63% good recovery in 19 with repair at 4.5 m
55 % recovery in 51 patients
92% in 32 nerves repaired at mean 4.5 m

25. Nerve damage
Nerve repair
Timing: within 10 weeks of injury
Lingual nerve: upto 47 months after injury with
good results
Repairs for dysesthesia carried a poorer
prognosis whatever the timing of repair

26. Nerve damage
Rare incidences
at least 50% recover spontaneously
Nerve surgery between 4.5-7 months, over
50% show improvements
Taste recovery can happen in case of lingual
nerve repair

27. Pearls
Remove Third molars
Do it early
Conservative Surgery
Risk assessment

29. http://web.mac.com/hrkazemi/ToThePoint/Welcome.html

30. www.facialart.com
hkazemi@facialart.com